NSB236 Integrated Nursing Practice 3: Septic Shock Case Study Analysis

This case study delves into septic shock, a life-threatening condition resulting from the body's imbalanced response to infection. It highlights the pathophysiology of septic shock, emphasizing systematic inflammation, temperature changes, and the body's immune response. The analysis id...Read More

Running head: SEPSIS 1
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Title: Septic Shock

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Sepsis is a life threatening health condition brought about by the body responding to
certain infections. In cases of infections, the body releases chemical substances in to the
bloodstream and the body has to respond back to these chemical substance (Seymour and
Rosengart, 2015). Sometimes the body’s response to the chemical substances is out of balance
leading to this condition called sepsis. Sepsis can occur to anyone and it is dangerous and
common among the elderly, pregnant mothers, children less than 1 year old, people with chronic
conditions like cancer, kidney or disease or diabetes, and individuals with weak immunity.
Severe sepsis is a condition whereby sepsis is accompanied with hypotension, hyperfusion and
organ dysfunction. Hyperfusion can lead to lactataemia or altering mental status and functioning.
Hotchkiss et al. (2016) describe septic shock as a condition of sepsis associated with perfusion
abnormalities and hypotension even after the patient has been provided with sufficient fluid
resuscitation and vasopressors need to be used. Early research on sepsis was more focused on the
disease causing microorganism and the pathogenicity. Current study on the infection indicates
the people’s understanding pathophysiology and the interaction between the host and the
microorganism.
With the invention of molecular cloning in the 1980s, the research on sepsis shifted to
less on pathogenicity and more on how the host responds to the pathogen. Despite more research
and increased understanding on this condition, researchers’ and health professionals’ ability to
intervene and change the trajectory of the disease has not yielded much fruits. The mortality rate
as a result of sepsis and septic shock has however reduced in the past decades. This is attributed
to nurses complying to the supportive therapies (Hernández, & Teboul, 2016). Septic shock is
characterized by different signs and symptoms. Among these is the systematic inflammation and
causing other immune responses on the host. The systematic inflammation is as a result of the

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body releasing cytokines and other mediators which start fighting the infection (Gligorijevic,
Stojanovic, & Obradovic, 2016). The body also experiences temperature change. Any
temperature change above the normal is considered hyperthermia and sometimes the temperature
drops (hypothermia). This is because the body is trying to fight the disease causing
microorganism. Individual who have had surgery, just like Greer, could experience local
infections such as UTI and pneumonia, whose signs and symptoms are localized. This is
accompanied by feeling unwell and malaise just like Elodie the time she was presented to the
hospital. This is because sepsis affects the mental status of an individual. The nurse would also
look for high white blood count, elevated procalcitonin, low blood pressure, high cardiac index,
low central venous, reduced oxygen level, clotting abnormalities, low platelets level, low urine
output, increased bilirubin level, reduced capillary filling and high lactate in blood (Jone et al.
2013).
As stated earlier that septic shock is as a result body responding to certain infection.
This body response causes systematic reactions causing the body immunity to produce cytokines
for fighting these infections. Typically, cytokines stimulates vasodilation of the blood vessels at
the infected area. This allows more blood carrying mediators and disease fighting cells to flow to
that area. However, this is not the case with septic shock. Septic shock causes inflammation of
the whole body. The dilation of blood vessels causes reduction in blood pressure. The dilation of
blood vessels does not help in fighting the infection like in other cases of dilation when body is
stacked by infection, in fact it slows down blood flow and makes the body immune system more
ineffective (Kuipers et al. 2016). Hypotension therefore affects the body immune system making
it a priority problem for patients suffering from septic shock (for Elodie in the case study). Since
there is reduced immunity, the bacteria affecting the body can cause damage of vital organs.

