Analysis of Septic Shock: An Evidence-Based Nursing Case Study, NSB236

This essay provides a comprehensive analysis of a nursing case study involving a patient with septic shock, stemming from a previous diagnosis of Acute Lymphoblastic Leukaemia and allogenic stem cell transplant. The essay meticulously examines two key signs and symptoms of clinical deterioration, relating them to the underlying pathophysiology of the patient's condition. It then identifies sepsis as the priority problem, providing a strong justification based on contemporary research. The essay further details two evidence-based nursing interventions to address the priority problem, along with methods to evaluate their efficacy. Additionally, it explores a significant psychosocial issue from the case study and proposes patient-centered approaches to manage it. The essay concludes by emphasizing the importance of recognizing and managing sepsis, and highlighting the application of NMBA standards in providing holistic patient care.

Running head: EVIDENCE BASED NURSING RESEARCH 1
Evidence Based Nursing Research
Student name
Student ID
Author’s note

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Table of Contents
Introduction......................................................................................................................................3
Two signs and symptoms related to case study...............................................................................3
Relating it to the patho-physiology of the patient presenting problem...........................................3
The priority problem chosen............................................................................................................4
Justification of the problem chosen.................................................................................................5
Intervention chosen to address the problem....................................................................................6
Collaborative or pharmacological intervention:..........................................................................6
Nurse initiated intervention.........................................................................................................7
Evaluate efficacy of the chosen interventions.................................................................................7
One psycho social issue from the case study and ways to address it using patient centred
approach...........................................................................................................................................7
Conclusion.......................................................................................................................................8
Reference.........................................................................................................................................9
Appendix........................................................................................................................................11

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Introduction
The essay aims to discuss about the pathophysiological conditions related to Acute
lymphoblastic leukaemia, a type of cancer affecting the bone marrows and blood contributing
to risk of bleeding and frequent infections for patient. The current essay utilizes the NMBA
standards for critically assessing the case study of Elodie Greer, a 14 year old girl with a
previous diagnosis of Acute Lymphoblastic Leukaemia and providing the best care to patient. In
addition, the essay makes use of knowledge related to pathophysiology, physiology and
anatomy to support decision making based on evidence for provide suitable care plan.
Two signs and symptoms related to case study
The matter of concern in the mentioned case study can be as follows; Elodie is a lively
child. However, with the passage of time she exhibited episode of malaise making her parents
worried. In addition to that Elodie was additionally suspected to have sepsis secondary to an
infected Hickman’s line. The dryness of mouth and dark urine is critical health concern for
patient. However, the incident of allogeneic stem cell transplant is termed as a potential cause of
concern that may lead to severe series of co-morbid conditions.
Relating it to the patho-physiology of the patient presenting problem
The Hickman line is a catheter used for administrating drugs during the event of
chemotherapy. There remains no evidence that the Hickman line was flushed once a day with
heparin solution; that can be termed as one of the leading cause of sepsis. On the basis of
objective data, it can be easily stated there is a rise in level of white blood cells. According to the
study by Cicconi and Lo-Coco (2016, p. 1476), increase in the amount of WBC is not related to

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specific disease; rather it indicates problems such as stress, infection or trauma. A large count of
lymphocyte is likely to occur in presence of bacterial or even viral infection.
In addition to that the patient exhibits tachycardia which is a common feature associated
with sepsis. Tachycardia is termed as a common feature of sepsis which is indicative of response
to stress. The mentioned event is a systematic response towards stress leading to psychological
mechanism increasing i cardiac output coupled with high rates of oxygen delivery to tissues
(Cicconi et al. 2016, 1987). With onset of tissue hypoperfusion, there is a rise in rates of
respiration compensating for metabolic acidosis.
The dark yellow urine cannot be termed as a major clinical problem for patient; however,
currently it does not pose threats in relation to sepsis. The yellow colouration of urine is
generally due to presence of pigments such as urochrome or urobilin. The dark yellow urine in
the mentioned case is commonly due to dehydration. The mentioned case study gives clear
understanding that Elodie exhibits symptoms of dryness in mouth and no passing of urine.
The priority problem chosen
In regards to the series of chosen problem, it can be clearly stated sepsis is a problem that
demands immediate priority. Elodie was diagnosed with Acute Lymphoblastic Leukaemia,
corrected with chemotherapy. She additionally received allogenic stem cell transplant. The
allogenic stem cell transplant involves donation of healthy multipotent stem cells. Thus, it is very
likely that that Elodie’s body may reject the cells of the donor. In addition to that, it can be stated
there remains probable chances of sepsis in case of Elodie.
In case the sepsis along Hickman Line, prompt action must be undertaken. Sepsis is often
termed as a life threatening organ dysfunction initiated due to dysregulated host response

