CASE STUDY: SEPSIS Scenario: A 73-year-old male

CASE STUDY: SEPSIS Scenario: A 73-year-old male was taken to the Emergency Department by ambulance because his wife found him sitting up in his recliner, awake but not responsive. He takes sitagliptin daily for type 2 diabetes mellitus and a daily multivitamin. A rapid assessment reveals the following: opens eyes when his name is called; otherwise keeps them closed. Does not follow instructions. Skin warm and flushed. Heart rhythm regular, rate 114; ECG shows sinus tachycardia. BP 96/52; respirations 24. Temperature 101.5°F (38.6°C). SPO2 96% on room air; lungs clear to auscultation bilaterally. Abdomen soft, nondistended, with normoactive bowel sounds in all quadrants. Trace edema noted on ankles and shins bilaterally. The patient has a large bandage on his right arm; his wife explained that he cut himself badly when gardening a few days ago and they wrapped it with a bandage to stop the bleeding. The wound on the right forearm is 3.2 cm long, 0.5 cm wide, and 0.2 cm deep, with redness around the wound and a moderate amount of yellowish drainage on the bandage. Laboratory results are listed below. The stroke team evaluated the patient using the NIH Stroke Scale; the evaluation was negative for a stroke. A STAT CT scan came back normal. Laboratory Results: Na: 144 mEq/L K: 4.9 mEq/L Glu: 134 mg/dL HIGH BUN: 22 mg/Dl Creatinine: 1.4 mg/dL HIGH Lactic acid: 2.9 mg/dl HIGH Procalcitonin: 0.6 ng.ml HIGH WBC: 19.2 1000/mm3 Hgb: 16 g/dL Hct: 44% Platelet count 249,000 mm3 1. 1) The nurse recognizes that based on the patient’s history and diagnosis, he is currently at risk for complications, especially __________, __________, and __________. Options: Septic shock Fluid overload Respiratory failure Hypertensive crisis Coronary vessel occlusion Acute kidney injury Scenario: Within the hour, the patient is transferred to a step-down unit and the admitting nurse is reviewing orders for cultures and antibiotics, which include piperacillin-tazobactam and vancomycin. The patient is receiving intravenous normal saline at 150 mL/hour after receiving two 500 mL fluid boluses of normal saline in the emergency department. He is more awake but still confused and does not know where he is. He states that his right arm “hurts really bad” but he is unable to rate the pain on a 1 to 10 scale. Vital signs are: Temperature 101°F (38.3°C), pulse 100, respirations 22, BP 104/98. He is on oxygen 2 L/min per nasal cannula, and the latest SpO2 reading is 97%. He voided 500 mL of dark amber urine into a urinal. A wound care specialist will be coming in to assess the arm wound; the arm wound is loosely covered with a gauze dressing and is draining a small amount of yellowish fluid. 2: 2) Based on the patient’s condition, the patient’s priority needs will be to prevent _____1_____ and _____1_____. In addition, he will need interventions to prevent _____2_____, _____2_____, _____2_____, and _____2_____. Options for 1: Options for 2: Musculoskeletal weakness Diarrhea Pain Stress ulcers Injury from falling Skin breakdown Hypoxia Fluid volume deficit Venous thromboembolism (VTE) Scenario: The wound care specialist assessed the patient’s arm wound and ordered wound cultures and indicates that the wound will heal by secondary intention. An alginate dressing is applied, with orders to change it twice daily. After 3 days, the patient is less confused but unsteady on his feet when assisted to the chair. He states that he does not like hospital food. 3: 3) Use an X to indicate which actions in the left column would be implemented by the nurse. Note that not all nursing actions will be used. Nursing Actions Implementation Maintain fall precautions. Assess and document the wound characteristics with every dressing change. Obtain a wound culture of the exudate from the wound. Clean the wound with povidone-iodine before applying a new dressing. Replace the dressing if it becomes saturated with drainage. Observe the wound for signs of delayed wound healing. Request a nutritional consult for parenteral nutrition. 4: 4) For each assessment finding, use an X to indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes). Assessment Finding Effective Ineffective Unrelated States that his pain level is a 4 1 hour after pain medication; previously stated it was an 8. Systolic blood pressure remains greater than or equal to 90 mm Hg. Gets out of bed by himself to walk in the room. Denies difficulty with urination. No drainage noted from the wound. Wound measures 3 cm long by 0.4 cm wide by 0.1 cm deep. Redness decreased. Patient eats 25% of his meals and 50% of the supplement provided. Cognitive Skill: Evaluate Outcomes Reference: Harding et al., Medical-Surgical Nursing, 11th ed., 2020, Ch. 5, p. 71; Ch. 8, p. 110; Ch. 11, pp. 164, 167. REFERENCES: Reference 1. https://youtu.be/70fxLxxOZmM Referednce 2. Harding et al., Medical-Surgical Nursing, 11th ed., 2020, Ch. 66 Please review: Lewis 11th Ed. Table 66.4 Diagnosis Criteria for Sepsis Infection: Sepsis/Septic Shock (Lewis 11th Ed.) “Nurse must be aware of the progression and “Carefully monitor all patients for the development of infection. Progression from an infection to sepsis and septic shock depends on the patient’s defense mechanisms.” (Lewis 11th Ed.) “Sepsis is a life-threatening syndrome in response to an infection. Sepsis is defined as a constellation of symptoms or syndrome in response to an infection. It is characterized by a dysregulated patient response along with new organ dysfunction related to the infection9 Links to an external site. (Table 66-4 Links to an external site.).” (Lewis 11th Ed.) “Septic shock is a subset of sepsis with an increased mortality risk due to profound circulatory, cellular, and metabolic abnormalities. Septic shock is characterized by persistent hypotension despite adequate fluid resuscitation requiring vasopressors, along with inadequate tissue perfusion resulting in tissue hypoxia.9 Links to an external site. The main organisms that cause sepsis are gram-negative and gram-positive bacteria. Parasites, fungi, and viruses can also cause sepsis and septic shock.9 Links to an external site. Fig. 66-5 Links to an external site. presents the pathophysiology of septic shock.” “Septic shock has 3 major pathophysiologic effects: vasodilation, maldistribution of blood flow, and myocardial depression.” Patients may be euvolemic, but because of acute vasodilation, relative hypovolemia & hypotension occur. In addition, blood flow in microcirculation is decreased, causing poor O2 delivery & tissue hypoxia.” For more on septic shock please see Lewis 11th, Ed. pages 1569-1571

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