Integrated Nursing Practice 3 - Case Study of Catherine's Story

This essay discusses the case study of Catherine Bexley, a 77 year old woman, presented to ED with right lower lobe pneumonia. The essay deals with primary and focused assessment, pathophysiology of septic shock, and appropriated nursing interventions, based on evidence to improve Catherine’s health outcomes.

Running head: Integrated Nursing Practice 3
Integrated nursing practice 3
Name of the Student
Name of the University
Author note

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Case study- Catherine’s Story
Introduction
To deliver the care for chronic illnesses, multiple factors have to be taken into
consideration. It is important for the nurse to consider the patient’s and the clinical needs.
Assessment of patient is an important part of the nursing as it can be life saving. It helps improve
the clinical performance, by identifying the priorities of care (Viera, 2016). Primary and
secondary assessments are important for the observation, and interpretation of data. It
significantly influences the patient’s diagnosis and the prioritisation of care. Prioritisation of care
will help improve the care delivery (Brown, Edwards, Seaton & Buckley, 2017). The essay deals
with case study of Catherine Bexley, a 77 year old woman, presented to ED with right lower lobe
pneumonia. The patient also has the history of heart disease, hypertension, and
hypercholesterolemia. In response to the case study the essay discusses the primary assessment
using the DRSABCDE approach followed by the focused assessment for respiratory distress.
The essay then discusses the pathophysiology of the shock experienced by the patient and
explains the clinical manifestations. Lastly, the essay presents the appropriated nursing
interventions, based on evidence to improve Catherine’s health outcomes.
Assessment
Primary assessment
DRSABCDE approach will be used for primary assessment. It stands for “Danger,
Response, Send for help, Airway, Breathing, Circulation, Disability, Exposure”. According to
Smith & Bowden (2017) it is the systematic approach to immediate assessment and treatment.
On assessment of Danger, initially the patient appeared to need HDU however, found safe to

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ward after oxygen and antibiotics. The DRS assessment showed that patient is conscious and
responsive. She was further assessed using PPE. Immediate help required in the ED is that of
physician. The patient may be at risk of shock and death due to low oxygen supply. The
neurological assessment showed that the patient is complaining of pain and is confused.
The airway assessment showed that the Catherine is using her upper accessory muscles.
She has decreased air entry to her Right lobe to midzone. There were no noisy respirations
found and no sign of cyanosis. On breathing assessment, shortness of breath was found and the
patient is having increased effort evident from speaking of short sentences. He patient has pain
5/10 in her Right lower chest with deep. Immediate intervention is needed to prevent to prevent
decreased GCS (15/15 in patient), life threatening conditions (Velasco & Howard, 2017). The
circulatory assessment revealed low BP 90/65mmHg instead of normal 120/80, HR 120 bpm
instead of 96 regular, The radial pulse was very weak, with skin flushed and sweaty. The
capillary refill is 3 seconds. Her ECG is NAD. Immediate intervention is required as
hypovolaemia, pump failure, and vasodilatation (sepsis) causes this breathing problem. Adequate
perfusion is needed (Perman, Goyal & Gaieski, 2012).
Further patient was assessed for disability to rule out possibility of stroke. Catherine was
confused to day and place. Further, assessment includes examination of patient head to toe and
front and back, showed no sign of haemorrhage but the patient was bleeding as she has removed
her IV line. The patient has sign of fever and is ensured to be warm. According to Zhang, Chen
& Ni (2015) fever, chills, confusion, difficult breathing and significant drop in blood pressure are
indicators of septic shock. Thereby, focused assessment is necessary.
Focused assessment

