Minicase Study Septic Shock

Sepsis Case Study-Student Copy Overview Sepsis is a systemic inflammatory response to a documented or suspected infection. Severe sepsis, defined as sepsis complicated by organ dysfunction, is diagnosed in more than a million patients per year and has a mortality rate as high as 28% to 50%. Septic shock is the presence of sepsis with hypotension despite adequate fluid resuscitation along with the presence of tissue perfusion abnormalities resulting in tissue hypoxia. Sepsis can occur in patients of all ages, although infants, older adults, and those with preexisting medical conditions are at higher risk. P.H. is a 58-year-old-female with a history of type 1 diabetes mellitus (since age 8), hyperlipidemia, renal insufficiency, and peripheral neuropathy. P.H. was diagnosed with stage IV ovarian cancer 4 months ago. Surgical management at that time included a total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node biopsies. Two weeks after surgery, aggressive combination chemotherapy was started. P.H.'s husband brings her to the emergency department (ED) with shaking chills and fever. Her last chemotherapy was 2 weeks ago. He states she is very weak and barely able to hold her head up. Vital signs obtained by you, the triage nurse, are as follows: blood pressure (BP) 96/72 mm Hg, heart rate (HR) 120 beats/min, respiratory rate (RR) 26 breaths/min, oxygen saturation 92% on room air, and tympanic temperature 102.6° F (39.2° C). 1. You immediately assign P.H. to an ED bed based on knowledge that the patient is at highest risk for sepsis related to a. Immunosuppression. b. Diabetic Ketoacidosis c. Hyperlipidemia d. Pyelonephritis 2. You conduct a focused assessment on P.H. Select the priority evaluations that should be part of this focused assessment. There are 9 correct answers. a. Capillary blood glucose b. Capillary refill. c. Date of last bowel movement. d. Exposure to potential pathogens. e. Mental status assessment. f. Muscle strength and quality. g. Breath sounds. h. Palpate for hepatomegaly. i. Pupillary reaction. j. Time and amount of last insulin dose. k. Time and amount of last food intake. l. Urine output. Case Study Progression You find P.H. oriented to person, place, and time but restless and apprehensive. Her breath sounds reveal soft crackles in the lung bases. Her skin is warm, flushed, and capillary refill is 5 seconds. Her abdomen is soft and nontender with hypoactive bowel sounds. She cannot 1 Sepsis Case Study-Student Copy remember the last time she voided. Her last meal was lunch 6 hours ago; she took 6 units of regular insulin to cover her pre-prandial blood glucose of 306 mg/dL. She ate half of a turkey sandwich and a glass of milk. Her capillary blood glucose is currently 348 mg/dL. Her husband states that their son was home from college and was diagnosed with bronchitis. He stated that P.H. tried to stay away from him. 3. Which findings in P.H.'s focused history and physical put her at high risk for sepsis? a. Recent chemotherapy. b. History of diabetes mellitus. c. History of hyperlipidemia. d. Delayed capillary refill. e. Exposure to son’s bronchitis. f. Hypoactive bowel sounds. g. Hyperglycemia. h. Hyperventilation. i. Soft, nontender abdomen. 4. Which findings reflect the compensatory stage of septic shock? a. Skin warm and flushed. b. Tachycardia. c. Soft, nontender abdomen. d. Delayed capillary refill. e. Hyperventilation. f. Hypoactive bowel sounds. g. Lethargy. h. Restlessness. i. Decreased urine output. 5. Suspecting that P.H. may be septic, you consider the pathophysiology and clinical manifestations of shock. The underlying pathophysiologic process occurring in septic shock is related to a(n) minimum distribution of blood flow. 6. For each of the following statements write either Compensatory, Progressive, or Refractory. a. Decreased perfusion from peripheral vasoconstriction and decreased cardiac output exacerbate anaerobic metabolism, ultimately leading to multisystem organ dysfunction. Refractory b. The body activates neural, hormonal, and biochemical mechanisms in an attempt to overcome the increasing consequences of anaerobic metabolism and to maintain homeostasis. Compensatory 2 Sepsis Case Study-Student Copy c. Continued decreased cellular perfusion and resulting altered capillary permeability are the distinguishing features of this stage. Progressive _ 7. Place the following findings in the appropriate column for septic shock: Hyperventilation, warm pink skin, decreased BP & bradycardia, severe hypoxemia with respiratory failure, Oliguria, mottle skin, cyanotic skin, anuria, oliguria, moist crackles, delirium Compensatory MAP 10-15 Hyperventilation Warm pink skin Oliguria (400ml/24 hours) Thirst Restlessness Tachycardia Narrow PP Increased contractility Septic shock Progressive MAP 20 Anuria Delirium Oliguria-anuria Moist crackles Cold clammy skin High lactate-High K Sense of impending doom Tachycardia-Thready pulse Increased LFTs, ammonia, Bilirubin Refractory- I got nothing Decreased BP & bradycardia Severe hypoxemia with respiratory failure