Etiology of the Disease
A majority of the patients who develop septic shock are commonly diagnosed with sepsis first, which occurs because of a bacterial, viral, fungi, or parasitic infection that invades the blood stream. While sepsis can be managed easily with proper treatment and constant observation, septic shock has a higher mortality rate because it entails a drop of the blood pressure to dangerously low levels (McConnell & Coopersmith, 2016). Sepsis, which leads to septic shock, is common among patients who have underlying health conditions such as severe ulcers in the gastrointestinal system that might lead to a perforation. Patients diagnosed with malignancies, diabetes, chronic renal disease, and chronic liver disease have a higher likelihood of being diagnosed with septic shock (Chang, 2019). Other predisposing factors include genetic susceptibility and immune-suppressing diseases.
Pathophysiology
At the cellular and sub-cellular level, dysfunctions of the immune system, microbiota, and the endothelium are evident. The endothelial surface plays a role in promoting vascular tone and modulating the permeability of blood vessels. Alteration of the permeability of endothelial cells can increase the risk of sepsis, which is the precursor for a septic shock. At the organ level, septic shock can lead to the failure of organ systems (McConnell & Coopersmith, 2016). Clinically, septic shock manifests as an altered blood glucose level, respiratory failures, circulatory system failure, characterized by hypotension, altered liver and kidney function, and adrenal dysfunction. The progression of sepsis to severe sepsis and then septic shock is based on factors such as inability to access proper healthcare services and a late diagnosis of severe sepsis.
Signs and Symptoms
Some of the signs and symptoms of septic shock include shortness of breath, a high fever of about 38oC, chills or rigors, anxiety, general body malaise, nausea and vomiting, and disorientation (Seymour & Rosengart, 2015). The patient might also experience unexplained confusion and a high heart rate. Septic shock is also characterized by low blood pressure, which might explain the presence of symptoms such as disorientation and confusion (Seymour & Rosengart, 2015). These symptoms often occur progressively within a few days ad may worsen if treatment is not administered.
Assessment
An assessment of septic shock or the risks of septic shock can be conducted by going through the patient’s history and looking for factors such a previous diagnosis of sepsis, existing chronic health condition like cancer, diabetes, gastrointestinal diseases like peptic ulcers, or an immune-suppressing disease such as poorly managed HIV/AIDS. The history of a UTI or a surgical wound that had not healed properly can also be used as indicators for septic shock (Seymour, et al., 2016). Additional assessments should be conducted using laboratory tests.
Septic shock can be determined using a series of different laboratory tests used to detect the presence of infections. Among patients diagnosed with sepsis, a complete blood count is conducted to determine the risks of infections. This is possible through an increase number of white blood cells that might indicate the immune system is working towards fighting the infection. Coagulation studies used to determine the prothrombin time, fibrinogen levels, and activate partial thromboplastin time can also be done to assess the risks of infections (Seymour, et al., 2016). A blood pressure assessment is essential because it is usually the main indicator of a septic shock in patients diagnosed with other comorbidities.
An electrolyte levels assessment is essential in ruling out other issues such as low sodium, magnesium, phosphate, or glucose levels. A urinalysis or a urine culture test should be performed to assess the risks of urinary tract infections or the presence of other pathogens. Other laboratory tests that need to be performed include renal and liver functioning test, gram stain tests, assessment of the cultures of secretions, and body tissues. Some of the imaging studies that can be performed include chest and abdominal radiography, abdominal ultrasonography, and computed topography (Seymour, et al., 2016; Lopansri, Miller, & Brandon, 2019). A lumbar puncture can be performed to rule out the risk of meningitis.
Diagnostic Tests
Among the criteria used to prove that a patient has septic shock include having a body temperature of more than 38.0oC or less than 36.0oC, a heart rate of more than 90 beats per minute, respiratory rate of more than 20 breaths per minute, and more than 12,000 mm3 or less than 4,000 mm3 white blood cells (WBC). If more than 10% of the WBCs are in an immature form, the results can also be used alongside other blood tests to prove that the patient has severe sepsis or septic shock mmHg (Fan, Miller, Lee, & Remick, 2016). The systolic blood pressure for these patients may fall by more than 40 mmHg and they might have a mean arterial pressure of less than 65 mmHg (Fan, Miller, Lee, & Remick, 2016). The presence of two or three of these symptoms accompanied by significantly low blood pressure is indicative of septic shock, especially in patients who had been diagnosed with sepsis.
Treatment/Nursing Care Management
First Nursing Care Plan
In patients diagnosed with sepsis or severe sepsis, an antimicrobial therapy is essential for treating the cause of the infection and preventing the risks of septic shock. In a patient with septic shock, the major focus is on resuscitating the patient by providing cardiovascular support and respiratory functioning. The patient requires intubation and use of a ventilator because of the risk of presence of respiratory failure. The next step involves correcting the state of shock and possible abnormal tissue perfusion. In patients with septic shock, the initial six hours are crucial for their survival. It is essential to obtain lactate levels and blood cultures before administration of any antibiotics to determine whether the cause of the septic shock is based on a virus or other pathogens (Seymour, et al., 2016; Seymour & Rosengart, 2015). For lactate levels that are higher than 4 mmol/L or for patients with hypotension, 30 mL/kg of crystalloid solution should be administered (Seymour, et al., 2016). These measures should be taken within the first three hours after the arrival of the patient.
