A patient in the emergency department is showing signs of possible septic shock with low blood pressure, elevated lactate levels, and increased confusion. Despite fluid resuscitation, hypotension persists. What should the nurse anticipate as the next priority intervention to stabilize the patient's hemodynamic status?

A) Administer a vasopressor such as norepinephrine

B) Increase the rate of isotonic crystalloid infusion

C) Begin a continuous insulin infusion to control hyperglycemia

D) Administer a sedative to manage the patient's agitation

A patient is being treated for suspected septic shock. Despite fluid resuscitation, the patient remains hypotensive and shows signs of respiratory distress and confusion. Which intervention should the nurse anticipate next to address the patient's hemodynamic instability?

A) Administer a vasopressor such as norepinephrine

B) Increase the rate of isotonic fluid infusion

C) Initiate a continuous insulin infusion

D) Apply supplemental oxygen via nasal cannula

A patient with sepsis is showing signs of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). The healthcare team has initiated non-invasive positive pressure ventilation (NIPPV). Which nursing intervention should be prioritized to address the patient's current condition?

C) Prepare for potential intubation and mechanical ventilation.

A) Increase the rate of vasopressor infusion to maintain blood pressure.

B) Monitor and document neurological status changes every 2 hours.

C) Prepare for potential intubation and mechanical ventilation.

D) Administer additional diuretics to manage fluid overload.

A patient with sepsis is showing signs of acute respiratory distress syndrome (ARDS), acute kidney injury, and potential septic encephalopathy. Which nursing intervention is the highest priority to address the patient's current condition?

C) Escalate respiratory support to invasive mechanical ventilation to manage respiratory acidosis

A) Increase the rate of intravenous fluids to improve urine output

B) Initiate continuous renal replacement therapy (CRRT) to manage acute kidney injury

C) Escalate respiratory support to invasive mechanical ventilation to manage respiratory acidosis

D) Administer a sedative to manage the patient's declining mental status

A patient with worsening respiratory acidosis, hemodynamic instability, and acute kidney injury is being managed in the ICU. Her oxygen saturation is 85% on non-invasive positive pressure ventilation, and her arterial blood gas shows a pH of 7.25. Which of the following nursing interventions is the highest priority to address the patient's immediate needs?

B) Prepare the patient for intubation and mechanical ventilation

A) Increase the settings on the non-invasive positive pressure ventilation

B) Prepare the patient for intubation and mechanical ventilation

C) Administer additional vasopressors to manage hypotension

D) Initiate continuous renal replacement therapy to support renal function

A patient with respiratory failure and hemodynamic instability has deteriorating respiratory acidosis despite being on non-invasive positive pressure ventilation (NIPPV). Her blood pressure remains low despite vasopressor therapy, and she shows signs of acute kidney injury. What is the most appropriate next step in managing this patient's condition?

C) Intubate the patient and start mechanical ventilation to stabilize respiratory status.

A) Increase the dose of vasopressors to improve blood pressure and tissue perfusion.

B) Initiate continuous renal replacement therapy (CRRT) to address the acute kidney injury.

C) Intubate the patient and start mechanical ventilation to stabilize respiratory status.

D) Administer diuretics to manage fluid overload and prevent pulmonary edema.

A patient who has been recently intubated is showing slight improvement in arterial blood gases but continues to have low PaO2 levels. The patient's cardiovascular status is unstable, and dobutamine has been initiated alongside norepinephrine. Considering the current ventilator settings and pharmacological management, which nursing intervention is the priority to optimize the patient's oxygenation and hemodynamic stability?

C) Collaborate with the respiratory therapist to consider increasing the PEEP.

A) Increase the FiO2 to 80% to improve oxygen saturation.

B) Monitor for signs of fluid overload and adjust fluid therapy as necessary.

C) Collaborate with the respiratory therapist to consider increasing the PEEP.

D) Initiate prone positioning to enhance lung perfusion.

A patient has been intubated and is receiving mechanical ventilation with an FiO2 of 60%, tidal volume of 6 mL/kg, and PEEP of 10 cmH2O. The arterial blood gases show a pH of 7.30, PaCO2 of 52 mmHg, and PaO2 of 68 mmHg. Despite these settings, the patient's oxygenation remains suboptimal, and there is a need to adjust the ventilator settings to improve oxygenation. Which ventilator adjustment should the nurse anticipate to enhance the patient's oxygenation status?