Cyanotic skin Mottle skin Coma Pupils non-reactive Measure O2 sat Anuria High Creatinine+ LTFs Case Study Progression The ED physician reviews your data collection and examines P.H. The following orders are written:        STAT basic metabolic panel (e.g., serum electrolytes, blood urea nitrogen [BUN], creatinine), complete blood count (CBC), liver function tests, lactate level, blood cultures × 2, urinalysis, urine culture and sensitivity (C&S), sputum C&S, arterial blood gases (ABGs), prothrombin time/international normalized ration (PT/INR), activated partial thromboplastin time (aPTT), fibrin split products (FSP) Chest x-ray Oxygen 2 L via nasal cannula PRN to keep O2 saturation greater than 92% Ceftriaxone 2 grams IV every 12 hr Initial fluid bolus of 30 ml/kg of normal saline bolus wide open Insert urinary catheter to monitor output Prepare for insertion of central line for central venous pressure (CVP) monitoring 3 Sepsis Case Study-Student Copy 8. What is most important to complete before giving the ceftriaxone? a. Hydrate with at least one L of Normal Saline. b. Administer oxygen via nasal cannula. c. Document history and physical findings. d. Obtain blood, urine, and sputum specimens for culture. 9. When reviewing assessment data, you identify the presence of septic shock when P.H.'s systolic BP remains low despite fluid resuscitation. A laboratory result corroborating this diagnosis would be a lactic acid level greater than 2 mmol/L. 10. Which diagnostic test is done after insertion of a central line? X-ray Case Study Progression One hour after receiving IV fluids and IV antibiotics, P.H.'s blood pressure continues to trend downward and her CVP reading is 6. A third fluid bolus of normal saline is administered with no hemodynamic improvement noted. The ED physician orders the following:    Norepinephrine (Levophed) infusion to start at 8 mcg/min and titrated to a mean arterial pressure greater than 65 mm Hg Famotidine 20 mg IV now and every 12 hr Regular insulin 10 U subcutaneously now 11. Norepinephrine (Levophed) is available as 4 mg in 1000 mL 5% dextrose in water. The nurse starts the infusion at which of the following rates? _____120__ mL/hr 12. Which of the following interventions can the RN delegate to the UAP. a. Obtain hourly vital signs, including urinary output. b. Obtain CVP reading. c. Obtain hourly capillary blood glucose measurements per agency policy. d. Assess I and O. e. Titrate norepinephrine infusion rates based on patient’s systolic blood pressure readings. f. Provide oral care at least q 4 hr. g. Auscultate lung sounds q 4 hours. h. Help position the patient to maximize comfort. 13. The critical care health care provider inserts an arterial line to accompany the already present central line for CVP monitoring. Identify the following landmarks used for correct placement of the system stopcock for zero referencing; 4 ICS, mid chest axilla line, Phlebostatic axis level static axal 4 Sepsis Case Study-Student Copy 14. Why is a central venous pressure monitored in shock states? Volume status 15. A CVP measurement goal in shock would be 2-6 Case Study Progression P.H.'s condition is medically complex, and she is critically ill. Her WBC count is 21,000/µL and blood cultures reveal gram-positive cocci. Over the course of the next day P.H. becomes more confused and then obtunded. Her oxygen saturation falls to 85% despite receiving 100% oxygen via a nonrebreather mask. Consequently, she is intubated and mechanically ventilated. A nasogastric tube is inserted, and continuous enteral feedings are begun at 15 mL/hr, titrating by 10 mL/hr every 4 hr, as tolerated, until infusing at the goal of 50 mL/hr. 16. You understand the importance of preventing ventilator-associated pneumonia (VAP) while caring for P.H. Select interventions aimed at preventing this complication. There are 5 correct answers. a. Elevate the HOB 30 to 45 degrees. b. Suspend enteral feedings during transport and/or position changes. c. Maintain continuous sedation to prevent self extubation. d. Administer ordered proton pump inhibitor. e. Perform frequent, meticulous oral hygiene. f. Maintain patient in supine position. g. Perform frequent hand washing. h. Change the ventilator circuit q 48 hours. 17. As P.H.'s condition deteriorates, the health care provider determines the need to order IV methylprednisolone. The patient's husband asks you how this drug will help his wife. Your best response is a. “This drug is a steroid that may help increase P.H.’s respiratory rate.” b. “This drug is a corticosteroid that may help increase P.H.’s blood sugar.” c. “This drug is a corticosteroid that may boost P.H.’s immune system.” 5 Sepsis Case Study-Student Copy d. “This drug is a corticosteroid that may boost P.H.’s blood pressure.” Case Study Conclusion You vigilantly monitor P.H.'s vital signs, capillary blood glucose readings, urine output, and laboratory results. Gradually, organ function improves, and P.H. is weaned from the ventilator and the vasopressor drip. You are acutely aware that she is very fortunate to recover from severe sepsis. 6