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The relevant focused assessment required in this case is related to respiratory. The red
flags for focusing on respiratory assessment are chest pain and shortness of breath. Therefore, the
secondary assessment is justified (Nemer & Villar, 2015). The oxygen flow rate and delivery
device is assessed. It is necessary as the patient demonstrated hypoxia, tachypnoea, tachycardia,
hypotension, hyperglycemia condition. The delivery device must be assed as the low flow
systems do not provide the adequate ventilatory requirement. The high flow system is used only
when approved but meets or exceeds their Peak Inspiratory Flow Rate. Mechanical ventilation is
associated with function of lungs (Perman, Goyal & Gaieski, 2012). In this case the patient may
ensured of high flow system.
The patient is assessed for auscultation of breath and type of breath that is cough or deep.
Cough is common in pneumonia, a noscomial infection. It is necessary to identify the wheezes,
crackles, adequate inspiration and expiration time. Wheeze indicates the narrowed airway and
respiratory distress. Sound indicates pulmonary congestion and impaired gas exchange indicates
abnormal breathing. Narrowed airway, pulmonary ventilation, perfusion, is common in septic
shock (sellarés et al., 2016). Further, injuries to the chest wall are observed and assessed for pain,
deformities, and movement of chest wall. The rationale is to rule out any clot formation due to
inflammatory process. Increased capillary permeability and Vasodilatation also hampers the
body’s adequate perfusion indicating sepsis. The chest pain was found to be 5/10 and may be due
to clot. Fever and increased heart rate may be due to systematic inflammatory response
syndrome trigged by activated immune system (Zhang, Chen & Ni, 2015). It is also evident
from the high respiration rate evident from the primary assessment. According to Silversides et
al. (2015), presence of sepsis leads to systematic inflammatory response syndrome. Heart rate,
temperature and respiratory rate are important criteria to confirm infection in respiratory tract.

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Two of the above criteria is fulfilled and is confirmation for sepsis. It rules out any other major
insult to the body such as myocardial infarction. Septic shock is further confirmed by the
hypoxemia, hypotension, and oliguria, as they are signs of organ dysfunction (Van Vught et al.,
2016).
Pathophysiology
Pathophysiology of septic shock
Sepsis is defined as a life threatening organ dysfunction which occurs as a result of
infection. The infection may be caused from a variety of conditions such as post operative
treatment procedures or due to incomplete cure from a variety of medical conditions. Under
sepsis conditions the blood pressure falls below the abnormal level and sufficient oxygen are
not transferred to the vital organs of the body leading to ac condition of multiple organ failure
(Avni, Lador, Lev, Leibovici, Paul & Grossman, 2015). The septic shock leads to tissue
perforations where the capillaries start to leak resulting in organ failure. It is defined by
persistent hypotension requiring vasopressin to maintain a mean arterial pressure of 65 mm hg or
higher and a serum lactate level greater than 2 mmol/L. The signs and symptoms of sepsis vary
within the patients such as fevers, chills, rigors, confusion, anxiety, difficult breathing, nausea,
vomiting etc. As mentioned by Damiani et al. (2015), the sepsis is further triggered by a variety
of clinical conditions such as the presence of chest and pulmonary infections. One of the major
features of septic shock is the occurrence of peripheral vasodilatation where the normal
mechanisms to vasoconstrict fail in the smooth muscles. Septic shock is further triggered by
conditions such as pneumonia. It affects the blood coagulation system resulting in tissue leakage.
As mentioned by Liu et al. (2014), sepsis has been mostly recently related to being immune-

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stimulated. Under sepsis schok cellular changes becomes activated in a deteriorating fashion
leading to lymphocyte apoptosis. The systematic inflammatory response syndrome is
characterised by a number of clinical conditions and symptoms such as body temperature garter
than 38 degree centigrade, heart beat greater than 90 per minute, respiratory rate greater than 20
per minutes along with blood white cells count greater than 12,000 /mm3 (Singer et al., 2016).
Additionally the medical professional worldwide have further developed another acronym for
dealing with the medical condition of the patient suffering from septic shock which is known as
PIRO, where P stands for pre-disposition indicating pre-existing co-morbid conditions, I refers
to infection, R represents the response to the infectious challenge and O stands for organ
dysfunction or organ failure. The septic infection results in disseminated intravascular
coagulation (DIC) (Duan et al., 2016). This disturbs the blood coagulation homeostasis resulting
in blood to clot when it should not, resulting in clogging of vessels, which further restricts the
blood flow in the patient. The dysfunctional vasculature results in local bleeding.
Additionally, the tissue perforations results in the contents between the cells to mix,
resulting in organ failure by disrupting the normal homeostasis of the body (Semler, Andrews &
Bernard, 2018). The sepsis shock results in the production of high amount of interleukins which
result in the development of hyper inflammatory responses. The tissue in jury also enhances the
levels of endotoxin which further triggers the release of cellular cytokines. The release of cellular
cytokines further induces widespread secondary infection. The excessive activation of TNF ad
endokines would result in suppression of activity of neutrophils, which fail to engulf the
phagocytic cells (Andrews et al., 2017). The disturbed homoeostasis also affects the normal
mechanism of apoptosis by delayed removal of the neutrophils and hastened removal of the
lymphocytes, which further enhances the rate of the infection resulting tissue lyses. The