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towards infection. Hence, it can be clearly stated, if the sepsis is not recognised initially and
managed promptly it can result in septic shock and even organ failure; even death. Hence, it
would be fair enough to conclude that sepsis demands immediate attention (Rhee, Dantes,
Epstein&Klompas, 2019, p. 306). However, to prevent further degradation of health, it is
important to ensure that Elodie is adequately hydrated for better provision of care. The high level
of white blood cells can be termed as a major cause of concern as it can increase chances of
trauma or infection for patient.
Justification of the problem chosen
The loss of protein and potassium from body stores in major trauma or sepsis is
accompanied by progressive cellular dehydration. This insight opens up new therapeutic options
for limiting the loss of body protein in critically ill patients. The level of dehydration can be
termed challenging in managing the events of sepsis and providing suitable mode of care. As
stated by Howell& Davis(2017, p.848), sepsis is linked with massive events of vasodilation that
increases permeability of the membrane’ resulting in intravascular fluid deficit.
The level of white blood cell increase hint indicate risk of infection confirming the event
of sepsis. However, Jatwaniet al. (2018, p.47) stated the fact the bone marrow, responsible for
keeping a balance on the blood cell count. The rise in blood cell count refers to the malfunction
of the bone marrow, suggesting the possibility of relapse of lymphoma or event of sepsis. In any
of the case it is equally important to understand the importance of maintaining blood cell count
to maintain positive health outcomes. The increase in the amount of white blood cell can indicate
leukopenia (WBC less than 4,000). In case of severe incidents of sepsis, the patient may
experience severe outcome and hypercytokinemia than leucocytosis if the count of white blood
cell is more than 12,000 (Geiset al. pp. 16-18). In the mentioned case study, the patient blood

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report is 12.5, suggesting the high chances of severe sepsis. Prolonged sepsis or even severe
sepsis can lead to septic shock; eventually organ failure and even death. As stated by Schmidt et
al. (2016, p. 2703), sepsis is often linked with incidents of mortality and morbidity if not
recognised on time and treated promptly. It would be fair enough to note the fact, since the
initiation of early goal directed therapy, rates of mortality have reduced. However, sepsis
remains a major concern of death among patients arriving within the infirmary for emergency
services (Makic& Bridges, 2018 p.37).
Intervention chosen to address the problem
Collaborative or pharmacological intervention:
Addressing the events of sepsis is important and a number of medications can be used for
treating sepsis and even septic shock. As stated by Urden, Stacy & Lough (2019) antibiotics,
should be administered immediately for addressing the events of infection. Initially, a broad
spectrum of antibioticsisadministered against a series of bacteria. However, all the drugs in the
mentioned case scenario needs to be administered intravenously for better results. The use of
intra-venous fluid is made within the three hours. The patient here is seen to suffer from
dehydration and needs to get fluid administered right away. In the mentioned case the patient
exhibits immense level of low blood pressure. Hence, if the level of intravenous fluid fails to rise
the blood pressure then vasopressors need to be administered. As stated by McCafferyet al.
(2016, p.88), the use of vasopressor is known to constrict the blood vessels and help in
increasing the level of blood pressure. Other medications include limited levels of corticosteroids
and even insulin to maintain suitable levels of blood sugar that can work on modifying the
response from immune system. The use of painkiller and sedative can be made for reducing the
pain if any.

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Nurse initiated intervention
The nurses should work on maintaining the fluid intake chart of the patient. In similar
instance, the nurses should work on reducing the chances of further infection, a common instance
in sepsis (Drahnaket al. 2016, p.233). The chances of ventilator-associated pneumonia (VAP) in
the mentioned case is significantly on the higher side. However, maintaining the elevation of
head at 30° can prevent the possibilities of VAP (Kleinpell, 2016 p. 16).
Evaluate efficacy of the chosen interventions
Addressing the issue related to VAP, the mentioned nursing intervention can be deemed
suitable. A growing sources of literature is seen to suggest the fact, oral care can work on
reducing the oropharyngeal colonization and therefore the risk of hospital acquired pneumonia.
The patient in the mentioned case scenario exhibits weak immunity and even issues related to
infection (Steinmo, Fuller, Stone &Michie, 2015 p. 111). Thus, the nursing intervention used to
address the line of infection control can be termed suitable as it reduces the possibility of further
infection. In similar regards alterative medication. In case of septic shock, and no response to IV
fluid and vasopressors. Low dose of cortisol
One psycho social issue from the case study and ways to address it using patient centred
approach
Stress associated with sepsis can be termed as a leading cause of concern. The events of
stress can trigger the response of immune system leading to inflammation. The management of
stress becomes important (Gatewoodet al. 2015 p.788). The patient is slowly recovering from a
major transplantation surgery and needs toaddress the stress. The patient needs to be educated
about the importance of maintaining proper immune system. In similar regards, it becomes

