NSB236: Septic Shock, Clinical Deterioration, Nursing Interventions

This case study delves into the complexities of septic shock, focusing on a 32-year-old male patient, Jedda Merinda, diagnosed with Acute Myeloid Leukemia and presenting with hypotension, tachycardia, and low urine output. The analysis identifies tachycardia and hypotension as key signs of clinical deterioration, stemming from the pathophysiology of septic shock, including immunosuppression due to chemotherapy and the release of inflammatory mediators. The primary clinical priority is identified as decreased tissue perfusion, resulting from reduced hemoglobin levels and impaired blood flow. Nursing interventions discussed include fluid administration, breathing exercises, and pharmacological interventions with vasopressors like vasopressin to improve blood pressure and tissue perfusion. The case study emphasizes the importance of collaborative care and continuous assessment to ensure effective management and improved patient outcomes. The essay concludes by highlighting the significance of these interventions in addressing septic shock and promoting patient well-being.

CASE STUDY 1-SHOCK: THE DETERIORATING PATIENT
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Introduction
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.
Physiology and Pathophysiology of Septic Shock
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
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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).
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
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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)
Symptoms of clinical deterioration of the patient
The two symptoms are tachycardia and hypotension
Tachycardia
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
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)
Clinical Priority of Clinical Care of the patient
Decreased Tissue perfusion
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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)
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).
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Nursing Interventions for Decreased Tissue Perfusion
The three nursing interventions include administration of fluid, breathing exercise/technique,
and pharmacological intervention.
Administration of Fluids
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).
Breathing exercises/Techniques
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
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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).
Pharmacological Intervention
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
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hypersensitivity, slow pulsations, difficulties in breathing, headache, skin rash, sweating, and
numbness of toes or fingers (Rudiger & Singer, 2013).
Assessment and Evaluation
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.
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References
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(2015). Timing and causes of death in septic shock. Annals of intensive care, 5(1), 16.
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