Case Study Shock, Respiratory and Urinary

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University Of Georgia *

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MISC

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Nursing

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Apr 29, 2024

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Case Study : Shock, Sepsis, and Multiple Organ Dysfunction Syndrome 1. Adam Smith, 77 years of age, is a male patient admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag. The patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min. The pulse oximeter reading is at 88% room air, so the primary provider ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO 2 greater than 92%. The patient responded to 2 L of oxygen per nasal cannula with an SaO 2 of 93%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000, and the C-reactive protein, a marker for inflammation, is elevated. The patient is treated with broad- spectrum antibiotics and norepinephrine beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x- ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the vasopressor therapy. a. What predisposed the patient to develop septic shock? The passage stated that Adam was admitted to the ICU with septic shock secondary to urosepsis. Urosepsis predisposed the patient to develop septic shock. He also has a history of urinary and bowel incontinence with having a foley cathether which increases his risk for infection. b. What potential findings would suggest that the patient’s septic shock is worsening from the point of admission? The passage states Adam is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His white blood cell count is 15,000 along with having a C-reactive protein elevated. He also has low oxygen saturation levels. c. Explain the importance of nutritional support for this patient and which type of nutritional support should be provided. The importance of nutritional support for Adam is because of the septic shock which can lead to increased metabolic demands. Due to the signs of infection, strengthening his immune system can be done through good nutrition. The type of nutritional support needed is a feeding tube to administer enteral nutrition through and lowers the risk of infection by associating with parental nutrition.

2. Carlos Adams was involved in a motor vehicle crash and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock. The following prescriptions are written for the patient:  Infuse 0.9% NS at 125 mL/hr  Obtain complete blood count, serum electrolytes  Oxygen at 2 L/min via nasal cannula  Transfuse 4 units of blood  X-ray of the abdomen STAT a. Describe the pathophysiologic sequence of events seen with hypovolemic shock. Hypovolemic shock results from fluid loss or blood loss. Due to a critical loss in circulating volume there isn’t enough blood to enter the heart. This leads to a decrease stroke volume and low cardiac output. In retaliation the body will vasoconstrict to compensate. The organs will continue to decline and shut down along with the blood pressure declining. b. What are the primary goals of medical management for this patient? The primary goals of medical management to counteract the hypovolemic shock and increased the level of fluid. Case Study: Patients with Lower Respiratory Tract Disorders 1. Harry Smith, 70 years of age, is a male patient admitted to the medical- surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked one pack of cigarettes per day for 55 years; he quit 3 years ago. The patient has a history of hypertension and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are blood pressure, 90/50 mm Hg; heart rate, 101 bpm; respiratory rate, 28 breaths/min; and temperature, 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC, 12,500; platelets, 350,000; HCT, 30%; and Hgb, 10 g/dL. ABGs on room air are pH, 7.30; PaO 2 , 55; PaCO 2, 50; and HCO 3 , 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, a flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower

lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline. His nail beds and lips turn a bluish tinge, and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. a. What nursing assessment findings support the diagnosis of pneumonia? The nursing assessment findings that support the diagnosis of pneumonia include fever of 101.5°F, patient being diaphoretic, fatigue, shortness of breath, cannot finish a short sentence before the respiratory rate increases above the baseline indicating tachypnea, pulse oximetry decreaseing to 82%, and altered mental status due to patient presenting with confusion as to time and place. b. What diagnostic findings support the diagnosis of pneumonia? The patient chest x-ray revealed that the righter lower lobe is consilated, presence of apical bullae, a flattened diaphragm, and a small pleural effusion in the right lower lobe. This suggest COPD. Harry’s white blood count is also elevated indicating infection. ABGs on room air are pH, 7.30; PaO 2 , 55; PaCO 2, 50 which indicates respiratory acidosis and hypoxemia. c. What goals should the nurse develop for the patient? Nursing diagnosis such as ineffective airway clearance related to severly diminished breath sounds in the right lower lobe should be developed for the patient to set a goal of having improved airway patency prior to discharge. Other goals can include improved breathing patten, improved gas exchange, maintenance of adequate nutrition, and maintenance of fluid electrolyte balance. d. What overall interventions should the nurse provide? Interventions should include placing a humidifier, obtaining any lab or cultures, elevating the head of the bed to promote oxygenation, and using an incentive spirometer to assess lungs. Case Study, Patients with Urinary Disorders 1. Sue Meade, 22 years of age, presents to the clinic with complaints of burning, pain, and urgency when urinating. The patient has a fever of 100°F. The urine is strong in odor and cloudy with sediments. (Learning Outcome 2) a. What questions should the nurse ask during the assessment to gain more information about the possible causes of the urinary tract infection? What type of undergarments and pants do you wear? What does your morning and/or nightly shower routine look like? Are you sexually active? If yes, do you use a condom? If yes, do you urinate after intercourse?

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Have you had a problem like this before in your past? How much water do you consume a day? Do you mainly consume water or soft drinks/jucies? b. What patient education should be provided? Patient education should include personal hygiene, avoiding tight clothing, wear loose breathable clothing, mainly drinking water, urinate after each sexually intercourse, clean your vagina from front to back to avoid any bacteria entering the vagina, take full course of antibiotics and contact your provider if there are any adverse effects from the antibiotics.

Case Study Shock, Respiratory and Urinary

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