Nursing Interventions To Manage Septic Shock In A Deteriorating Patient: An Essay.

The assessment tasks requires you to:

1. Identify and discuss two (2) signs or symptoms of clinical deterioration associated with the presenting problem, from chosen case study. This discussion should consider the potential impact of case study data (e.g. pathology results, past medical history) on the health status of the patient in the chosen case.

2. Following on from your presented discussion associated with point one (1), develop a clinical plan of care which identifies:
One (1) priority of clinical care and; Discuss three (3) nursing interventions that directly address the identified clinical priority. The discussion should refer to relevant  clinical assessments. Measurable outcome parameters for each intervention will be discussed to justify the intervention and evaluate its efficacy. Discussion is to be supported with contemporary research.

Symptoms of Deterioration in a Patient with Septic Shock

The purpose of the assignment is to analyze a case study of a deteriorating patient. In this regards the case of a patient with septic shock has been chosen for the assignment. Septic shock is occurred due to the result of any infection within a person. It causes significant changes in the body and leads to the consequence of life-threatening situation and even death as well (Angus et al., 2015). There are three stages of sepsis or septic shock such as bloodstream infection and inflammation, severe sepsis that affects the function of brain, lungs, kidney and heart and septic shock due to significantly low blood pressure that leads to the consequence of heart and respiratory failure and even death (Asfar et al., 2014). This infection arise when chemicals released by the immune system to fight infection leak into the blood stream (Garay-Fernández, 2017) .The symptoms include low blood pressure, increased breathing rate and increased temperature. The increase in temperature is due to stimulation of the thermostat in hypothalamus while the low blood pressure is due to widened blood vessels when chemicals cause dilation (Vassiliou, Orfanos, & Kotanidou, 2017). The increased heart rate is due to increased work rate of the heart. There is also difficulty in breathing due to blood vessels leaking in the lungs. According to the statistics, 12% of the world population die annually due to sepsis (Kaukonen et al., 2014). Thus it is important to understand the pathophysiology in order to introduce adequate treatment to manage the illness.

The chosen case study for the assignment is about a indigenous male, Jedda Merinah aged 33 years. He has been hospitalized in the Hematlogy/Oncology department due to the emergency call for hypotension by the oncology day unit. To manage his acute myeloid leukemia he was receiving chemotherapy in the oncology unit. His health history has indicated that he has been given chemotherapy for induction phase and reported about nil temperature and blood culture has shown nil growth. In addition he has suffered from acute rheumatic fever in childhood, however, no structural abnormalities were found except mild dilation of the left ventricle. Depression and hypercholesteromia and has tried to attempt suicide as well. On assessment increase heart rate, respiratory rate, low blood pressure, reduction in food intake due to mouth ulcer, loose bowel action, reduction in urinary output and high temperature have been found. Blood test has been done which has indicated lack of Hb and platelets and increase in creatinine and urea. Center venous catheter line has been inserted by the senior register of ED. Such situations have led to the deteriorating condition.

Priority Area for Clinical Care and Relevant Nursing Interventions

The following paper will discuss about the symptoms of deterioration and will provide effective nursing interventions in order to improve the health condition off the patient in an effective manner. In this regards the paper will provide one area of priority for clinical care and introduce three relevant nursing interventions in order to manage the health condition of the patient and help him to recover faster.

As mentioned in the case study the two major symptoms or reason for the deteriorating condition of the patient are high temperature that is 38.8 degree Celsius and low blood pressure such as 92/65 mmHg. According to study high temperature such as 101 degree Fahrenheit or 38 degree Celsius is one of the early sign of septic shock and it should not be ignored (Coopersmith et al., 2018). Thus, it can be said that such increase in the body temperature is one of the most important signs of deterioration in health condition of the patient. On the other hand low blood pressure is another sign. It has been found that low blood pressure affect the cardiovascular function in an effective manner. For example, due to low blood pressure less oxygen is able to reach to the vital organs thus, heart needs to work harder in order to compensate and the heart rate elevated significantly as found in the patient (Heart rate 118/min) (Lee, 2014). In addition low blood pressure leads to the leakage of fluid from the blood vessel in the lungs that accumulates and creates difficulties in breathing, which leads to the increase in the respiratory rate (Leone et al., 2015). Due to such situation the respiratory rate of the patient elevated to 28 breaths/min. Furthermore, low blood pressure could lead to the consequence of hypovolemia as well. The significant drop in the blood pressure could lead to shock state as it could cause blood loss by 30% in individual that could lead to the consequence of hypovolemic shock (Chappell et al., 2014). Thus, it can be said that such symptoms have contributed to the deteriorating condition of the patient and need proper treatment to improve the health condition of the patient in an effective manner.

The patient has been assessed with ABCD assessment method which has indicated increase in heart rate, respiratory rate, low blood pressure and poor fluid intake. The central venous catheter has been inserted by the senior register in the emergency department. With the signs of high body temperature, low blood pressure that could cause hypovolemia the insertion of catheter could lead to the consequence of infection. As found in the blood pathology the decrease in the Hb and plasma has indicated the lack of blood volume and consequence of hypovolemic shock. Increase in the creatinine and urea have led to the diagnosis that there is a high chance that severe infection might have occurred. Such infection could increase the risk of septic shock in an effective manner (Garay-Fernández, 2017). Thus it is important to provide adequate focus in infection control in order to reduce the risk of septic shock in an effective manner.