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Research indicates that the bacteria mostly affect the lungs, abdomen, urinary tract, blood vessels
and the central nervous system. Additionally, since the blood flow rate has been altered, body
organs especially the vital one like the heart, brain and liver are not supplied with sufficient
blood (Hernandez et al. 2012). This puts the individual (Elodie in the case study) at a risk of
organ failure. Failure of these organs leads to death. According to Jeon, Song, Chung, Yang and
Suh (2018) low blood pressure and organ failure are the biggest dangers associated with severe
septic and septic shock.
Dunser and Dubin (2018) claim since the systemic inflammation result to reduced blood
flow, the body cells do not get sufficient oxygen for respiration. This leads to them respiring
anaerobically producing large amounts of lactic acid in the body. Though the lactic acid could be
oxidized to energy, the lactic acid could be acidic to the body cells. Bosmann, & Ward (2013)
further claim that the systemic inflammation is associated with conditions like change in body
temperature (>38.3 or <36 degrees Celsius) , heart rate, the white blood cells count, respiratory
rate, hyperglycaemia and also altering the mental activity. As earlier stated that systemic
inflammation just like hypotension are stimulated by the body producing cytokines, research by
Keeley, Hine and Nsutebu (2016) showed that systemic inflammation could also be stimulated
by the bacteria, their toxins and inflammatory mediators. High levels of cytokines in the blood,
other that causing vasodilation lead to capillary leakage.
Before administering any treatment measures, nurses have first to carry out diagnostics
so as to identify the cause of a certain ailment. There are different diagnostic methods for
hypotension. For the case of Elodie the nurses could carry out blood tests to determine if she had
other infections such as hypoglycemia, diabetes or anaemia. The health professionals are likely
to find Elodie with hyperglycemia as Dunser and Dubin (2018) claim that the systemic

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inflammation is associated with this condition. Electrocardiogram can also be done to detect the
heart rhythm and electric signals. This diagnosis can also detect the nature of the heart rhythm,
nature of the heart and blood and oxygen supply to cells and tissue. This is important considering
the dilation of blood vessels. Other tests would include stress test, Valsalva maneuver and tilt
table test. Alsolamy et al (2018) claim that despite the nature of hypotension (showing or not
showing any signs and symptoms) it needs to be treated. However, the treatment for hypotension
depends is dictated by the underlying cause. If the low blood pressure is due to certain
medications, the therapy here would be stopping the medication, giving it at a lower dose or
changing it.
There are different therapies recommended for low blood pressure. Health professionals
would recommend limiting the amount of salts in Elodie’s diet. This is because sodium can
drastically increase the blood pressure. It is however important to consult the health professional
because sodium could cause heart failure. Another therapy applied in management of low blood
pressure is the use of drugs. However, Shibao, Lipsitz and Biaggioni (2013) pdrugs are not
completely sufficient in the treatment of low blood pressure. The therapy includes a combination
of vasoconstrictors, postural adjustment, compression garments and volume expansion drugs.
There are different set of drugs used in the treatment of low blood pressure. These could include
morphine, imipramine, paroxetine, venlafaxine, phenelzine, quetiapine (just to name a few).
Shibao et al. (2018) think that health professionals should also consider non-pharmacological
interventions. These interventions can be applied in any order depending on the patient’s safety
and consideration. Interventions like increasing fluid and salt intake could increase blood
volume, raising the bed head could reduce nocturia and physical activity and putting on an
abdominal binder could reduce venous pooling. In cases whereby the plasma volume does not

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change even after fluid and salt intake, fludrocortisone should be administered. Pyridostigmine
has vasoconstrictor effects especially when standing. However, it is used in cases of mild
hypotension that does not show changes after application of the non-pharmacological measures.
It can be used in collaboration with midodrine, which is mostly used in severe cases of
hypotension. Dunser and Dubin (2018) suggest the use A-to-F mnemonic as a management
strategy for hypotension. A stands for abdominal compression, patients should put on abdominal
binders before going to bed, B for bolus of water and bed up. The patient should drink two 8
ounces glasses of cold water before standing and should sleep with their head in a 4 inch
elevated area. C stands for counter maneuvers, which involves physical activity so as increase
one’s blood pressure, D for drugs, using drugs to raise the blood pressure, E for education, that
the patient should be aware of conditions that lower their blood pressure, symptoms that show
the blood pressure is dropping and also know what the individual should do to increase the blood
pressure. The patient is also advised to avoid inactivity. Finally is F for fluid and salt. The patient
needs a high intake of fluids and salts.
Having been previously diagnosed with acute lymphoblastic leukaemia, where she
underwent a chemotherapy, the case study also indicates that she underwent an allogenic stem
cell transplant some time ago. She is now taken to the health centre feeling unwell and malaise.
She is quite and withdrawn. Elodie’s mother claims that her daughter does like the hospital and
could do anything to avoid being there. Christine is also very worried about her daughter’s state.
The nature of her health affects her psychology as diseases affect also the psychological status of
an individual. She feels unwell, malaise and depressed. I could say this is due to her health
status. Her mother claims that she is withdrawn. She is not social anymore. Her being taken to
the emergency department shows the seriousness of her condition. Considering that the patient is

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young and also withdrawn, she cannot make any decision concerning her treatment. Lyu and
Zhang (2018) argue that since the patient’s family is present, the health professionals should
balance the ethical consideration in making any decision concerning the patient and also in
allocation of resources to be used by the patient. In every decision made pertaining the patient,
her mother should be involved (Biswas, Karabin and Turner, 2019). In cases where she is unable
to decide, then she should get help from the health professionals.

