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Discuss about the Assessment of Clinical Criteria for Sepsis.

Clinical Deterioration Associated with Septic Shock

Septic shock is a life-threatening medical condition that presents with persistent hypotension following inflammatory responses to infections. It is very common among the aging population. Disproportionately, it affects people with immunosuppression or cancer. The paper will focus on case study 2 of Jedda Merinda, a 32-year-old male who was admitted to the hematology and oncology unit following a recent diagnosis of Acute Myeloid Leukemia. Jedda has a past medical history of depression, Acute Rheumatoid Fever, suicidal attempt and hypercholesterolemia.

On assessment, it was discovered that Jedda was hypotensive (BP-92/65mmHg), tachycardic (Pulse rate 118beats/minute), and a low urine output (less than 0.5mL/kg/hr). He is tachypneic (28 breaths/min) evidenced by use of accessory muscles during breathing. The essay will identify and discuss two signs/symptoms of clinical deterioration associated with the presenting condition of the patient, develop a clinical plan of care with one priority of clinical care. Eventually, the paper will identify and discuss three nursing interventions directly addressing the identified clinical priority of patient care.  Discussing this case study would be help in exploration of the clinical priorities of patient care and appropriate nursing interventions required.

Septic shock is a multi-organ disorder which is caused by chronic illnesses such as hypotension, hypertension, cancers such as Acute Myeloid Leukemia, and hypercholesterolemia. The illnesses suppress the immune system of the patient leading to its reduced ability to fight invading pathogens and infection. Hypercholesterolemia is associated with great risk of hypertension which is risk factor for the development of septic shock in a patient. In connection with the case study, the patient has Acute Myeloid Leukemia and a past medical history of hypercholesterolemia which leads to immunosuppression hence increasing the risk for the development of septic shock (Angus & Van der Poll, 2013).

Septic shock involves reduction in organ and tissue perfusion and acute multi-organ failure. The organs involved include kidneys, heart, liver, lungs, and brain. An inflammatory stimulus such as bacterial and viral toxins stimulate production and release of proinflammatory mediators and cytokines which lead to neutrophil-endothelia adhesion of cells hence activating the clotting mechanism and generating microthrombi (Daviaud et al., 2015)  Other mediators such as serotonin, lipoxygenase, leukotrienes, bradykinin, histamine, and interleukin-2 are also fought back by the anti-inflammatory factors such as interleukin-4 and interleukin-10 leading to initiation of a negative feedback mechanism(Angus, & Van der Poll, 2013).

The dilatation of arteries and arterioles decreases the arterial peripheral resistance hence leading to decreased cardiac output. Later, this stage is followed by a decrease in cardiac output, fall in blood pressure, and appearance of now the typical features of shock. The vasoactive mediators are attributed to the flow of blood to bypass the vessels of capillary exchange (Dellinger et al., 2013).

Clinical Plan of Care

Poor blood flow in capillaries due to the shunting and obstruction of the capillaries by microthrombi causes a decrease in oxygen delivery and impairment of waste products and carbon (IV) oxide removal from the body. Reduced tissue perfusion causes dysfunction and failure of body organs like lungs, heart, lungs, liver and brain.  Signs of septic shock include hypotension, tachycardia, confusion, fever, confusion and oliguria as presented in the case study (De Backer, Orbegozo Cortes, Donadello, & Vincent, 2014).  

According to the case study, the patient had been recently diagnosed with Acute Myeloid Leukemia (AML) and he is on chemotherapy. Chemotherapy impacts on the body’s immune system by weakening hence leading to immunosuppression. Damage of bone marrow due to chemotherapy causes low production of White Blood Cells (patient’s WBC count is 3.4 against a normal range of 4-11(*10 *9/l) resulting to failure of the immune system to fight pathogens hence leading to sepsis/septic shock. Immunosuppression has a great risk for the development of septic (Angus & Van der Poll, 2013)

Tachycardia is defined by a heart rate above 100 beats/minute. According to the case study, the patient’s pulse rate is 118 beats/minute, which is more than the normal range. In septic shock, tachycardia usually occurs as a compensatory mechanism secondary to systemic vasodilation to ensure maintenance of cardiac output and effective tissue perfusion (King, Bauza, Mella, & Remick, 2014).