Use of Sterile Technique, Keep Patient in Isolation Room, Use of PPE

Use of sterile technique, keep patient in the isolation room, use of PPE:

In case of sepsis the infection is not restricted to a specific portion rather that it affects the function of whole body, such as function of kidney, lungs, heart and brain as well (Angus et al., 2015). Thus, it is important to use aseptic techniques in order to control the infection. Dressing and medication need to be provided accurately (Berend et al., 2013). Personal protective equipment such as gloves, mask, gown, eye protection and respiratory protection need to be used by the nurse to avoid transmission of the infection (Tran & Major, 2015). As the infection could be transmitted through air thus it is important to keep the patient in the isolation room to ensure the safety of other patients (Berend et al., 2013). Study has indicated that using such aseptic techniques help to control infection in an effective manner and reduce the risk of transmission of infection (Lo et al., 2014).

SMART goal to evaluate the intervention:

A fluid challenge, use of IV and antibiotic:

In order to control infection and correct the hypovolemic state it is important to provide the fluid challenge. In this regards, it is important to administer initial fluid challenge 30ml/Kg crystalloid solution rapidly (Schnell et al., 2013). However, the patient has been given 250ml NaCl 0.9% fluid challenge which is effective for improving the condition of the patient. The fluid could be administered intravenously. Study has indicated fluid challenge could help to elevate the BP and blood volume as well, thus could help to reduce the risk of hypovolemia (Marik & Lemson, 2014). In addition, effective intravenous antibiotics could be provided to control the infection. For example, ceftriaxone, azithromycin and ciprofloxacin could be administered (Seymour et al., 2017).

SMART goal to evaluate the intervention:

Reduce hyperthermia:

Another important nursing intervention is reducing hyperthermia in this case. In this regards it is important to monitor the temperature of the patient in every four hours. The nurses could provide antipyretics to control the temperature (Drewry et al., 2013). The nurse should also provide tepid sponge baths and avoid the use of alcohol .Studies have shown that use of tepid sponges considerably reduce fever. Alcohol on the other hand may lead to chills leading to increased temperature and dehydration of the skin. The nurse should also provide cooling blankets or cooling therapy to control the hyperthermia (Luehr et al., 2013).

SMART Goal to Evaluate the Intervention

SMART goal to evaluate the intervention:

Conclusion:

From the above discussion it can be said that, the patient Jedda Merinah has been found to be suffering from the symptoms such as high body temperature, low blood pressure, high heart rate and respiratory rate, lack of HB and platelets and reduction in blood volume, increase in creatinine reduction in fluid intake and urea level and decrease in urination. The symptoms have indicated that severe infection might have occurred and there is a high risk of septic shock induced by such infection. Thus, infection control has been identified as the priority of care. It is expected that effective nursing interventions such as use of sterile technique, keep patient in the isolation room, use of PPE, fluid challenge, IV antibiotics and reducing hyperthermia could help the patient to recover faster and avoid the risk of septic shock in an effective manner.

References:

Angus, D. C., Barnato, A. E., Bell, D., Bellomo, R., Chong, C., Coats, T. J., … Young, J. D. (2015). A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Medicine, 41(9), 1549-1560.

Asfar, P., Meziani, F., Hamel, J., Grelon, F., Megarbane, B., Anguel, N., … Radermacher, P. (2014). High versus Low Blood-Pressure Target in Patients with Septic Shock. New England Journal of Medicine, 370(17), 1583-1593. Coopersmith, C. M., De Backer, D., Deutschman, C. S., Ferrer, R., Lat, I., Machado, F. R., … Rhodes, A. (2018). Surviving sepsis campaign: research priorities for sepsis and septic shock. Intensive Care Medicine, 44(9), 1400-1426.

Berend, K. R., Lombardi, A. V., Morris, M. J., Bergeson, A. G., Adams, J. B., & Sneller, M. A. (2013). Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clinical Orthopaedics and Related Research®, 471(2), 510-518.

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Drewry, A. M., Fuller, B. M., Skrupky, L. P., & Hotchkiss, R. S. (2015). The presence of hypothermia within 24 hours of sepsis diagnosis predicts persistent lymphopenia. Critical care medicine, 43(6), 1165.

Garay-Fernández, M. (2017). Sepsis Management: Non-antibiotic Treatment of Sepsis and Septic Shock. Sepsis, 117-133. Kaukonen, K., Bailey, M., Suzuki, S., Pilcher, D., & Bellomo, R. (2014). Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA, 311(13), 1308.

Lee, S. (2014). Treatment of Severe Sepsis-Based on Surviving Sepsis Campaign Guideline. Korean Journal of Medicine, 86(5), 557.

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Luehr, M., Bachet, J., Mohr, F. W., & Etz, C. D. (2013). Modern temperature management in aortic arch surgery: the dilemma of moderate hypothermia. European Journal of Cardio-Thoracic Surgery, 45(1), 27-39.

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Vassiliou, A. G., Orfanos, S. E., & Kotanidou, A. (2017). Clinical Assays in Sepsis: Prognosis, Diagnosis, Outcomes, and the Genetic Basis of Sepsis. Sepsis.