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respiratory syndrome has been associated with decreased chemotactic responses, which could be
related to disrupted homeostasis of the cell. One of the most serious concerns of the septic shock
is the occurrence of multi-organ failure which could enhance the chances of mortality in the
patient. The pro-inflammatory and the anti-inflammatory responses lead to mitochondrial or
endothelial dysfunction (Semler, Andrews & Bernard, 2018). The series of septic shock also
affects the normal neurotransmission in the patient. This results in loss of sense regarding time
and surroundings and result in the development of utter confusion in the patient. This situation
has also been referred to as encephalopathy with sepsis. In this respect, administration of
glucorticoids has been seen to relive the condition of sepsis within the patient (Gawlytta et al.,
2017). However, the results are debatable as no assured benefits have been obtained for the
follow up of the method.
Pathophysiology of experienced clinical manifestations
The clinical condition of the patient could be studied over here in order to understand the
deep rooted pathophysiology of the patient. The patient here depicted a number of clinical
conditions as an associated symptom of septic shock. Some of these have been studied in details
in order to understand the current health scenario pertaining the patient. Catherine’s past medical
conditions shows that she had a history of cardiac ischemia. Therefore, the disturbed homeostasis
owing to sepsis could have hampered the rate of neurotransmission resulting in delayed
responses across the sinoatricualr (SA) node of the heart (Toan et al., 2018). The patient recorded
a respiratory rate of 36 breaths/ mins. The septic shocks lead to tissue and blood vessels blockage
resulting in disrupted flow of oxygen. The patient was admitted to the hospital with decreased air
entry to right lower lobe.

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Additionally, the sepsis shock could further aggravate the condition of the patient leading
to airway block. One of the most common clinical symptoms expressed in sepsis is the lock jaw
syndrome which could have fatal consequences. As mentioned by Montull et al. (2016), most of
the times the lock jaw happens owing to secondary infections caused by pathogens , which
gain entry into the body of the patient through catherer port channels. The doctor further
examined her symptoms based upon nursing scales and standards such as PEARL which refers to
Pupil equal, accommodating and reactive to light. The pupil dilations were noted around 3 mm
which signifies a state of anxiety or confusion in the patients. The IDC drainage bag of the
patient has 30 ml of urine output which further confirms the presence of oligourea. Additionally,
the medical emergency team has suggested the administration of 500 mg of azithromycin to the
patient in a 2 L of normal saline solution. The purpose for the administration of Azithromycin
was to regulate the spread of the sepsis shock infection in the patient. As mentioned by Singer et
al. (2016), the use of azithromycin has been associated with more ICU free days for sepsis with
or without pneumonia.
The sepsis shock and resultant tissue perforations resulted in blood coagulations s directly
cutting off the oxygen supply in the patient. Therefore, the patient had been feeing
breathlessness. On increasing the oxygen supply the state of panting in the patient could be
reduced. Therefore, the patient was put upon increased oxygen supply in order to reduce the
chances of a septic shock. As commented by Andrews et al. (2017), the restricted blood flow
cuts off the required amount of glucose to the brain resulting in neural shock. Therefore,
administration of glucose in standard normal solutions may prevent the chances of a severe
septic shock. Therefore, the glucose control acts as substantial protection of the endothelial cells.
Therefore, at any point care should be taken to avoid the administration of steroids to the patient.

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It has seen to produce lethal consequences in the patient resulting in high mortality rates most of
the times.
Nursing interventions
Based on the assessment and the evaluation the prioritisation of care involves oxygen
supply followed by fluid resuscitation, blood culture tests and lastly antibiotic therapy. The
patient may be provided with significant respiratory support. It includes monitoring and
providing adequate oxygen supply. High flow system is used only when approved but meets or
exceeds their Peak Inspiratory Flow Rate. In this case the patient may be ensured of high flow
system. Mechanical ventilation is associated with function of lungs. The goal would be to
maintain SpO2 greater than 94% (Gaudry et al., 2018). It will help reduce the shortness of breath
and maximise the oxygen level for cellular uptake. When resting the patient’s head on bed will
be elevated and the position to be change frequently. It will help lower the diaphragm. It will
promote aeration of lungs by chest expansion. It will promote the mobilization and expectoration
of secretions. It will ensured by nurse that the patient is conscious and the airway is clear by
regular monitoring. Active intolerance is common in this condition due to decreased gas
exchange. Therefore, the care will be clustered to conserve the patient’s energy. It is needed for
essential task like ambulation, eating, deep breathing and coughing (Silversides et al., 2015).
The patient may then be provided width N/S infusion. A massive fluid resuscitation is
required in patient with sepsis. As per instructions from the medical emergency team 2L of
Normal Saline 0.9% STAT will be started. A large amount of fluid may be required to maintain
the tissue perfusions as the oxygen intake is already low (Silversides et al., 2015). It will help
support the circulating volume and overcome hypovolemia and reduce fever diaphoresis