Hypotension is a medical condition that is characterized by a constant and consisted blood pressure of less than 95/70 mmHg. In accordance with the case study, the patient is hypotensive since the assessment findings reveal that he has a blood pressure of 92/65mmHg. Low blood pressure is usually attributed to reduced tissue perfusion which consequently results in tissue hypoxia. Large number of cytokines produced during the inflammatory responses cause massive vasodilation and increased permeability of blood capillaries resulting in hypotension (O'Donnell & Waskett, 2016)


Tissue perfusion is defined as the flow of arterial blood through body organs and tissues such as heart, lungs, kidney, bones, and liver. Being knowledgeable on tissue perfusion is essential in nursing because it helps in prioritization of the needs of patient care to prevent morbidity and mortality (Singer et al., 2016). During perfusion, hemoglobin is always off-loaded from Red Blood Cells in arterial blood as it goes through the body tissues and organs.  Adequate tissue perfusion is important to meet metabolic needs through adequate pumping of oxygenated blood to body tissues. Adequate hemoglobin molecules are important to ensure adequate supply of oxygen to body tissues through the arterial blood (O'Donnell & Waskett, 2016) 

Nursing Interventions for Clinical Priority of Patient Care

According to the case study, the patient has been put on chemotherapy following a diagnosis of AML diagnosis. Chemotherapy is commonly associated with the destruction of bone marrow reducing its reduced ability to produce Red Blood Cells. According to the case study, the patient has a low Hemoglobin (Hb) of 89 in compassion to a reference range of 130-180 g/L. Hemoglobin plays a key role in oxygen transportation to various body organs and tissues. Low levels of Hb in blood leads to low supply of oxygen to the distal organs and other body organs and tissues due to reduced oxygen capacity of the Hb molecules to transport oxygen (Singer et al., 2016).

 Dilation of arteries and decreased arterial peripheral resistance due to the inflammatory mechanism causes hypotension which the results to decreased perfusion of tissues. Arterial obstruction by the microthrombi formed during capillary shunting and action of vasoactive mediators result to decreased blood flow of blood to body tissues including the distal organs hence leading to decreased tissue perfusion. From the case study, some of the indicators of decreased tissue perfusion are cold peripheries, tachycardia (pulse rate-118 beats/minute), tachypnea (28 breaths/minute), and use of accessory muscles when breathing indicating inadequate supply of oxygen (Turi & Von Ah, 2013).

 Fluid administration therapy is a collaborative approach in management of decreased tissue perfusion in septic shock. Based on the assessment findings of the patient in the case study, unacceptable respiratory parameters (28 breaths/min), use of accessory muscles and oliguria are key indicators that the patient requires fluid therapy. In this approach, the nurse should collaborate with the physician whose responsibility should be ordering Intravenous Fluid therapy including type of solution, rate of infusion, date, duration and time based on fluid requirements of the patient (Goldstein et al., 2014).

The nurse should also collaborate with a nutritionist/dietitian whose responsibility would be to enlighten the patient on importance of adequate intake of fluids and dietary requirements for overall well-being. In this instance, the nurse plays an important role in assessing, monitoring and evaluating fluid therapy given to the patient. In case of abnormal findings in the course of the therapy, the nurse should report to the physician immediately for implementation of appropriate measures. The recommended fluids for this patient are crystalloid fluids such as Normal Saline (0.9%) or colloids. The nurse, physician and nutritionist collaborate through sharing ideas and suggestions required for patient care. Collaborative approach of nursing management ensures holistic patient care hence promoting positive patient outcome (Martin, 2012).

Risk Factors for the Development of Septic Shock

This approach is totally nurse-initiated. The nurse can initiate patient breathing exercises to increase oxygen supply to the body tissues. The nurse should implement this by instructing the patient to inhale deeply and exhale slowly while standing upright and bending forward at his waist. The knees of the patient should be bending and limply hanging his hands to the floor. Diaphragmatic breathing can also be implemented to increase lung capacity hence increasing oxygen concentration and supply. The nurse should position the patient in a semi-Fowler’s or higher to promote improvement in gas exchange in the alveolar (Rudiger & Singer, 2013).

