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Case study of a deteriorating patient- Septic shock

Learning outcome 1. Consolidate knowledge of key NMBA Registered Nurse Standards for Practice, National Safety and Quality Health Services Standards, and National Health Priorities to enable effective decision planning and action in a range of complex clinical situations across the lifespan.

Learning outcome 2. Apply knowledge of anatomy, physiology and pathophysiology to support evidence-based decision making associated with planning and action.

Learning outcome 3. Demonstrate structured decision making and clinical reasoning to review a range of health situations, synthesise evidence and data, determine priorities and formulate plans of care and interventions in line with timeframes and agreed goals

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Introduction:

Sepsis was initially thought to be an untreatable bacterial infection with symptoms such as fever, tachycardia and loss of body fluids. Over the course of the years the definition of sepsis has been modified into being a prolonged immune response by the body against an infection. Sepsis is one of the major challenges even today in health care and is a leading cause of mortality in the emergency units. It is characterised by a systemic immune response of the body towards an infection. The immune responses elicited in this course have a negative effect on multiple organs sometimes with a consequence of multiple organ dysfunction. History of past and existing medical conditions both acute and chronic, susceptible genetic makeup may predispose an individual to sepsis eventually leading to septic shock (Hotchkiss et al., 2016; Karnatovskaia&Festic, 2012). The current case study reveals the case of a 14-year-old female Ms. Elodie who underwent a recent surgery for the allogenic stem cell transplant as a cure for Acute Myeloid leukaemia (AML). Initially the individual was treated for AML with chemotherapy. Stem cell transplant was performed in addition to the immunosuppressive medication. Sepsis is observed as a clinical complication post-chemotherapeutic treatment received by an individual aggravated by the immunosuppressive medication of the individual.

Question 1: Identify and discuss two (2) signs or symptoms of clinical deterioration associated with the pathophysiology of the patients' presenting problem.

Solution: Signs, symptoms and pathophysiology:

Any organ damage or infection in the body initiates a natural immune response, when the extent of damage is severe a systemic response is elicited through the employment of the inflammatory elements which further damages the tissues across the body, this condition is defined as sepsis. Common findings of sepsis included high body temperature usually associated with altered mental health (delirium) i.e., confusion, rapid heartbeat (tachycardia) of over and above 95 beats per minute to compensate the lowered blood volume in the case of a hypovolemic shock. The capacity to respire is decreased and hence a dramatic increase in the rate of respiration is commonly observed (at least 21 breaths per minute). The number of white blood cells (leucocytosis) or leucocytes and C-Reactive protein is elevated indicating the sudden onset of severe inflammation. A significant drop in the blood volume decreases the systolic pressure below 90mm Hg causing hypotension (Karnatovskaia&Festic, 2012)(Rello, Valenzuela-Sánchez, Ruiz-Rodriguez, &Moyano, 2017)(Rello et al., 2017)

In the current case scenario, the patient Eloide showed clear signs of sepsis with an elevated oral temperature of 380 C. The rapid denigration of blood pressure to 102/67mm Hg in association with an increase in the heart beat to 103 beats. Percentage saturation of oxygen is slightly lower i.e, 91%. However, an optimum level of haemoglobin concentration is observed. In the cases of ALL the patients are observed to be anaemic and the current data suggests the successful treatment of ALL (Meenaghan, Dowling, & Kelly, 2012)

During the normal healthy state, the blood stays as liquid with regulated clotting mechanisms. Clotting occurs in the vessels which leads to the vessel blockage thus resulting in the low blood flow and thereby reduced blood pressure. These coagulation abnormalities occurs locally across the body causing a systemic effect on the vital organs.

However, an elevated level of WBCs (neutrophils) reflects the state of inflammatory processes. Prolonged inflammatory processes result in the increased risk of multiple organ damage.

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Question 2. Identify one (1) priority problem associated with the patient's clinical presentation, and through the application of contemporary research provide a justification as to why the problem is a clinical priority within the case.

Solution: Clinical manifestations- Priority problem and its clinical significance:

Septic shock is an advanced state of sepsis with an acute impairment of circulatory system characterised by hypovolemia. In the current case, low blood pressure is recorded that conveys a hypovolemic state. The peripheral perfusion or the supply of nutrient to the tissues is severely hindered. This redirects the cellular metabolism from aerobic to anaerobic causing lactic acidosis. Extended periods of acidosis lead to the ischemic injury to the vital organs and hence is very important to immediately control the blood volume and thereby improving the oxygen supply. Brain cells are prone to damage with both lack of fluid as it results in insufficient supply of oxygen (Karnatovskaia&Festic, 2012). A simultaneous significant clinical consequence is dehydration reflected through the colour of the urine output and the skin. Dehydration leads to disruption in the cognitive function. A case of delirium is also observed in the cases of severe dehydration. The effects of mild dehydration can be reversed without permanent complications however prolonged dehydration leads to shrinkage of cells. The excess ions on the extracellular compartment transfers water outside the cells thereby maintaining the state of equilibrium. However this is dangerous to the cells as excessive loss of water also increases the possibility of necrosis. The renal systen manages the excretion of metabolites and toxic nuteients. Lack of sufficient quantity of fluid volume doesnot allow the filtration in the glomeruli as the pressure is reduced. As a consequence toxins accumalate Hence, changes in the blood volume has a direct effect on the body systems such as brain, kidneys and liver. It is a case of emergency and should be closely monitored.