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(Rastegar, 2015). Adequate precautions will be taken to prevent fluid over resuscitation.
According to Semler, Andrews & Bernard (2018), sepsis is a combination of arterial dilation,
venodilation, intravascular volume depletion, therefore, care will be clustered to address each
problem.
Prior to commencing antibiotics the blood test may be conducted, as antibiotics may alter
the blood test results. For Catherine, appropriate labs shall be obtained that includes antibiotic
troughs, ABGs and sputum cultures. For Catherine two sets of blood culture will be taken from
separate sites. It will used to check for coagulations, blood glucose level and FBE. The next
assessment will comprise of lactate (venous blood gas). The rationale is to assess CRP, LFTs and
ELIC. The cultures will be taken without delaying the antibiotic administration. Senior clinician
will be informed immediately if unable to access IV or obtain blood cultures. Ensure the blood
cultures will be properly examined for identification of appropriate pathogen. Identification of
organism is crucial to effective septic shock treatment. The timings of the collection of the lab
reports are essential as related to administration of antibiotics and ensure accuracy (Urden et al,
2017).
These interventions will be immediately followed by the administration of the antibiotics
as the responsibility of nurse. The patient will be assessed for penicillin allergy and use of
antibiotics previously that may have caused any side effects. The same will discussed with
concerned physician. In case of renal impairment the dosage may be reviewed. Antibiotic
therapy will also be discussed with ID service. Currently as per the Medical emergency team
advice, Azithromycin- 500 mg will be administered on the right time and in right dosage to
ensure efficacy. The use of azithromycin has been associated with more ICU free days for the
patient affected with severe sepsis with or without pneumonia. Broad spectrum antibiotics will

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be used such as methicillin, but the dosage will be balanced against the renal function clearance.
If MRSA is detected then vancomycin may be preferred for its efficacy (Hagen et al., 2017).
Followed by the above interventions the patient and the family members will be educated
on energy conservations, symptoms requiring emergency care, food and nutrition and effective
airway clearance as well as coughing and breathing. It is necessary create awareness among
patient on these aspects of recovery. It will ensure adherence the treatment protocol and
compliance to medication (Viera, 2016).
To evaluate the effectiveness of the treatment, and determine the next steps, it is
imperative to draw the labs promptly. It is very sensitive in sepsis treatment. Therefore, the lab
studies for the neutrophils and band counts will be monitored. Body’s response to the infection is
indicated by the elevation of band cells. The room temperature may be decreased as the patient
has high fever. Catherine may be provided with the antipyretics and the cooling blankets to save
her from chills and shivering. The nursing interventions may further involve continuous
monitoring of temperature. The patient may be assisted with tepid sponge bath. According to
Zhang, Chen & Ni (2015) septic patient has fluctuating temperature. It is essential to maintain
the body temperature as an increase in the temperature increases metabolic oxygen demands. The
patient’s cardiac output may be monitored as indicated. The patient will be monitored of the
urinary output as the decrease in urine output indicates hypovolemeia associated with
vasodilation (Viera, 2016). Further evaluation may comprise assessment of hemodynamic status,
nutritional status and fluid intake and output. The patient may evaluate the patient for
hemodynamic stability. It must be evaluated if the patient can verbalise the feelings and
understanding of disease process. Based on the findings appropriate discharge and home care
guidelines will be provided (Urden et al., 2017).

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Conclusion
In conclusion the essay helped understand the importance of assessment and need of
early findings prevent shock. The case study analysis of Catherine has developed insights into
the pathophysiology of septic shock and the cause of clinical manifestations. It helped develop
the care plan based on prioritisation. It was evident from case study analysis that considering the
client’s personal and clinical needs is essential in prioritisation of care. A comprehensive
nursing plan has been developed for Catherine. The first priority is supplying adequate oxygen
followed fluid volume and then performing blood tests to determine the antibiotic therapy. Lastly
the treatment is evaluated to ensure positive outcomes.

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