Sepsis/Septic Shock

Sepsis/Septic Shock RAPID Reasoning Case Study STUDENT Jack Holmes, 72 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Inflammation • Infection • Tissue Integrity • Clinical Judgment • Patient Education • Communication NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23%  Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity Basic Care and Comfort 6-12%  Pharmacological and Parenteral Therapies 12-18%  Reduction of Risk Potential 9-15%  Physiological Adaptation 11-17%  Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. History of Present Problem: Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to wake him this morning, he would not respond, and his BP was 74/40 with a MAP of 51. He has a history of Parkinson’s disease, COPD, CHF, HTN, depression, and a stage IV decubitus ulcer on his coccyx that developed three months ago. He does not follow commands, is unresponsive to verbal stimuli, but responds to a sternal rub with grimacing and withdrawing from stimulus. Personal/Social History: He has lived in the skilled nursing facility the past three years and has been bed bound the past year due to his advanced Parkinson’s disease. He was a heavy smoker, 1 PPD for 40 years until he moved to the SNF. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Low BP with MAP of 51 Stage 4 Ulcer on his coccyx that developed 3 months ago COPD, CHF, HTN, Parkinson’s disease and old age Unresponsiveness to verbal stimuli Hypoperfusion of the tissue which can hinder oxygenation Ulcer not healing due to inadequate tissue perfusion Altered immune response due to these comorbidities and lowered functioning immune system given the patient’s age. Altered LOC RELEVANT Data from Social History: Clinical Significance: Skilled Nursing Facility More exposure to pathogens or iatrogenic illness at the facility Bed bound due to his Parkinson’s Poor skin integrity, atrophy of muscle, renal calculi, DVT, isolation Depression Isolation, no interest or motivation in performing ADL’s, unable to self-advocate, withdrawing from peers Patient Care Begins Current VS: P-Q-R-S-T Pain Assessment: T: 103.4 F/39.7 C (oral) Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators of pain P: 135 (irregular) Quality: R: 32 (regular) Region/Radiation: BP: 76/39 MAP: 51 Severity: O2 sat: 91% 2 liters n/c Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Temperature is high There is an active infection in the body, this can also cause higher metabolism which can lead to fatigue Respiration is high BP is low Compensating for low BP in order to adequately oxygenate the tissues O2 Sat is low (91%) This is an indication of septic shock Could be normal for a patient with COPD who is a heavy former smoker with a history of 1 PPD for 40 years. Determine current Glasgow coma scale score based on neurological assessment data: Current Assessment: GENERAL APPEARANCE: Pale and warm to touch. Appears tense. RESP: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light crackles in lower lobes bilat. Nail beds have noticeable clubbing, barrel chest present. CARDIAC: Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds NEURO: Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. PERRL GI: Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants GU: Foley catheter placed to monitor urine output. 50 mL tea-colored urine with no sediment, and no odor present SKIN: Stage IV decubitus to coccyx 1 cm x 0.5 cm x 0.5 cm depth, wound bed with visual bone noted at the base with large areas of necrosis on both sides of the sacrum bone. When dressing was removed, a large amount of yellow/green purulent drainage on dressing with a foul odor. Mucus membranes dry and pale. Glasgow Coma Scale Eye Opening Spontaneous 4 To sound 3 To pain 2 Never 1 Motor Response Obeys commands 6 Localizes pain 5 Normal flexion (withdrawal) 4 Abnormal flexion 3 Extension 2 None 1 Verbal Response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Total 7 What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light Low blood pressure and low level of oxygen can lead to tachypnea in order to compensate for poor oxygenation. It could indicate that the lungs aren’t functioning properly due to presence of fluids in the lungs as a result of CHF. crackles in lower lobes bilat. Nail beds have noticeable clubbing, barrel chest present. Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants 50 mL tea-colored urine with no sediment, and no odor present Stage IV decubitus to coccyx 1 cm x 0.5 cm x 0.5 cm depth, wound bed with visual bone noted at the base with large areas of necrosis on both sides of the sacrum bone. When dressing was removed, a large amount of yellow/green purulent drainage on dressing with a foul odor. Mucus membranes dry and pale Chronic hypo-oxygenation of the tissues can lead to clubbing, COPD can lead to barrel chest. Pitting edema due to his CHF, sluggish cap refill due to low BP Altered level of consciousness because the brain is not being adequately perfused due to shock Distended abdomen indicates patient has ascites; firm bowel, hypo-active sounds indicate peritonitis. This reinforces patient’s diagnosis of septic shock. This indicates patient’s liver and kidneys and not working properly. Tea colored urine is also a sign of pyelonephritis and failing liver. This could be a sign that the patient is starting to develop multi organ dysfunction syndrome. Ulcer is not healing or progressively getting worse due to lack of oxygen to the tissues. Purulent drainage indicates active infection. Pt is dehydrated. Cardiac Telemetry Strip: Regular/Irregular: P wave present? PR: QRS: Interpretation: This is an a-fib because the rate is irregular, there is no p wave and the QRS is narrow. Clinical Significance: This can lead to clot formation which can cause stroke or PE. A-fib also leads to low cardiac output and low BP. Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Radiology: Chest X-Ray Results: Clinical Significance: Cardiac silhouette slightly enlarged. No infiltrates present. This is an indication of CHF, which can lead to low CO and low BP. Enlarged heart also requires extra myocardial oxygenation. Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 18.5 13.1 250 85.2 3 Most Recent: 12.4 13.2 175 64 0 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC Active infection Bleeding or anemia Thrombocytosis due to anemia or iron deficiency in his diet Active infection Active infection Worsening Hgb Worsening Platelet Worsening Neutrophils Bands Worsening Worsening Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 147 5.2 172 1.6 Most Recent: 138 4.4 98 0.88 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Sodium Hypernatremia can cause changes in LOC, seizures, cerebral edema Worsening Potassium: Hyperkalemia can lead to arrhythmia, respiratory distress, urine abnormalities all of the symptoms which are being presented by the client Worsening Glucose Elevated glucose could be due to increased level of stress in the body. Worsening Creatinine Elevated creatinine level indicates renal hypoperfusion and dehydration Worsening Misc. Lactate PT/INR GFR Current: 7.4 1.6 45 Most Recent: n/a 0.9 >60 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Lactate PT/INR GFR Elevated lactic acid level indicates poor oxygenation of the tissues. Elevated PT/INR indicates poor liver function as it is not producing clotting factors, this can lead to increased risk of bleeding Reduced GFR indicates hypoperfusion of the kidneys and poor kidney function, which is concerning because blood is not being filtered which will lead to waste build up in the blood Worsening Worsening Worsening Liver Panel Albumin Total Bili Alk. Phos. ALT AST Current: 2.9 5.1 285 134 175 Most Recent: 3.1 0.9 48 17 12 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Albumin Hypoalbumin can be due to malnutrition. Due to lack of proper nutrients, the patient's wound is not healing. Worsening Urinalysis + UA Micro Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial Current: Tea thCelealrive r 1d.0a5m0 a geNEoGr d iseNaEsGe. WNhEiGch cou<l5d <5 NEG None Most Recent: Yellow mCeleaarn tha1.t02t5he livNeErGis noNtEGcle arNinEgG b iliru<b5in <5 NEG None Alk Phos ALT AST properly. An elevated ALk Phos means that the liver is not functioning properly. An increase in ALT can be due to damage or inflamed liver An elevated level could indicate damage to liver and other organs Worsening Worsening Worsening What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Tea colored urine and sp gravity 1.050, This indicates dehydration, acute kidney injury, or liver injury, which is causing it to produce high level of bilirubin. Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Lactate Value: 7.4 0.5-1 Critical Value: As hypoxemia progresses, cellular metabolism becomes anaerobic, which increases lactic acid levels. Excess lactic acid limits ATP production and cell function cannot be maintained. This impairment results in sodium accumulation and loss of potassium. Cellular edema occurs and further decreases cardiac output, while increasing capillary permeability. As a result, electrolytes and fluid enters cells causing damage and eventually cell death. Elevated levels of lactate are associated with sepsis and severe inflammatory response syndrome. 1. Impaired tissue oxygenation- Increase perfusion to organs a. Intubation and ventilatory support to increase oxygenation and remove carbon dioxide. This also reduces the work of breathing, which helps prevent exacerbation of lactic acid production → lactate. b. Norepinephrine is a vasopressor that constrict blood vessel to keep MAP elevated. MAP >65 promotes kidney perfusion. c. Prone and lateral positioning will help increase oxygen delivery. 2. Deficient Fluid Volume- Increase fluid and electrolyte accumulation within the body to prevent cellular edema and cell death and promote oxygenation. a. Administer fluid bolus (0.9% NS) to help increase blood pressure, which results in improved perfusion. b. Administer Vasopressin, which can lead to the prevention of fluid loss leading to an increase fluid in vessel and MAP. Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: The patient is in Septic shock. According to the lab values, it looks like the patient is starting to develop multi organ dysfunctio n syndrome. Pathophysiology of Problem in OWN Words: Septic shock results from severe infection within the blood due to endotoxins causing vasodilation and a drastic fall in blood pressure. Perfusion of tissues decreases and vital organs cease to receive adequate oxygenation and functioning is altered. Septic shock is a medical emergency. The patient’s particular cause of sepsis could be related to the infected and necrosed wound from the ulcer in the coccyx. Additionally, the patient has several comorbidities, such as; CHF, COPD, HTN and Parkinson’s that place him at an increased risk for developing infections and being immunocompromised. Primary Concept: Since the patient