Septic Shock - page 2

Hi, I'm kind of desperate for some help. I've got a 24 yo pt. who received a GSW to the abdomen with perforation of the mall intestine and the colon. He had intestinal resection and right side... Read More

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    Quote from superana
    No. At least I don't think so. It's a "hypothetical clinical situation."
    Grrrrrrrrr this drives me nuts. I believe that this is why student have such difficulty with nursing diagnosis and care plans because it is all about the patients assessment.

    Ok......first. What is shock? Welcome to Critical Care Medicine Tutorials What is sepsis? Infections and Intensive Care
    What does it do to the body?
    • The patient is initially injured in some way - this may be, for example, infection, trauma or inflammation.
    • The result of this injury is activation of host defense mechanisms, including release of inflammatory cytokines, particularly interleukin-6 and tumor necrosis factor alpha.
    • The physiologic manifestations of this process include tachypnea, tachycardia, leucocytosis and pyrexia, and we call this the systemic inflammatory response. The body is, in effect, responding to the source of inflammation and making physiologic compensation for the systemic upset.
    • If the patient is unable to adequately compensate, and suffers acute organ failure, then he /she requires critical care interventions - usually mechanical ventilation, often with cardiovascular support.
    • The patient has undergone a "first hit". He/she is now vulnerable to further injury.
    • At this point one of three things may happen: 1) the injury and inflammatory and or inflammatory response may persist (26). 3) The patient may develop a second (or third or fourth) injury, such as nosocomial pneumonia, ventilator induced lung injury or bacterial translocation from the gut, which stokes up the inflammatory response.
    • Persistent inflammation leads to widespread endothelial dysfunction, and ischemic tissue injury (due to hypotension, intravascular thrombosis, tissue edema, abnormal oxygen extraction etc).
    • The result of this is sequential organ damage - multi organ dysfunction. Examples of this are an increase in the alveolar to arterial oxygen gradient, a reduced ejection fraction, agitation or coma, a reduction in creatinine clearance, and increase in serum bilirubin, a decrease in platelets and clotting factors etc.
    • As the disease process progresses, multi-organ dysfunction becomes multi-organ failure. This is characterized by the requirement for external interventions to maintain homeostasis - mechanical ventilation, inotropes and vasopressors, renal replacement therapy, continuing blood product transfusions etc.
    • The patient becomes severely catabolic, physiologic reserve deteriorates and neuroendocrine exhaustion occurs. The latter is characterized by the inability of the patient to mount an appropriate endocrine response to ongoing stress and inflammation.
    • The majority of patients who develop multi organ failure succumb, due to inability to wean external interventions (usually mechanical ventilation and vasopressors).
    • Death is inevitably as a result of withdrawal of this support.
    Systemic inflammatory response syndrome (SIRS)
    is a general inflammatory response to various causes. It is considered to be due to cytokines ("cytokine storm")
    SIRS can be diagnosed when two or more of the following are present
    (1) Heart rate > 90 beats per minute
    (2) Body temperature < 36 or > 38C
    (3) Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg
    (4) White blood cell count < 4000 cells/mm3 or > 12000 cells/mm3, or the presence of greater than 10% immature neutrophils. SIRS + proof of infection = sepsi
    Care of the Patient with Sepsis

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  2. 0
    Quote from superana
    They gave ABGs results.

    pH: 7.31
    PO2: 75 mmHg
    PCO2: 31 mmHg
    HCO3: 18 mEq/L
    T: 39.3
    P: 118
    BP: 88/58
    R: 20
    SpO2: 90%
    24 yo pt. who received a GSW to the abdomen with perforation of the mall intestine and the colon. He had intestinal resection and right side hemicolectomy. He's got metabolic acidosis, elevated WBC, BUN, creatinine and glucose. Continues to present elevated temperature, respirations and pulse, but low BP. He's intubated, and has gone into septic shock.
    OK now what does your patient need by looking at this scenario. Your patient is febrile (hyperthermia), hypoxic(impaired gas exchange), acidotic, and hypotensive. Knowing what we know about sepsis and the patients high fluid requirements from leaky capillary beds....could the hypotension be caused by deficient fluid volume. Does this patient have impaired gas exchange from the pneumonia? Is the patient at risk for ineffective airway clearance R/T mechanical ventilation? Is this patients acidosis metabolic from lactic acid and multi-system failure? From the multi-liumen is the patient at risk for injury related to impaired catheter function? Does this patient have acute pain from the surgery?

    Do you have a Nursing diagnosis book? Look there for the taxonomy.
    Last edit by Esme12 on Nov 7, '12
  3. 0
    Thank you! My textbook explained surprisingly little about Sepsis and Septic Shock so I was also having a hard time understanding the exact pathophysiology of the condition. I think I've got a better idea of how to interpret the data I was given and how to apply it to the care plan.

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