infection - Nursing Case Study

Pathophysiology

• Primary mechanism: The invasion and multiplication of microorganisms such as bacteria, viruses, or fungi in body tissues. This can occur when the body's immune system is already compromised, or the pathogen is highly virulent, leading to an initial local response (e.g., inflammation) and possibly systemic effects if not controlled.

• Secondary mechanism: The body's immune response to infection can lead to tissue damage. The immune cells, while fighting off the infection, release substances that can cause local tissue damage and inflammation. Prolonged inflammation can result in permanent tissue damage and loss of function.

• Key complication: Sepsis is a major complication when the body's response to infection goes into overdrive, causing widespread inflammation throughout the body. This can lead to organ failure and death if not promptly treated. It is crucial to monitor for signs of sepsis in patients with severe or systemic infections.

Patient Profile

Demographics:

64-year-old male, retired teacher

History:

• Key past medical history: Diagnosed with type 2 diabetes, hypertension, and high cholesterol.

• Current medications: Metformin, Lisinopril, Atorvastatin.

• Allergies: Penicillin.

Current Presentation:

• Chief complaint: Persistent high fever and a productive cough for the past week.

• Key symptoms: Chest pain, shortness of breath, fatigue, excessive sweating, and mild confusion.

• Vital signs: Body temperature of 38.7C (101.6F), heart rate 110 bpm, blood pressure 145/95 mmHg, respiratory rate 24 breaths per minute, oxygen saturation 93% on room air.

Section 1

Change in patient status:

Over the next 24 hours, the patient's condition worsens. His temperature rises to 39.2C (102.6F) and his respiratory rate increases to 28 breaths per minute. Oxygen saturation drops to 88% on room air, indicating a difficulty in maintaining adequate oxygen levels. He becomes increasingly confused and disoriented, which may be a sign of cerebral hypoxia due to the decreased oxygen saturation or may be a symptom of sepsis. His skin becomes clammy and he complains of increased chest pain, which may suggest that the infection and inflammation in his lungs are increasing.

Response to interventions:

In response, the nursing staff increases the oxygen flow to 4 liters per minute via nasal cannula, which helps to raise his oxygen saturation to 92%. They administer acetaminophen to help reduce his fever and a chest x-ray is ordered to assess the extent of the lung infection. Despite these interventions, the patient's mental status continues to deteriorate and he becomes increasingly lethargic. His blood pressure also begins to drop, with readings now at 110/70 mmHg, suggesting the possibility of septic shock. Blood cultures are drawn to identify the pathogen causing the infection and broad-spectrum antibiotics are started as a precaution until the results come back.

These changes in the patient's status and the escalating interventions are indicative of a deteriorating condition that requires immediate medical attention. The nursing staff continues to monitor him closely for further signs of sepsis and organ dysfunction.

Section 2

New Diagnostic Results:

The chest x-ray reveals an extensive area of infiltration in both lungs, indicative of pneumonia. The blood cultures come back positive for Streptococcus pneumoniae, a common cause of community-acquired pneumonia. The patient's complete blood count shows a high white blood cell count of 18,000 cells/mm3, which is indicative of an ongoing infection. His C-reactive protein, a marker of inflammation, is also elevated at 180 mg/L.

These diagnostic findings confirm the diagnosis of pneumonia, which has likely progressed to sepsis. The high levels of inflammation and the presence of Streptococcus pneumoniae in his bloodstream suggest that the infection has spread beyond his lungs. This could explain his deteriorating mental state, as sepsis can lead to altered mental status due to the body's systemic response to the infection.

Moreover, his deteriorating vital signs, such as increasing respiratory rate, decreasing oxygen saturation and dropping blood pressure are indicative of the body's struggle to compensate for the systemic effects of the infection. The nursing staff needs to reassess the patient's care plan in light of these new findings, focusing on managing his sepsis, supporting his vital functions, and treating the underlying pneumonia.

Section 3

Change in Patient Status:

The patient's condition continues to deteriorate. His respiratory rate has increased to 30 breaths per minute, and his oxygen saturation has further dropped to 88% on 2L of supplemental oxygen via nasal cannula. His blood pressure readings are also concerning, with a systolic pressure that has dropped to 90 mmHg and a diastolic pressure of 50 mmHg. The patient is increasingly lethargic and disoriented, showing signs of confusion and difficulty following commands. His skin is cool and clammy to the touch, and his capillary refill time is delayed at 4 seconds, suggesting poor peripheral perfusion.

These changes in the patient's status indicate a progression of the sepsis, possibly developing into septic shock—a severe and potentially fatal condition characterized by low blood pressure, decreased tissue perfusion, and organ dysfunction. The patient's altered mental status, increased respiratory rate, and decreased blood pressure are indicative of his body's struggle to compensate for the systemic effects of the infection. The nursing staff must act quickly to prevent further deterioration and to support the patient's vital functions. Immediate interventions include increasing oxygen delivery, initiating fluid resuscitation, and contacting the medical team for possible initiation of vasopressor medications.

Section 4

Change in Patient Status:

Despite the immediate interventions implemented by the nursing staff, the patient's condition has not improved. His respiratory rate has escalated to 35 breaths per minute, and oxygen saturation has plummeted to 84% on 3L of supplemental oxygen via nasal cannula. Disturbingly, his blood pressure continues to drop, with a systolic pressure now at 85 mmHg and a diastolic pressure of 45 mmHg. The patient's level of consciousness has further decreased, and he is now responding only to painful stimuli. His skin has become more pallid, and his capillary refill time is even more delayed at 5 seconds.

These alarming changes in the patient's status suggest a further escalation of the sepsis into severe septic shock. The patient's deteriorating vital signs, decreased level of consciousness, and poor peripheral perfusion indicate that his body's compensatory mechanisms are failing. The nursing staff must quickly escalate their interventions and communicate with the medical team regarding the need for more aggressive treatment measures. This may include intubation and mechanical ventilation, increasing intravenous fluid resuscitation, initiating vasopressor therapy, and considering the use of broad-spectrum antibiotics if not already started. The patient's worsening condition also necessitates a discussion with the family regarding his prognosis and possible goals of care.

Section 5

New Diagnostic Results:

The patient's latest blood cultures have returned from the lab, showing growth of a multidrug-resistant strain of Pseudomonas aeruginosa, a gram-negative bacterium notorious for causing severe infections in immunocompromised individuals. This finding, coupled with the patient's persistent fever, supports the diagnosis of severe sepsis, likely secondary to a pneumonia. Additionally, the patient's latest complete blood counts show an alarming drop in platelets to 50,000/uL and white blood cells escalating to 20,000/uL, indicating rampant infection and the beginning of disseminated intravascular coagulation (DIC), a life-threatening complication of sepsis. Furthermore, arterial blood gas results show a pH of 7.28, PaCO2 of 32 mmHg, and bicarbonate of 18 mEq/L, indicating a primary metabolic acidosis with a partial respiratory compensation, in line with lactic acidosis often seen in severe sepsis.

These new diagnostic results heighten the urgency for immediate, aggressive intervention. The nursing team will need to work closely with the medical team to manage the patient's deteriorating condition. This may include administering appropriate antibiotics to combat the Pseudomonas infection, monitoring the patient for signs of worsening DIC such as abnormal bleeding or petechiae, and preparing for possible intubation given the worsening acid-base imbalance. The team will also need to consider the need for a higher level of care, such as transfer to the intensive care unit. The patient's family should be kept informed of these developments, to facilitate shared decision-making regarding the patient's care.