has multiple signs that define SIRS, it is realistic to say that he has it. For example, the patient’s fever is above 38C (39.7C), he is tachycardic (135 bpm), and tachypneic (32 bpm). At least three signs out of the four are present and fit the criteria for SIRS. Following the Sequential (sepsis-related) Organ Failure Assessment, The patient’s condition is indicating MODS due to MAP of less than 65, renal dysfunction as evidenced by elevated BUN and creatinine and UOP results. Additionally, bilirubin is elevated at 5.1, indicating hepatic impairment. The patient’s GCS score of 7 signifies CNS alteration and a comatose state. As mentioned previously, the patient is in respiratory distress as well as cardiovascular impairment as shown by an irregular and dangerous heart rhythm known as Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Two large bore (18 g) IVs Fluid bolus 0.9% NS 30 mL/kg (2250 mL) Blood cultures x2 Rationale: This allows the patient to receive medication and fluid rapidly. This is administered to improve fluid level of septic patients which will raise their blood pressure. Raising blood pressure will help perfuse the tissues. This test is carried out to determine if there is a bacterial infection within the blood. Performing 2 culture ensures the Expected Outcome: Pt will start to stabilize, and the lines will remain patent and clear. BP will rise and help stabilize perfusion. figure out what kind of infection we are dealing with so we can presence of infection in the fy the antibiotic treatment. Urine culture This test is done to determine the pathogen that is causing the infection and the right antibiotic to treat the infection This test is carried out to determine the The right antibiotic will treat the infection. Would figure out why the sepsis cause of sepsis and the type of antibioticoccurred and Wound culture Vancomycin 2 g IV after cultures collected Clindamycin 600 mg IV every 6 hours If MAP remains <65 after 2250 mL of 0.9% NS…start Norepinephrine 1-12 to use This is a broad-spectrum antibiotic that is used to treat infection until the main cause of the infection is determined This is an antibiotic that is used to treat patient with infection An elevated MAP <65 initiate kidney perfusion. Norepinephrine is a vasopressor that constrict blood vessel to keep MAP elevated. how to prevent In the future. This will help initiate the process of killing off the bacteria, but it isn’t strong enough so a more specific will need to be used. This will also start to slow the process of the bacteria with the infection. The MAP will be >65 after the NS. The norepi will also raise it and keep it PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • 2 large bore (18 g) IVs • Vancomycin 2 gram IV after cultures collected • Clindamycin 600mg IV every 6 hours • Fluid bolus 0.9% NS 30 mL/kg (2250 mL) • Blood cultures, urine culture, wound culture • Cardiac telemetry • 2 large bore (18 g) IVs This needs to start first so that if anything goes wrong with the heart while I am doing another priority the monitor will alert me and I can refocus on the heart issue. The IV’s need to be placed so I can start all of the fluid and medication management. • Cardiac telemetry • VS every 5-15” • Acetaminophen 1000 mg PR every 6 hours PRN for temp >101 • Blood cultures, urine culture, wound culture Need to collect these before the antibiotics can be ran, so this would happen as soon as the IVs are placed. • Fluid bolus 0.9% NS 30 mL/kg (2250 mL) Fluids need to be run so we can get the BP and MAP to raise up and the pt can become more hydrated. The meds will work better if they are in a hydrated circulatory system. • Vancomycin 2 gram IV after cultures collected This is to start right after the cultures are taken. The other antibiotic will be run at the same time in another IV. • Clindamycin 600mg IV every 6 hours This will run concurrent with the Vanco. • VS every 5-15” These need to start asap once the IVs and meds are given so that we can monitor the vitals for the signs of sepsis trending better or worse. • Acetaminophen 1000 mg PR every 6 hours PRN for temp >101 This can be given last as the antibiotics starting will work on the infection and the fever can be reduced, but its not emergent to be given as the temp of 101 isn’t dangerous, just needs to be watched and the med will kick in shortly after given. Collaborative Care: Nursing 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: Impaired Gas Exchange Pt is not getting adequate oxygenation from the comorbidities and the sepsis isn’t helping either. PT has COPD. Need to work on getting oxygen levels over 93% continually for when the pt discharges. 02 level will be up to at least 93% at discharge and pt can teach back steps needed to maintain this at home. Ineffective tissue perfusion Since the oxygen has been depleted long term, the pt is hypoxic and will remain that way until we can increase the oxygen in the blood. Once that is successful, we also need to keep the BP maintained and the fluid off the heart so the cardiac output is working to its best ability. The oxygen will remain above 93% and the HTN will be decreased so that the BP is more within normal range and not adding stress to the cardiac output. This will help profuse the tissues. Deficient fluid volume Work on pushing fluids with the pt once they are off IV fluids and teach the importance of maintaining hydration for tissue health and for maintaining their BP. Pt will be compliant with med management at home and with maintaining hydration by drinking adequate amounts of decaffeinated fluids daily to stay hydrated. Imbalanced nutrition less than body requirements Work on educating the pt about proper nutrition and dietary needs for a pt his age/weight/height. Pt will teach back what was learned from the dietary education taught during the hospitalization. 3. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: Respiratory system Cardiovascular Body tissues Need to maintain at least a 93% saturation to adequately profuse the tissues so we don’t start having necrosis kick in. Want to watch the heart with the sepsis circulating around the blood and the increased stress on the cardiac output with the HTN. Also want to work on reducing the BP to more normal levels via medication and hydration. Check for any signs of poor perfusion and decreased tissue integrity to prevent any start or necrosis. 4. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Pt sepsis would get worse and he could die. Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: Monitor blood levels Watch trends for blood levels out of range. Titrate oxygen to a target of at least 93% or higher. Blood cultures x 2 Administer empiric IV antibiotics within 1 hr of diagnosis. Measure lactate levels. Start IV fluid resuscitation. accurate urine output measurement / weights. Medication management Interprofessional collaboration Start antibiotics within 1 hr of diagnosis of sepsis to try to prevent death. Supportive care: IV, oxygen therapy, ventilation, etc. Work together with other healthcare professionals as a team and bounce ideas off each other. Use any assistive devices needed to get the pt the care the need in the time they need it to prevent worsening of the condition. 5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Explain procedures and routines for treatment to alleviate stress PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse This will help the pt feel more comfortable in an unfamiliar and stressful situation. Pt will become a little more relaxed and compliant Physical comfort measures Pt can feel as comfortable as possible and that can also lessen the stress of the situation. Pt can relax as much as possible while getting comfortable in this situation. EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: • Rapport • Trust • Respect • Genuineness • Empathy A therapeutic relationship helps the pt trust the nurse taking care of them. When you have a pt in a critical condition that they are alert enough to be concerned with their well being it can be very scary and stressful if the nurse doesn’t make the effort for you to build rapport with them and make you feel like you can trust your life with them. Incredibly important for the pt to feel like they have faith you will help save their life. The pt will survive and will always remember the caring considerate nurse that took a minute or two out of the critical moments to make a bond with them. CULTURAL Considerations Remember to consider cultural Pt will recognize (IF APPLICABLE) differences so that you don’t appear to the nurse has be disrespectful. This will not help the learned about therapeutic relationship. their culture enough to get through the situation with understanding and compassion directed towards their pt centered beliefs and values. Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: Teach back needs to be a priority for this pt to avoid a lot of the critical situations they are here for today. PRIORITY Topics to Teach: Rationale: Hydration techniques Medication management Oxygen Therapy The pt needs to be independent enough to stay hydrated throughout the day by asking for drinks, helping themselves to the fridge, making sure they drink a full glass of water with each medication dose and at all meals, not to drink excessive amounts of caffeine. Pt will need to stay compliant with taking meds to maintain his BP and his COPD and his cardiac stressors. These all need to work in sync together and if one goes bad the others shortly follow suit. Pt needs to understand the importance of maintaining his oxygen saturation at least 93% at all times for adequate perfusion to the tissues to prevent necrosis. Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: Pt is going through a lot of mixed emotions- fear, stress, unknown, will they live or die?, who will take care of the house, kids, etc. Nurse can engage by taking a few minutes each time they come in the room and sit bedside and just ask the pt to hold their hand and let them talk if they feel like it. If they don’t, the nurse can explain the steps she is going to take at that moment and why we are doing it to save their life. It helps to build rapport, educate the pt on the procedures happening, and it allows the pt to build trust in the person taking care of them . Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events unfold to make a correct clinical judgment. What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future? What Did You Learn? How to Use to Improve Future Patient Care: I learned that even in emergent situations pts are not always not alert. Sometimes they are and it can add stress to a situation and the nurse needs to work on building a therapeutic relationship to make the pt feel more comfortable in a scary unknown scenario. I will need to work on building skills on creating therapeutic relationships with my patients in every interaction because you never know when one can turn emergent quickly.