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 beats per minute; respirations 28 breaths per minute; blood pressure 86/44 mmHg , with a mean arterial pressure, or MAP, of 58 mmHg; and oxygen saturation 89 percent on 4 liters 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 liter bolus of IV fluids that just finished infusing.

Next, Nurse Miguel analyzes these cues. He reviews the electronic health record, or EHR, and notes Scott’s white blood cell, or WBC, count is elevated at 18,500 cells/ µL; 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’s profound cellular, circulatory, and metabolic dysfunction, and that it’s a subset of sepsis, which involves life-threatening 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 non-pharmacologic interventions; and he establishes the expected outcome that after intervening, Scott’s MAP will increase to 65 mmHg or greater within 15 minutes.