For management effective management of decreased tissue perfusion, vasopressors like vasopressin are recommendable. Vasopressin is an endogenous hormone essential in cardiovascular and osmotic homeostasis. Vasopressin is produced in the hypothalamus following conditions like hyperosmolarity, hypovolemia, and hypotension (Howell & Davis, 2017).

Vasopressin medication acts by inducing vasoconstriction in smooth muscle cells by acting on vascular (V-1) and renal (V-2) receptors. It also induces vasoconstriction in non-vital circulations by activating the V-1 receptors leading to high levels of second messengers; diacylglycerol and inositol phosphate. The messengers activate then the voltage-gated calcium channels which increases the levels of intracellular calcium resulting to vasoconstriction which leads to narrowing of arteries hence raising the blood pressure (Rhodes et al., 2017).


Increased blood pressure increases tissue perfusion. The nurse should ensure intravenous administration at low doses of approximately (0.01-0.04 units/minute) of vasopressin to improve the Mean Arterial Pressure (MAP). The nurse is responsible for monitoring the side effects of vasopressin on the patient. Some of the side effects include hypersensitivity, slow pulsations, difficulties in breathing, headache, skin rash, sweating, and numbness of toes or fingers (Rudiger & Singer, 2013).

On assessment, the patient should have effective tissue perfusion evidenced by a blood pressure within a normal range of 120/80mmHg-140/90mmHg, breathing rate of 12-20 breaths/minute, warm peripheries and extremities, a pulse rate less than 100 beats/minute and little or no use of accessory muscles when breathing. This would be an indication of the efficacy and effectiveness of the implemented nursing interventions (Seymour et al., 2016).

Conclusion

The essay has adequately addressed a patient who presented with septic shock. He is on chemotherapy following a diagnosis of Acute Myeloid Leukemia and a past medical history of acute rheumatic fever, depression, suicidal attempt, and hypercholesterolemia. The primary interventions implement in patient care and support include; fluid therapy, oxygen therapy and pharmacological intervention.

References

Angus, D. C., & Van der Poll, T. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 369(9), 840-851.

Daviaud, F., Grimaldi, D., Dechartres, A., Charpentier, J., Geri, G., Marin, N., ... & Pène, F. (2015). Timing and causes of death in septic shock. Annals of intensive care, 5(1), 16.

De Backer, D., Orbegozo Cortes, D., Donadello, K., & Vincent, J. L. (2014). Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence, 5(1), 73-79.

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., ... & Osborn, T. M. (2013). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.

Goldstein, S., Bagshaw, S., Cecconi, M., Okusa, M., Wang, H., Kellum, J., ... & Shaw, A. D. (2014). Pharmacological management of fluid overload. British journal of anaesthesia, 113(5), 756-763.

Howell, M. D., & Davis, A. M. (2017). Management of sepsis and septic shock. Jama, 317(8), 847-848.

King, E. G., Bauza, G. J., Mella, J. R., & Remick, D. G. (2014). Pathophysiologic mechanisms in septic shock. Laboratory investigation, 94(1), 4.

Martin, G. S. (2012). Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes. Expert review of anti-infective therapy, 10(6), 701-706.

O'Donnell, P., & Waskett, C. (2016). Understanding Sepsis. Nursing the Acutely Ill Adult, 71.

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., ... & Rochwerg, B. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377.

Rudiger, A., & Singer, M. (2013). The heart in sepsis: from basic mechanisms to clinical management. Current vascular pharmacology, 11(2), 187-195.

Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., ... & Deutschman, C. S. (2016). Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama, 315(8), 762-774.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... & Hotchkiss, R. S. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). Jama, 315(8), 801-810.

Turi, S. K., & Von Ah, D. (2013). Implementation of early goal-directed therapy for septic patients in the emergency department: a review of the literature. Journal of Emergency Nursing, 39(1), 13-19.

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