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Septic Shock Case Study (45 min)

sepsis nursing case study
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Mr. McMillan, a 92-year old male, presents to the Emergency Department (ED) with urinary hesitancy and burning and a fever at home of 101.6°F.  His caregiver states “he just doesn’t seem like himself”.

Critical Thinking Check
Bloom's Taxonomy: Application

What initial nursing assessments need to be performed for Mr. McMillan?

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Upon further assessment, Mr. McMillan is weak, his face is flushed, his skin is warm and dry. He is oriented to person and place, but states the year is 1952. His vital signs were as follows:

BP 99/60 mmHg Ht 170.2 cm

HR 92 bpm and regular Wt 60 kg 

RR 28 bpm SpO2 93% on Room Air

Temp 38.9°C

Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests should be ordered for Mr. McMillan?

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Critical Thinking Check
Bloom's Taxonomy: Application

What nursing actions would you take at this time for Mr. McMillan? Why?

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The ED provider orders the following:

  • Bloodwork – CBC, BMP, ABG, Lactic Acid, Blood Cultures x 2
  • Urine Tests – Urinalysis, Urine Culture
  • Diagnostics – CXR (chest x-ray), KUB (x-ray of kidneys, ureters, and bladder)
  • Nasal Cannula to keep SpO2> 92%
  • Meds – 1L Normal Saline bolus IV x 1, now.  1,500 mg Vancomycin IVPB x 1 dose, now

Critical Thinking Check
Bloom's Taxonomy: Analysis

Which order should you implement first? Why?

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All blood and urine tests are completed and you initiate the fluid bolus for Mr. McMillan. You are still waiting for the Vancomycin to arrive from the pharmacy. You notice he is more drowsy. He is now only oriented to self and feels warmer. You take another set of vital signs to find the following:

BP 86/50 mmHg MAP 62 mmHg

HR 108 bpm Temp 39.3°C

RR 36 bpm SpO2 88% on Room Air

Mr. McMillan’s lab results have also resulted, the following abnormal values were reported:

WBC 22,000 / mcL Lactic Acid 3.6 mmol/L

pH 7.22 pCO2 30 mmHg

HCO3 16 mEq/L pO2 64 mmHg

Urine Cloudy with sediment

Critical Thinking Check
Bloom's Taxonomy: Application

What action(s) should you take at this time? Why?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What orders do you anticipate for Mr. McMillan? (procedures, meds, transfer, etc?)

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Mr. McMillan responds well to the first liter of fluids, and antibiotics are initiated within an hour of arrival. The ED physicians place an arterial line and central line to initiate vasopressors. They order a Norepinephrine infusion to be titrated to keep MAP > 65 mmHg. The Critical Care team asks you to prepare the patient for transfer to the ICU.

Art. Line BP 82/48 mmHg MAP 58 mmHg

HR 122 bpm CVP 4 mmHg

RR 32 bpm SVR 640 dynes/sec/m-5
SpO2 90% on Room Air

Critical Thinking Check
Bloom's Taxonomy: Analysis

What, physiologically, is going on with Mr. McMillan?

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Critical Thinking Check
Bloom's Taxonomy: Comprehension

What does it mean to titrate an infusion to keep MAP >65?

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After 2 days in the ICU, a norepinephrine infusion and a total of two liters of normal saline, Mr. McMillan’s blood pressure is stable, his MAP is 67 mmHg. He is becoming more alert and is now oriented to person, place, and time.  His blood and urine cultures were positive for bacterial growth. He has received multiple doses of Vancomycin as well as antibiotics targeted to his specific bacterial infection. He is being weaned off of the vasopressors, and the providers hope he can transfer out of the ICU tomorrow.

 

Critical Thinking Check
Bloom's Taxonomy: Application

What explanation or education topics would you want to provide to the patient and his caregiver before discharge?

View Answer

 

Happy Nursing!

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