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UNIVERSITAS BINAWAN
PRODI KEPERAWATAN PROGRAM B 2019 GANJIL
TA 2019/2020
CASE
Mr. Michael is an 81 years old who has brought to emergency department via an
ambulance from a local nursing home. He was found by the nurses on their 6 AM rounds
to be very confused, restless, and hypotensive.
Subjective:
- Denies any pain and discomfort
Objective data:
- Neurologic : lethargic, confused, easly aroused, does not follow command, moves all
extremities response to stimuli.
- Cardiovascular : B/P: 80/60, HR: 112 x/m and regular, T: 104 0 F (400 C) rectal, heart
sounds normal without murmur or S3, S4; peripheral pulses weak and thready.
- Skin : warm, dry, flushed
- Respiratory : RR : 34 x/m and shallow; breath sounds audible in all lobes with
crackles bilaterally in the bases
- GI/GU : abdomen soft with hypoactive bowel sounds, urinary catheter in place
draining scant, purulent urine
In the ED, two 16 gauge IVs were inserted and 700 ml of normal saline was giver over
the first hour. The patient was place on 40% oxygen via facemask. The urinary catheter
was removed and cultured and blood cultures were drawn at the three intervals. A new
was inserted. The patient was started on IV antibiotics and was transferred to the ICU
with diagnosis of sepsis due to gram negative sepsis.
In the ICU, a pulmonary catheter was inserted in additional to an arterial line.
- ABG results were pH 7.25, PaO2 60 mmHg, Pa CO2 28 mmHGg,; HCO3 12mEq/L,
and SaO2 82%
- Hemodynamic pressure taken were right atrial pressure (CVP) , PAP, PAWP, cardiac
output and SVR
- Lab result were WBC 21.000 /µ l, Na 133 mEq/L, Cl 96 mEq/L, glucose 230 mg/dl,
creatinine 1.7 md/dl, Hb 12 g/dl, Hct 36 %
Mr. Michael’s blood pressure continued to drop despite several liters of crystalloid.
Dopamine was started and titrated up as needed to try to maintain the patient’s blood
pressure, in additional to more fluid administration. Despite all effort, including
intubation and mechanical ventilation, Mr. Michael did on the sixth hospital day. The
cause was multiple organ dysfunction syndrome due to gram-negative sepsis.
2. What preventive measures could have been taken by nursing home staff in regard to Mr
Micheal ?
Answer:
- Menjaga kebersihan pasien dan lingkungan
- Hand Hygiene
- Monitor gula darah dan mengatur diit pasien
- Monitor kateter urine
3. What are the major pathophysiologic changes associated with sepsis ?
Answer:
Infeksi sistemik yang terjadi biasanya karena kuman gram negative yang menyebabkan
kolaps kardiovaskuler. Endotoksin basil gram negative ini menyebabkan vasodilatasi
kapiler dan terbukanya hubungan pintas arteriovena perifer. Selain itu terjadi
peningkatan permeabilitas kapiler. Peningkatan kapasitas vaskuler karena vasodilatasi
perifer menyebabkan terjadinya hipovolemia relative, sedangkan peningkatan
permeabilitas kapiler menyebabkan kehilangan cairan intravaskular ke interstisial yang
terlihat sebagai edema. Pada saat syok sepsis hipoksia sel yang terjadi tidak disebabkan
oleh penurunan perfusi jaringan melainkan karena ketidakmampuan sel untuk
menggunakan oksigen karena ketidakmampuan sel untuk menggunakan oksigen karena
toksin kuman. Berlanjutnya proses inflamasi yang maladaptive akan menyebabkan
gangguan fungsi berbagai organ yang dikenal sebagai disfungsi/gagal organ multiple.
5. Explain the physiologic reasons for the following assessment parameters found this
patient
Decreased LOC
Answer:
Hipotensi yang terjadi pada Mr. Michael menyebabkan terjadinya hipoperfusi
jaringan termasuk jaringan saraf sehingga mengalami hipoksia sel.
Warm,dry, and flushed skin
Answer:
Terjadi penyebaran infeksi ke jaringan kulit
Tachycardia
Answer:
Merupakan kompensasi tubuh untuk meningkatkan cardiac output keseluruh tubuh.
Tachypnea
Answer:
Merupakan kompensasi tubuh untuk memenuhi kebutuhan oksigen ke sel dan
jaringan
Fever
Answer:
Merupakan respon fisiologis tubuh terhadap terjadinya infeksi
Decreased SVR
Answer:
Gagal jantung kongesif yang diderita Mr. Michael menyebabkan disfungsi pada
miokard, pada keadaan sepsis disertai peningkatan konsentrasi nitric oxide dalam
jumlah besar hal tersebut akan mengakibatkan penurunan tekanan SVR.
9. Explain the rationale for fluid therapy and the use of dopamine
Answer:
Pemberian cairan berguna untuk meningkatkan cairan di intravascular. Dopamin
bekerja dengan meningkatkan kekuatan pompa jantung dan aliran darah ke ginjal.
10. Base the assessment data provided, whire one or more nursing diagnosis. What
collaborative problems are present ?
Answer:
1) Ketidakefektifan pola nafas berhubungan dengan ketidakseimbangan antara suplai
dan kebutuhan O2 , edema paru.
2) Penurunan curah jantung berhubungan dengan perubahan afterload dan preload.
3) Hipertermi berhubungan dengan proses infeksi
4) Intoleransi aktivitas berhubungan ketidakseimbangan antara suplai dan kebutuhan
oksigen.
5) Ketidakefektifan perfusi jaringan perifer berhubungan dengan cardiac output yang
tidak mencukupi.
Masalah Kolaboratif:
- Intubasi
- Pemasangan CVC dan ABP
- Pemberian terapi vasopresor
- Berikan antibiotic spectrum luas.