Case Study, Chapter 15, Shock and Multiple Organ Dysfunction Syndrome

Objective: 6, 7

Adam Smith is 77 years oI age and is a male patient who was admitted Irom a nursing
home to the intensive care unit with septic shock secondary to urosepsis. The patient has
a Foley catheter in place Irom the nursing home with cloudy greenish yellow colored
urine with sediments. The nurse removes the Foley aIter obtaining a urine culture and
replaces it with a condom catheter attached to a drainage bag since the patient has a
history oI urinary and bowel incontinence. The patient is conIused, aIebrile, and
hypotensive with a blood pressure oI 82/44 mm Hg. The respiratory rate is 28 breaths per
minute and the pulse oximeter reading is at 88 room air, so the physician ordered 2 to 4
liters oI oxygen per nasal cannula titrated to keep SaO
2
greater than 90. The patient
responded to 2 liters oI oxygen per nasal cannula with a SaO
2
oI 92. The patient has
diarrhea. The blood glucose level is elevated at 160 mg/dL. The white blood count is
15,000 and the C-reactive protein, a marker Ior inIlammation, is elevated. The patient is
being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning
at 2 mcg per minute and titrated to keep systolic blood pressure greater than 100 mm Hg.
A subclavian triple lumen catheter was inserted and veriIied by chest x-ray Ior correct
placement. An arterial line was placed in the right radial artery to closely monitor the
patient`s blood pressure during the usage oI the vasopressor therapy.

What predisposed the patient to develop septic shock? URINARY AND BOWEL
INCONTINENCE
The situation stated that while the patient is in the Nursing home, he has a Foley
catheter in place which is one oI the most common sources oI inIection/microorganisms.
Once removed, it has sediments and the appearance was cloudy and greenish yellow in
color, which may signiIy inIection oI the Urinary tract. The presence oI that contraption
might be the one that predisposed the patient to Urosepsis, which then progressed to
septic shock.

What potential findings would suggest that the patient`s septic shock is worsening
from the point of admission?
O Hypotension (82/44 mmHg) which may indicate inadequate cardiac pump
O ##: 28 breaths per minute (tachypnea) [normal 12-20 cpm] as compensatory
mechanism
O 0
2
saturation: 88 which may signiIy insuIIicient circulatory perIusion [normal
95-100 ]
O lood glucose: 160 mg/dl [normal 80-100 mg/dl] which may signiIy adjacent
organ dysIunction
O levated C-reactive protein, a marker Ior inIlammation
O C count oI 15,000 [normal 5-10
9/
L], indicative that there is a presence oI
toxin contained in the cell wall oI microorganism that is released and broken
down in the body once it dies

The norepinephrine concentration is 16 mg in 250 mL of NS. Explain how the nurse
should administer the medication. What nursing implications are related to the
usage of a vasoactive medication?
The norepinephrine should be given at 2 mcg per minute. The solution should be
added in small, measured quantities to a known volume oI a standard solution until a
reaction occurs, as indicated in color or pH oI the product.

THE MEDICATION WILL BE ADMINSITERED THRU DOUBLE INFUSION
PUMP TITRATED ACCORDINGLY TO THE CLINICAL PRESENTATION OF
CLIENT AND THRU IV INFUSION

Levophed given to the strength oI myocardial contractility, initiate
vasoconstriction leading to in lood Pressure; and regulates the heart rate.

Nursing Considerations:
O Obtain history, including drug and known allergies.
O onitor Vital signs as well as CG. P every 2 minutes Irom the time oI
administration until desired P is obtained.
O Observe Ior cyanosis which may indicate ineIIective tissue perIusion.
O t should not be given with Normal Saline alone may cause degradation;
administer with D
5
or D
5
saline.
O Use inIusion pump, enter on a large vein.
O Discard solution aIter 24 hours.
O Advise patient to notiIy nurse iI V site Ieels cool or painIul.
O nstruct patient to report the Iollowing symptoms: dizziness, nausea,
syncope, abdominal and chest pain, as well as conIusion, the adverse
eIIects oI Levophed.

Explain why the effectiveness of a vasoactive medication decreases as the septic
shock worsens. What treatment should the nurse anticipate to be obtained help the
patient?
This may be because oI the condition wherein the shock already progresses into
the next stage. ultiple organ dysIunction associated with acute illnesses compromises
the tissue perIusion, it may be irreversible. For these stages, the doctor may order blood
transIusion, high-Ilow oI oxygen, removal oI cellular waste products with severely
altered tissue perIusion, and insulin administration to control the increase in blood
glucose. owel and bladder training may be arranged Ior urinary and bowel incontinence.
AXNG OLUS ANTOTCS AND FLUD #SUSCTATON AND
P#VNTNG AG GAS O#SNNG

Explain the importance for nutritional support for this patient and which type of
nutritional support should be provided?
Nutritional support may be given to Iacilitate the delivery oI nutrients to systemic
tissue. Foods high in iron may be given to help increase the amount oI oxygen-carrying
cells in the body. Low-calorie and low-carbohydrate could also be ordered to prevent
Iurther increase in blood glucose. NUT#TONAL SUPPO#T LL ANLY
P#OVDD N A FO# OF TPN AND CA#FUL ALANCNG NCSSA#Y
NUT#NTS, LCT#OLYTS AND HAND N HAND TH FLUDS.