case study help - page 4

by ckirkpa

3,052 Views | 41 Comments

I am currently working on the following case study and need a little guidance on which way to go with the info. Any ideas? I think the patient is possibly septic r/t her leg??? I am not sure though. There is so much going on.... Read More


  1. 0
    Lactic acidosis from shock. .yes
  2. 0
    Quote from laurensummers
    There are no ketones in HHS because there is insulin so how can the ACIDOTIC STATE be explained. ..Septic shock-!!!.we cannot say this is HHS without Osmolarity and urine output.
    Sepsis or septic shock is systemic inflammatory response syndrome (SIRS) secondary to a documented infection. Detrimental host responses to infection occupy a continuum that ranges from sepsis to severe sepsis to septic shock and multiple organ dysfunction syndrome (MODS). The specific clinical features depend on where the patient falls on that continuum.

    Symptoms of sepsis are often nonspecific and include fever, chills, rigors, fatigue, malaise, nausea, vomiting, difficulty breathing, anxiety, or confusion. These symptoms are not pathognomonic for sepsis syndromes and may be present in a wide variety of other conditions. Alternatively, typical symptoms of systemic inflammation may be absent in severe sepsis, especially in elderly individuals.

    Fever is a common symptom of sepsis.

    Chills are a secondary symptom associated with fever, which is a consequence of increased muscular activity that produces heat and raises the body temperature. Sweating occurs when the hypothalamus returns to its normal set point and senses the higher body temperature, stimulating perspiration to evaporate excess body heat.


    Alteration in mental function often occurs. Mild disorientation or confusion is especially common in elderly individuals. Apprehension, anxiety, agitation, and, eventually, coma are manifestations of severe sepsis. The exact cause of metabolic encephalopathy is not known; alteration in amino acid metabolism may play a role.


    Hyperventilation with respiratory alkalosis (this patient has respiratory acidosis) is a common feature of patients with sepsis secondary to stimulation of the medullary respiratory center by endotoxins and other inflammatory mediators.


    This patient is afebrile.
  3. 1
    Quote from laurensummers
    Yea I believe so..just because you been a nurse for so many years really doesn't mean you know everything..open any text book..this case matches Septic shock to capital T. At every hospital the sepsis and SIRs screening criteria is the SAME..and this matched..not to mention I explained the tenting as septic shock begins the capillary hydrostatic pressure drops resulting in fluid shift from interstitial space to vessels to compensate. .it is hypo-perfusion..then when it gets to the progressive stage it reverses and the capillary pressure changes and vessels get LEAKY..please look this up because sometimes one must humble themselves..
    I have no argument with you....I just disagree.

    I have looked this up and I have no need to do so now.

    I agree sometimes one must humble oneself.

    I wish you all the best
    psu_213 likes this.
  4. 0
    Quote from laurensummers
    I would hardly say a BGM of 550 is an emergency over the fact that this patient is in SEPTIC SHOCK.
    I am saying that they both need to be treated. Yes, I agree with septic shock, but there is a degree of hypovolemic shock RT osmotic diuresis.
  5. 0
    I just do not see any data that states the patient is hypovolemic...sepsis is not always presented with fever...it can be high or low..surely a CVP OR PAWP would be great right about now lol
  6. 1
    Quote from laurensummers
    Yea I believe so..just because you been a nurse for so many years really doesnt mean you know everything..
    Was that really called for? Though we were having a pretty intelligent conversation about the case, but it seems to have devolved.

    Yes, the meets checklist items for many aspects of septic shock. However, it certainly appears that there are diabetic issues here to (Esme says HHS, but I think we still need to consider DKA--and we cannot know until we get a UA back, possibly a serum acetone level and serum osmo). You seem to be digging your heels in that this is sepsis and only sepsis. Perhaps the HHS/DKA is secondary to severe infection, but that does not mean that we just treat the sepsis any nothing else.
    Esme12 likes this.
  7. 1
    Quote from laurensummers
    Lactic acidosis from shock. .yes
    We know the pt is somewhat acidotic (although I've seen much worse), but there is no evidence that this is (just) a lactic acidosis. Certainly an elevated lactate level would point toward shock, but even that is quite nonspecific.
    Esme12 likes this.
  8. 0
    I wasnt trying to be rude..but this person is resistant to any FACTS im offering...I truely do not think this sitiation was caused by DM... look at the data..if the patient had poirly controlled DM they would be on SQ insulin..this pt is only on metformin...not saying the is no fluid deficit maybe mild but the The first part if stem clearly shows the pneumonia is the beginning of all the subsequent problems..really. .as they teach in school..the underlying problem must be fixed and treat symptoms I.e. insulin etc...
    Last edit by MendedHeart on Mar 20, '13
  9. 0
    PaO2=70=anareobic metabolism=lactic acid
  10. 0
    Quote from laurensummers
    I wasnt trying to be rude..but this person is resistant to any FACTS im offering...I truely do not think this sitiation was caused by DM... look at the data..if the patient had poirly controlled DM they would be on SQ insulin..this pt is only on metformin...not saying the is no fluid deficit maybe mild but the The first part if stem clearly shows the pneumonia is the beginning of all the subsequent problems..really. .as they teach in school..the underlying problem must be fixed and treat symptoms I.e. insulin etc...
    I think your teachers would be proud of you for your grasp of physiology. Applied medicine isn't always clear and patients seldom meet the exacting criteria that is presented in the texts. The pneumonia, or the infected leg, clearly began a sequale of events of events and of course more information is needed to make a definitive diagnosis.

    I think we can agree this patient is sick and acidotic we just disagree on the definitive cause of the presenting labs.
    Shock is hypotension with end organ injury: it classified as being due to malfunction of 1) the Pump (cardiogenic), 2 ) the Tubing (distributive), or 3) the Fluid (hypovolemic). http://www.ccmtutorials.com/cvs/Shock/page_03.htm

    Hypotension and Shock are caused by a problem with Heart Rate, Stroke Volume or Peripheral Resistance.
    There are only three types of shock, problems with the heart, sometimes called cardiogenic shock, problems vascular system, known as distributive shock, and loss of circulating volume, known as hypovolemic shock.
    Although textbooks and examiners often emphasize the classification of shock, in the real world, it is often more effective to use the physiologic approach to shock:

    • Shock is due to inadequate blood pressure.
    • Low blood pressure is due to inadequate cardiac output or low peripheral resistance.
    • Low cardiac output is caused by a problem with heart rate or stroke volume.
    • Heart rate abnormalities: too fast (tachycardia), too slow (bradycardia).
    • Stroke Volume abnormalities: failure to receive, failure to eject, inadequate volume
    • Low peripheral vascular resistance is due to inappropriate vasodilatation.
    When you graduate you will find that the reality of caring for patients is convoluted and is seldom clearly defined........Be open to opinions even if they are in conflict with your own. You are intelligent and have a great grasp on physiology. I think you will make a great nurse.

    Great job! All the best.
    Last edit by Esme12 on Mar 22, '13


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