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Question 3. Discuss two (2) nursing interventions to address the priority problem and how to evaluate the efficacy of these interventions.

Solution: Nursing interventions:
Treatment of sepsis is one of the emergency procedures employed in the hospital setting. The most common strategy applied is to suspect, action includes provision of ventilation with positive oxygen therapy and continuous evaluation. The primary goal is to provide adequate supply of oxygen through artificial ventilation and treat the individuals with antibiotics to bring down the infection. The success rate of treatment relies heavily on the early diagnosis and intervention for sepsis (Alsolamy et al., 2018).

Fluid resuscitation and management of dehydration:
The fluid resuscitation to maintain the blood volume through the supply of saline and albumin to improve the mean arterial pressure. Resuscitation of fluid volume sometimes may result in a worsened health outcome given the condition of patient such as organ dysfunction. There has been cases of fluid accumulation and a systemic oedema thus care should taken while administering the fluids as it may lead to fluid overload one of leading causes of morbidity and mortality (Malbrain et al., 2018)

Administration of fluids alone is ineffective in improving the blood pressure and tissue perfusion. The hormones such as vasopressin and norepinephrine are recommended. These hormones are involved in the regulation or urinary output and an increase in the hormones is preferred as a cohesive effort to maintain the required blood volume Sepsis also presents with a hyperglycaemic condition attributed to the impaired glucose uptake due to insulin resistance (Kim & Park, 2019). Blood volume can be evaluated through the observation of heart rate which usually return to its normal state. Amount of urinary output in a day i.e, 1.5 litres. Skin turgor i.e., the fluid present in the cutaneous layer of the skin tissue. Formation of indentations and presence of skin folds reflect the status of hydration. Blood pressure is an ideal measure for both blood volume and dehydration.

Antibiotics administration:
Antibiotic therapy in the case of sepsis is initiated in the first hour of diagnosis and a culture is usually obtained from the blood culture. The culture results may delay the identification of the type of organism, hence usually a broad-spectrum antibiotic is recommended. Research shows a significant delay in the administration of the first dosage of antibiotic post the diagnosis is often the reason for such poor prognosis. The intravenous route is ideal for the antibiotic administration. Failing to determine the type of causative organism often causes delays in deciding the type of antimicrobial especially in the case of an immunosuppressed individual the complication of increasing the numbers of drug-resistant bacteria is a threat and deciding factor. At regular intervals temperature is recorded. The combination therapy of antibiotics and antifungals is highly recommended initially to address all the pathogens followed by re-evaluation of the treatment based on the culture results. The site of source for the infection should be determined and the physical measure such as drainage of the pus inhibits the severity(Berg & Gerlach, 2018).

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Question 4. Identify one psychosocial issue derived from the information provided within the case study, and applying a patient centred approach, discuss the care needs and considerations related to the patient and their family.

Solution: Psychosocial issues:

In the current case, the active living is compromised as it is dependent upon an individual's ability to perform all the functions independently. The neurological damage due to cerebral ischemia causes delayed response time often incapacitating the patient to self-care such as holding objects, sanitation practises. Myopathy and encephalopathy are a common observation in the individuals who are successfully discharged post sepsis treatment. Ms.Elodie may experience severe Muscular fatigue even with the simple tasks given her low blood pressure and Cognitive function impairment has short and long-term effects such as level of consciousness, analytical skills, memory retention. A significant change in the appetite, and symptoms of post-traumatic stress is also observed (Prescott & Angus, 2018)(Brück, Schandl, Bottai, & Sackey, 2018).

Depression is observed both in the young and elderly those that survive sepsis as the reduction in the cognitive functioning and muscular ability is dramatic in comparison to younger people. In a short period of time the complications of sepsis are also visible in the. A previous history of comorbidities and chronic illness increases the mental health complications as is the case of Ms.Elodie with AML(Davydow, Hough, Langa, &Iwashyna, 2013; Rello&Rubulotta, 2018) Critical care is stressful for the patient and the their families. Hence a patient-centred-approach is implemented which is established through assuring the family that the patient is being taken care of, the family members are spoken to regarding their concerns. One of the significant factors of stress is the information update on the medical condition of the patient as the patient themselves express their health status.

Conclusion:
Sepsis is a debilitating and lethal physiological condition caused by the systemic immune response by the body towards acute infection. The most challenging part is the identification of the source of infection, determination of type of causative organisms and the evaluating an ideal strategy for treatment. Early nursing intervention is the key to the effective treatment. The treatment regimen of sepsis includes the maintenance of oxygen, circulation blood volume, electrolytes, core temperature and a reduction in the infection (Bullock & Benham, 2019; Mira et al., 2017)

The after effects of a sepsis treatment are multi-fold from physical disability attributed to tissue damage, psychological issues. PTSD and depression are common among the sepsis survivors majorly due to the decline in the quality of life especially among the elderly. Open-communication regarding the treatment, physiotherapy with adequate diet is observed to have positive effect the anxiety. Physiotherapy and collaboration with other individuals is highly recommended (Gehrke-Beck et al., 2017).

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