Vasopressors should be administered for hypotension within the next six hours in cases whereby the patient does not respond to the initial fluid resuscitation. If the hypotension persists despite the use of volume resuscitation, it is essential to measure the central venous pressure and aim for more than 8 mmHg (Seymour, et al., 2016). It is important to assess the patients continuously within the first six hours to determine their response to the treatment and evaluate the need to consider other alternative treatment plans. After obtaining the laboratory results, antimicrobial drugs can be initiated if the tests indicate the presence of a bacterial infection. This should be done within the first few hours to reduce the risks of mortality (Seymour, et al., 2016; Deng, Zhou, & Wu, 2018). Using a broad-spectrum antibiotic is advisable in such cases because it covers anaerobic and gram positive and gram-negative bacteria.
The nursing care for patients with septic shock extends beyond the first critical hours. Once the patient has stabilized, the other diagnostic tests should be performed to determine the cause of the septic shock and the nature of the organs. Renal and liver functioning tests are important in evaluating the risks of numerous conditions affecting the gastrointestinal system. A CBC will also evaluate the risks of other conditions such as anemia. Unless the patient has a poor cardiac reserve or has myocardial ischemia, hemoglobin levels of as low as 7 g/dL might not necessitate the need for transfusion. Nurses should also assess the patient’s body temperature to ensure that it has significantly lowered within the first two hours of treatment. Provision of nutrition support is important in promoting the patients’ health, especially among patients with a history of gastrointestinal diseases like peptic ulcers and severe gastritis. Enteral nutrition can be delivered to the patient through a nasogastric tube to protect the gut mucosa (Bloos, 2018). These should be addressed after stabilizing the patient and conducting the essential tests.
Second Nursing Care Plan
Hyperthermia is a common problem among patients with septic shock. Some of the nursing interventions that will be applied to manage hyperthermia include monitoring the patient temperature patterns and assessing the environment’s temperature. The room and linens temperature should be modified to maintain a near-normal body temperature. This will promote the patient’s ability to retain a proper body temperature. Tepid sponge baths should also be provided instead of use of alcohol as it might cause chills or dehydration of the skin (Beverly, Walter, & Carraretto, 2016). Cooling blankets can also be used to reduce the patient’s fever especially when the temperature are above 104oF.
Aside from the approaches used in promoting respiratory functions, it is also essential to auscultate breath sounds and observe for crackles, wheezing, and areas of decreased ventilation. The presence of adventitious sounds usually indicate the risks of pulmonary congestion and atelectasis. The care process should also involve assessing for coughs, presence of circumoral cyanosis, and changes in sensorium to determine the risks of hypoxemia. The patient should be placed in a comfortable position with the head being elevated at a 30o angle to promote lung expansion (Kim & Hong, 2016). Continuous monitoring of the patient will ensure that changes in respiratory functions are noted and addressed.
Health Teachings
Patients diagnosed with septic shock should adhere to their treatment to reduce the risks of complications. It is essential for nurses to inform the family members about the possible need of admitting the patient in the ICU to promote their chances of recovery thereby minimizing exposure to other infections. Admitting the patient in the ICU also ensures that they receive constant care and review by specialists (Seymour & Rosengart, 2015). This prevents the risks of organ failure.
References
Beverly, A., Walter, E., & Carraretto, M. (2016). Management of hyperthermia and hypothermia in sepsis: A recent survey of current practice across UK intensive care units. Journal of the Intensive Care Society, 17(1), 88-89. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606379/.
Bloos, F. (2018). Diagnosis and therapy of sepsis. Journal of Emergency and Critical Care Medicine, 2(1). Retrieved from http://jeccm.amegroups.com/article/view/4021/4641.
Chang, J. C. (2019). Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease. Thrombosis Journal, 17(10), Retrieved from https://thrombosisjournal.biomedcentral.com/articles/10.1186/s12959-019-0198-4.
Deng, Q., Zhou, X., & Wu, F. (2018). Updated Knowledge About the Diagnosis and Treatment of Sepsis and Septic Shock. Journal of Emergency Nursing, 44(5), 444-445. Retrieved from https://www.jenonline.org/article/S0099-1767(18)30306-4/fulltext.
Fan, S.-L., Miller, N. S., Lee, J., & Remick, D. G. (2016). Diagnosing Sepsis – The Role of Laboratory Medicine. Clinica Chim Ata, 1(460), 203-210. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980259/.
Kim, W.-Y., & Hong, S.-B. (2016). Sepsis and Acute Respiratory Distress Syndrome: Recent Update. Tuberculosis & Respiratory Diseases, 79(2), 53-57. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823184/.
Lopansri, B. K., Miller, R. R., & Brandon, R. B. (2019). Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort. Journal of Intensive Care, 13(7), Retrieved from https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-019-0368-2.
McConnell, K. W., & Coopersmith, C. M. (2016). Pathophysiology of septic shock: from bench to bedside. Presse Med. Quarterly Medical Review, 45(4 Pt 2), e93-e98. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868872/.
Seymour, C. W., & Rosengart, M. R. (2015). Septic shock: Advances in diagnosis and treatment. Journal of American Medical Association, 314(7), 708-717. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646706/.
Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., . . . Angus, D. C. (2016). Assessment of Clinical Criteria for Sepsis: For the third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 315(8), 762-774. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433435/.