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References
Alsolamy, S., Al-Sabhan, A., Alassim, N., Sadat, M., Al Qasim, E., Tamim, H. Arabi, Y. M.
(2018). Management and outcomes of patients presenting with sepsis and septic shock to
the emergency department during nursing handover: a retrospective cohort study. BMC
Emergency Medicine, Vol. 18, Article number: 3 (2018). Doi:
https://doi.org/10.1186/s12873-018-0155-8DO
Bosmann, M., & Ward, P. A. (2013). The inflammatory response in sepsis. Trends in
immunology, 34(3), 129–136. doi:10.1016/j.it.2012.09.004
Biswas, D., Karabin, B., & Turner, D. (2019). Role of nurses and nurse practitioners in the
recognition, diagnosis, and management of neurogenic orthostatic hypotension: a
narrative review. International journal of general medicine, 12, 173–184.
doi:10.2147/IJGM.S170655
Cecconi, M., Evans, L., Levy, M. and Rodhes, A. (2018). Sepsis and septic shock. The Lancet,
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Dünser, M. W., & Dubin, A. (2018). There is more to septic shock than arterial hypotension and
elevated lactate levels: another appeal to rethink current resuscitation strategies!. Annals
of intensive care, 8(1), 55. doi:10.1186/s13613-018-0406-6
Gligorijevic, D., Stojanovic, J., & Obradovic, Z. (2016). Disease types discovery from a large
database of inpatient records: A sepsis study. Methods, 111, 45-55.
Hernández, G., & Teboul, J. L. (2016). Is the macrocirculation really dissociated from the
microcirculation in septic shock? Intensive care medicine, 42(10), 1621-1624.

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Hernandez, G., Bruhn, A., Castro, R., Pedreros, C., Rovegno, M., Kattan, E.,Veas, E.,
Fuentaelba, A., Ruiz, C. and Ince, C. (2012). Persistent Sepsis-Induced Hypotension
without Hyperlactatemia: A Distinct Clinical and Physiological Profile within the
Spectrum of Septic Shock. Critical Care Research and Practice, Vol. 2012, Article ID
536852, 7 pages. Doi: http://dx.doi.org/10.1155/2012/536852
Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L.
(2016). Sepsis and septic shock. Nature reviews. Disease primers, 2, 16045.
doi:10.1038/nrdp.2016.45
Jones, A. E., Shapiro, N. I., Trzeciak, S., Arnold, R. C., Claremont, H. A., Kline, J. A., &
Emergency Medicine Shock Research Network (EMShockNet) Investigators. (2013).
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randomized clinical trial. Jama, 303(8), 739-746.
Jeon, K., Song, J., Chung, C. R., Yang, J. H. and Suh, G. Y. (2018). Incidence of hypotension
according to the discontinuation order of vasopressors in the management of septic
shock: a prospective randomized trial (DOVSS). Critical Care, Vol. 22,
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Kuipers, J., Oosterhuis, J. K., Krijnen, W. P., Dasselaar, J. J., Gaillard, C. A. J. M., Westerhuis,
R., & Franssen, C. F. M. (2016). Prevalence of intradialytic hypotension, clinical
symptoms and nursing interventions - a three-months, prospective study of 3818
haemodialysis sessions. Bmc nephrology, 17(1),[21]. https://doi.org/10.1186/s12882-016-
0231-9

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Keeley, A., Hine, P. and Nsutebu, E. (2016). The recognition and management of sepsis and
septic shock: a guide for non-intensivists. BMJ Journals, Vol. 93, No. 1104. Doi:
http://dx.doi.org/10.1136/postgradmedj-2016-134519
Lyu, C. and Zhang, L. (2018). Who decides in withdrawal of treatment in a critical setting? A
case study on ethical dilemma. International journal of Nursing Sciences, Vol. 5, No. 3.
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Shibao, C., Lipsitz, L. A., Biaggioni, I., & American Society of Hypertension Writing Group
(2013). Evaluation and treatment of orthostatic hypotension. Journal of the American
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Treatment. JAMA, 314(7), 708–717. doi:10.1001/jama.2015.7885