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important to understand the fact that patient needs to obtain a clear idea about the condition she
is facing.
The use of teach back method can be implemented for understanding the level of
understanding exhibited by the patient. The patient needs to be aware of the condition and
possible issues associated with the condition (Cicconiet al. 2016 p. 307).The patient should
further be probed for expressing the cause of concerns and possible ways of answering the issues
of stress. The standard 4 can as per NMBA Standards can work on interpreting a range of
information for planning appropriate care (Cicconi& Lo-Coco, 2016 p. 1475). It is for the same
reason; a holistic approach is undertaken for ensuring better provision of care. The standard 9 of
care is in regards to the practise to improve quality. It is for the same reason teach back method
is used for improving the scope of aspect of quality care
Conclusion
To summarize, the risk of sepsis was a major health concern for patient. In addition to
that dehydration is a successive cause of concern that can lead to health problems. Hence, it can
be concluded the mentioned scenario works on understanding the importance of addressing the
issues related to sepsis and managing the same. The importance of managing the sepsis can be
rightly confronted through the mentioned scenario and addressed. The use of the NMBA
standards in the mentioned scenario, provides a clear understanding to the fact that nursing
profession improved a lot in the last few years. The role of the nurses is not limited to
physiological cure; rather nurses are seen to apply holistic policies for ensuring better sense of
care among the patients

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Reference
Cicconi, L., & Lo-Coco, F. (2016). Current management of newly diagnosed acute
promyelocyticleukemia. Annals of Oncology, 27(8), 1474-1481.
Cicconi, L., Divona, M., Ciardi, C., Ottone, T., Ferrantini, A., Lavorgna, S., ... & Ferrara, F.
(2016). PML–RARα kinetics and impact of FLT3–ITD mutations in newly diagnosed
acute promyelocytic leukaemia treated with ATRA and ATO or ATRA and
chemotherapy. Leukemia, 30(10), 1987.
Drahnak, D. M., Hravnak, M., Ren, D., Haines, A. J., & Tuite, P. (2016). Scripting nurse
communication to improve sepsis care. MedSurg Nursing, 25(4), 233.
Gatewood, M. O. K., Wemple, M., Greco, S., Kritek, P. A., &Durvasula, R. (2015). A quality
improvement project to improve early sepsis care in the emergency department. BMJ
QualSaf, 24(12), 787-795.
Geis, G. L., Wheeler, D. S., Bunger, A., Militello, L. G., Taylor, R. G., Bauer, J. P., ... &
Patterson, M. D. (2018). A Validation Argument for a Simulation-Based Training Course
Centered on Assessment, Recognition, and Early Management of Pediatric
Sepsis. Simulation in healthcare: journal of the Society for Simulation in
Healthcare, 13(1), 16-26.
Howell, M. D., & Davis, A. M. (2017). Management of sepsis and septic shock. Jama, 317(8),
847-848.
Jatwani, K., Jatwani, S., Chugh, K., Rajeeve, S., Sharma, R. K., Perimbeti, S., ... &Mannem, S.
K. (2018). Comparison of Hospital Costs and in-Hospital Outcomes of Patients Admitted
with Sepsis with and without Non Hodgkin Lymphoma. 17(8), 47-48.

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Kleinpell, R. (2017). Promoting early identification of sepsis in hospitalized patients with nurse-
led protocols. journal of the Society for Simulation in Healthcare, 13(1), 16-26.
Makic, M. B. F., & Bridges, E. (2018). CE: Managing Sepsis and Septic Shock Current
Guidelines and Definitions. AJN The American Journal of Nursing, 118(2), 34-39.
McCaffery, M., Onikoyi, O., Rodrigopulle, D., Syed, A., Jones, S., Mansfield, L., & Krishna, M.
G. (2016). Sepsis-review of screening for sepsis by nursing, nurse driven sepsis protocols
and development of sepsis hospital policy/protocols. Journal of Management of sepsis
and septic shock. 3(2), 88-92.
Rhee, C., Dantes, R. B., Epstein, L., &Klompas, M. (2019). Using objective clinical data to track
progress on preventing and treating sepsis: CDC’s new ‘Adult Sepsis Event’surveillance
strategy. BMJ QualSaf, 28(4), 305-309.
Schmidt, K., Worrack, S., Von Korff, M., Davydow, D., Brunkhorst, F., Ehlert, U., ... & Freytag,
A. (2016). Effect of a primary care management intervention on mental health–related
quality of life among survivors of sepsis: a randomized clinical trial. Jama, 315(24),
2703-2711.
Steinmo, S., Fuller, C., Stone, S. P., &Michie, S. (2015). Characterising an implementation
intervention in terms of behaviour change techniques and theory: the ‘Sepsis Six’clinical
care bundle. Implementation Science, 10(1), 111.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2019). Priorities in Critical Care Nursing-E-Book.
Elsevier Health Sciences.

