Question

Case Study, Chapter 14, Shock and Multiple Organ Dysfunction Syndrome

1. Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)

What predisposed the patient to develop septic shock?

What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?

The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?

Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?

Explain the importance for nutritional support for this patient and which type of nutritional support should be provided?

Answer 1

1.Septic sub-shock is a subset of Severe Sepsis Syndrome in which the organ dysfunction is cardiovascular ,ie sepsis induced hypotension that persists despite adequate and aggressive volume resuscitation.Septic shock usually begins with the invasion and growth of micro organisms in a normally sterile tissue space.The endothelium is damaged due to infection or other insult and this triggers the activation of host immune responses.Sepsis syndrome develops when the balance between the pro-inflammatory and anti inflammatory substances are lost.Here the main predisposing factor is urosepsis.Infection at the cathetersite became the portal of entry for the microrganism to enter the body of the patient further signalling the signs of infection.

2.Septic shock is a subset of severe sepsis syndrome in which the organ dysfunction is cardiovascular,ie sepsis induced hypotension that persists despite adequate and aggressive volume resuscitation.Patients will require vasopressors to keep MAP greater than or equal to 65mm Hg and the C-reactive protein is also elevated .If hypotension still prevails it indicates that the patients condition is life threatening.

3 Before administration of norepinephrine check the medical history of the client .Also assesst he vital signs of the client and tissue integrity.Check the urine output frequently.Check the patency of the intravenous catheter before administering the medications.

4 One of the main goalsof the haemodynamic therapy in shock is to restore tissue perfusion.It is found that norepinephrine can increase blood pressue in patients with septic shock without causing deterioration of the cardiac index organ function.The goal of the vasopressor agent is to improve the arterial pressure.Vasopressin levels in shock are lower that of the shock state.vasopressin concentrations are elevated in septic shock,but with continued shock,concentration decreases to normal range in the majority of patients between 24 and 48 hours which is called vasopressin deficiency.

5.The initial action of the nurse will be based on ABC of resuscitation ie Airway,Breathing and Circulation.Assess the airwayand check whether ventillation is necessary.The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

6.Patient under shock should be given adequate nutritional supplementation by the parentaral route or enteral will eventually decrease the incidence of septic complications and enhance rapid wound healing and speedy recovery..Enteric nutrition is the preferred choice as it mintains gut structure and function ,reducing the inflammatory response to sepsis and thereby improving clinical outcomes.