case study help

[ckirkpa]

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. Thanks for any input!

48year old Mexican American female admitted with fever,difficulty breathing, pleuritic chest pain, weakness, and shaky chills. Hx of flu like symptoms from approximately one week ago, took over-the-counter medications with moderate resolution of symptoms. On the day of admission, pt sleeping more than usual and seemed confused. In ER, pt's chest x-ray revealed left lower lobe pneumonia.

Health History Data:diagnosed with type 2 diabetes and hypertension about15 years ago and a "thyroid problem" for a year or two.

Prescribed Oral Medications:

Glucophage (Metformin) 500 mg twice a day.

Pravastatin(Pravachol) 40 mg daily at bed time

Levothryoxine100 mcg daily

Vasotec(Enalapril) 5 mg twice a day

Diltiazem(Cardizem) 240 mg daily

Reportfrom ER nurse

Vitals:HR 116, BP 88/56, RR 26, T 96.4°F, Wt 180, Ht 5'4",

Neuro:lethargic, responds to verbal stimuli and oriented to self

CV:heart tones distant, S1S2S4audible, capillary refill 3 > seconds

Pul:lungs clear bilaterally

GI:abdomen protuberant, hypoactive bowel sounds in all 4 quadrants

Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked, left lower leg edematous and erythematous with serous fluid oozing from lateral aspect of calf.

AdmissionLabs: SerumChemistry:

Glu 550,

K 5.6,

NA 132,

Cl 80, Cr 2.3,

BUN 82

ABGS: pH 7.30, Pa0270, PC0247, HC0320mEq/L

Hematologypanel:HCT 30. %, HGB 10.1 g/dL, RBC 3.9 x 10⁶/µL

WBCwith differential: WBC 17,000/mm³, segmented neutrophils 79%, bandneutrophils 10%, monocytes 9%, lymphocytes 30%, eosinophils 4%, basophils 3%

[MendedHeart]

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.

[Esme12, ASN, BSN, RN]

I completely understand that you are studying this in school.....I have been a nurse and educator for 34 years. An argument can be made for both but which needs immediate attention......acidosis, glucose, severs dehydration. The labs do match

While most shock like states require volume (except certain cardiogenic shock) The question is does Septic shock cause severe dehydration AEB tenting of the skin over the sternum.....lab values aside.....it's all about the patient assessment to complete the picture....does Septic shock cause severe clinical dehydration?

HHS "starts" at a glucose of 600....550 is good enough for me. A WBC if 17,000 doesn't scream sepsis. Sepsis usually cause the capillarity beds to leak causing edema and anasarca.....not severe dehydration that causes tenting of the skin over the sternum. It's the whole picture that needs to be looked at......everything you are saying is right about partially compensated metabolic acidosis and that the patient as an elevated WBC......We are saying the same thing....I just believe the acidosis is from the glucose induced HHS caused by a raging infection which isn't necessarily SIRS. And you believe the acidosis is from SIRS

We will have to agree to disagree.

[Esme12, ASN, BSN, RN]

I would hardly say a BGM of 550 is an emergency over the fact that this patient is in SEPTIC SHOCK. ..there is no resson in this stem that would indicate this patient was hypovolemic...and not to mention the K is high but not that high...but the Na is low..135-145 is norm

There absolutely was evidence given that this patient is dehydrated......Integ:skin dry with tenting present over sternum, lips and oral mucus membranes dry and cracked. Hypotensive with tachycardia.

BUN 82

CR 2.3

pH of 7.30- what does this indicate? Acidosis, right?

PCO2 47- what does this mean? CO2 is an acid with normal range of 35-45. So you have too much acid which produces an acidotic state.

HCO3 20- what does this mean? HCO3 is a base with a normal range of 22-26, so you have lost base which also gives you an acidotic state.

[Esme12, ASN, BSN, RN]

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.

Anerobic acidosis.....Lactic acidosis

[Esme12, ASN, BSN, RN]

The point is the labs dont match what your going for and Shock causes AKI

HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable.

HHS has also been reported in patients with type 1 DM, in whom DKA is more common.

HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at approximately 10-20%.

HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.In as many as one third of cases, the clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases); this suggests that these 2 states of uncontrolled DM differ only with respect to the magnitude of dehydration and the severity of acidosis.

HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable.

HHS has also been reported in patients with type 1 DM, in whom DKA is more common.

HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at approximately 10-20%.

HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.In as many as one third of cases, the clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases); this suggests that these 2 states of uncontrolled DM differ only with respect to the magnitude of dehydration and the severity of acidosis.

[MendedHeart]

Yea I believe so..just because you been a nurse for so many years really doesnt 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 interstial space to vesseks to compensate. .it is hypoperfusion..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 myst humble themselves..

[MendedHeart]

Lactic acidosis from shock. .yes

[Esme12, ASN, BSN, RN]

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.

[Esme12, ASN, BSN, RN]

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, BSN, RN]

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.

[MendedHeart]

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

[psu_213, BSN, RN]

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.