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Appendix
Howell, M. D., & Davis, A. M. (2017). Management of sepsis and septic
shock. Jama, 317(8), 847-848.
The research article addresses the challenges and importance of managing sepsis among the
patients. Evidence suggest sepsis is often a manifestation of body’s response to infection leading
to life threatening organ dysfunction. Management of sepsis has been termed as a complicated
challenge and requires early recognition depending on the seriousness of the situation
Jatwani, S., Chugh, K., Rajeeve, S., Sharma, R. K., Perimbeti, S., ... &Mannem, S. K.
(2018). Comparison of Hospital Costs and in-Hospital Outcomes of Patients
Admitted with Sepsis with and without Non Hodgkin Lymphoma. 17(8), 47-48.
Sepsis has been considered as a major cost contributor to healthcare. The cost associated with
healthcare expenditure is high in case of sepsis. The chosen research article helps in formulating
the preventing sepsis and avoiding complications from infections. Future studies are often
needed for focusing on the improving strategies such as early diagnosis, coupled with prompt
treatment for improving the events of sepsis
Geis, G. L., Wheeler, D. S., Bunger, A., Militello, L. G., Taylor, R. G., Bauer, J. P., ... &
Patterson, M. D. (2018). A Validation Argument for a Simulation-Based Training
Course Centered on Assessment, Recognition, and Early Management of Pediatric
Sepsis. Simulation in healthcare: journal of the Society for Simulation in
Healthcare, 13(1), 16-26.

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The research paper discusses about the circulatory distress with individuals suffering from
sepsis. The mentioned paper focuses on the paediatric problems during the course of sepsis. The
research discussed about the four potential scenarios with sepsis among children with moderate
dehydration but has maintained better mental status coupled with distal skin perfusion.
Simulations of paediatric sepsis were seen to provide sufficient validity for training the new
paediatric physician in recognising and managing paediatric sepsis
Schmidt, K., Worrack, S., Von Korff, M., Davydow, D., Brunkhorst, F., Ehlert, U., ... &
Freytag, A. (2016). Effect of a primary care management intervention on mental
health–related quality of life among survivors of sepsis: a randomized clinical
trial. Jama, 315(24), 2703-2711.
Survivors of sepsis are often subjected to long term stress that can degrade the quality of life and
result in increased need for care within the primary settings that includes medication, mental
healthcare and even physiotherapy. Among the survivors of sepsis and septic shock the
implementation of mental health provision can help in understanding the importance of holistic
mode of care.
McCaffery, M., Onikoyi, O., Rodrigopulle, D., Syed, A., Jones, S., Mansfield, L., &
Krishna, M. G. (2016). Sepsis-review of screening for sepsis by nursing, nurse
driven sepsis protocols and development of sepsis hospital policy/protocols. Journal
of Management of sepsis and septic shock. 3(2), 88-92.
Due to the increasing rate of sepsis occurrence among the hospitalised patients, it is extremely
important to ensure proper screening as soon as possible, as per the protocols. However, the
focus on the protocols such as educating the staff and even collaborating with the patients. The

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focus on educating the staff for treating the nurses gained immense prominence. The newly
implemented protocol can be termed as the initial roadblocks and there has been significant
improvement in the mode of diagnosis among the septic patients for reducing the mortality of the
patients
Kleinpell, R. (2017). Promoting early identification of sepsis in hospitalized patients with
nurse-led protocols. journal of the Society for Simulation in Healthcare, 13(1), 16-26.
The mentioned research paper highlights the importance of patient to nurse interaction in
managing the events of sepsis. Targeting early recognition in sepsis through multifaceted
performance has been demonstrated for improving compliance with sepsis management linked
with reduction in mortality rates in hospital settings. The research provides a clear idea about the
importance of communicating with the nurses for ensuring timely care
Steinmo, S., Fuller, C., Stone, S. P., &Michie, S. (2015). Characterising an implementation
intervention in terms of behaviour change techniques and theory: the ‘Sepsis
Six’clinical care bundle. Implementation Science, 10(1), 111.
The event of sepsis can be termed as one of the leading cause of concern as it leads to organ
failure. In the cohort studies conducted in this phase, it can be conclusively stated flow chart
intervention can be used for ensuring systematic intervention for addressing the sepsis related
issue among patients
Gatewood, M. O. K., Wemple, M., Greco, S., Kritek, P. A., &Durvasula, R. (2015). A
quality improvement project to improve early sepsis care in the emergency
department. BMJ QualSaf, 24(12), 787-795.

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The nursing intervention need not be as per the protocol rather it should be prompt. The research
article provides a clear idea to the fact that sepsis management and care needs to be done on
immediate basis based on the demand of the situation.