Critical care case study - Septic shock: Nursing

Nurse, Miguel works in the intensive care unit and is caring for Scott, a 64 year old admitted for septic shock. Nurse, Miguel goes through the steps of the clinical judgment measurement model to make clinical decisions about Scott's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Miguel recognizes important cues including Scott's vital signs which are temperature 101.2 °F or 38.4 °C, heart rate 105 BPM, respirations, 28 breaths per minute BP, 86/44 millimeters of mercury with a mean arterial pressure or map of 58 millimeters of mercury and oxygen saturation.

89% on 4 L of oxygen per nasal cannula upon assessment. Nurse Miguel notes, Scott's skin is warm and flushed.

He's oriented to person and place but not time and appears restless. Scott also has a 1 L bullous of IV fluids that just finished infusing.

Next. Nurse Miguel analyzes these cues.

He reviews the electronic health record or E Hr and notes, Scott's white blood cell or W BC count is elevated at 18,500 cells per microliter.

His lactate is increased and his arterial blood gas or ABG results indicate metabolic acidosis. Nurse, Miguel knows septic shock is a condition in which there is profound cellular circulatory and metabolic dysfunction.

And that it's a subset of sepsis which involves lifethreatening organ dysfunction caused by an extreme and dysregulated systemic response to an infection.

He understands that the inflammatory mediators released by immune cells in response to the infection causes vasodilation of the endothelial cells lining the blood vessels along with increased capillary permeability where the endothelial cells begin to separate, allowing plasma proteins to move out into the tissues, pulling fluid with them.

This results in circulatory alterations that include relative hypovolemia, reduced circulating volume, hypotension, decreased preload and decreased cardiac output which together result in decreased tissue perfusion and hypoxia without oxygen cells throughout the body start to rely on anaerobic metabolism for energy which produces lactic acid leading to acidosis simultaneously.

The coagulation cascade is activated resulting in microvascular thrombosis which impairs tissue perfusion even more. Eventually, this widespread clotting can lead to disseminated intravascular coagulation and hemorrhage.

Ultimately, as compensatory mechanisms fail, septic shock can lead to multiple organ dysfunction syndrome and death. Nurse, Miguel knows Scott needs prompt management of septic shock.

Now, using the information he's gathered nurse, Miguel chooses a priority hypothesis of impaired cardiac output. Then he generates solutions to address Scott's impaired cardiac output, including pharmacologic and nonpharmacologic interventions.

And he establishes the expected outcome that after intervening Scott's map will increase to 65 millimeters of mercury or greater within 15 minutes.

Then nurse Miguel takes action to implement these solutions. First.

He speaks with the critical care provider to report his assessment findings. Nurse Miguel receives an order to begin a continuous vasopressor infusion in to titrate it to maintain a map of 65 millimeters of mercury or greater in to titrate oxygen as needed to ensure oxygen saturation above 92%.

There is also a dose of a broad spectrum antibiotic scheduled and an order for an antipyretic as needed for fever. Nurse, Miguel gathers the necessary supplies and reenter Scott's room and explains the plan of care to Scott after Scott communicates understanding of the plan of care.

Nurse, Miguel increases his oxygen from 4 to 6 L. Then he ensures Scott is on a continuous monitor and that it's programmed to take Scott's BP every five minutes.

He administers the vasopressor antibiotic and antipyretic. Following the principles of safe medication administration.

He elevates Scott's legs to increase venous, return to the heart and hands. Scott the call light explaining he will be monitoring him closely.

Five minutes later, nurse Miguel evaluates the outcomes of his actions. He notes Scott's vital signs which are temperature 101.0 °F or 38.3 °C, heart rate, 100 and three BPM, respirations, 20 breaths per minute BP, 90/46 millimeters of mercury with a map of 61 millimeters of mercury and oxygen saturation.

93% on 6 L per nasal cannula. He titrates the vasopressor and after five minutes, he rechecks Scott's BP which is 94/50 millimeters of mercury with a map of 65 millimeters of mercury.

All right. As a quick recap, nurse, Miguel recognized and analyzed cues related to Scott's impaired cardiac output and prioritized hypotheses and generated solutions to address this problem.

Nurse Miguel then implemented pharmacologic and non pharmacologic measures to manage Scott's impaired cardiac output and evaluated outcomes compared with the expected outcomes.

Since Scott's map increased to 65 millimeters of mercury within 15 minutes. Nurse Miguel determined the plan of care was successful.