D) Decrease the respiratory rate

A patient on mechanical ventilation develops a fever, increased white blood cell count, and new infiltrates on a chest X-ray. Despite norepinephrine and dobutamine infusions, the patient's blood pressure remains low. CRRT is initiated to manage fluid overload. Which nursing intervention is most critical to prioritize in this scenario?

B) Monitor and adjust vasopressor infusion rates closely.

A) Increase the sedation to reduce metabolic demands.

B) Monitor and adjust vasopressor infusion rates closely.

C) Administer antipyretics to control the fever.

D) Prepare for immediate intubation and mechanical ventilation adjustment.

Shock - Nursing Case Study

Pathophysiology

• Primary mechanism: Shock is primarily caused by inadequate tissue perfusion, leading to insufficient oxygen and nutrient delivery to cells, which disrupts cellular metabolism and function. This results in cellular injury and, if uncorrected, organ failure.

• Secondary mechanism: Compensatory mechanisms, such as increased heart rate and vasoconstriction, attempt to maintain blood pressure and perfusion but can exacerbate the problem by further compromising microcirculation and increasing metabolic demand.

• Key complication: If not promptly addressed, shock can lead to systemic inflammatory response syndrome (SIRS), exacerbating organ dysfunction and potentially progressing to multiple organ dysfunction syndrome (MODS), significantly increasing mortality risk.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Lightheadedness and confusion

• Key symptoms: Rapid heartbeat, cold and clammy skin, low urine output

• Vital signs: Blood pressure 85/55 mmHg, heart rate 120 bpm, respiratory rate 24 breaths per minute, temperature 98.6°F

Section 1

As the healthcare team initiates treatment for shock, further assessment and diagnostic testing are completed to evaluate the extent of the patient's condition. Initial laboratory results reveal an elevated lactate level of 4.5 mmol/L, indicating significant tissue hypoperfusion and anaerobic metabolism. The complete blood count shows leukocytosis with a white blood cell count of 15,000/mm³, suggestive of a possible systemic inflammatory response. Additionally, blood glucose levels are elevated at 250 mg/dL despite the patient's regular use of Metformin, reflecting the body's stress response and potential insulin resistance during critical illness.

Despite fluid resuscitation efforts with isotonic crystalloids, the patient's blood pressure remains low at 88/54 mmHg, and her heart rate persists at 118 bpm. The patient begins to exhibit signs of respiratory distress, with increased respiratory rate climbing to 28 breaths per minute and the onset of mild hypoxia, as evidenced by an oxygen saturation of 92% on room air. The nurse notes increased confusion and agitation, indicating possible cerebral hypoperfusion or worsening metabolic derangement.

These evolving clinical findings suggest that the patient's condition may be progressing towards septic shock, given the evidence of a systemic inflammatory response and potential infection source. The interdisciplinary team must now consider the initiation of broad-spectrum antibiotics and closer hemodynamic monitoring. Further diagnostic imaging, such as a chest X-ray or abdominal ultrasound, may be warranted to identify any underlying infection source. The clinical team needs to continue assessing for signs of SIRS and potential organ dysfunction, as prompt recognition and intervention are critical to prevent progression to multiple organ dysfunction syndrome (MODS).

Section 2

As the healthcare team implements the initial interventions, including broad-spectrum antibiotics, vasopressors are also started to address persistent hypotension. The patient is placed on supplemental oxygen via nasal cannula to address hypoxia, but despite these measures, her condition continues to evolve. Over the next hour, the patient's respiratory status deteriorates further, with her respiratory rate increasing to 34 breaths per minute and oxygen saturation dropping to 88% on 4L of oxygen. There is also a noticeable increase in her use of accessory muscles, indicating worsening respiratory effort. A follow-up arterial blood gas analysis reveals a pH of 7.30, PaCO2 of 52 mmHg, and PaO2 of 60 mmHg, suggestive of acute respiratory acidosis and hypoxemia.

Further diagnostic imaging is expedited, and a chest X-ray reveals bilateral infiltrates, raising concerns for acute respiratory distress syndrome (ARDS) secondary to sepsis. In light of these findings, the team decides to escalate respiratory support to non-invasive positive pressure ventilation (NIPPV) to improve oxygenation and reduce work of breathing. Concurrently, the patient's mental status continues to decline; she becomes increasingly lethargic and difficult to arouse, with a Glasgow Coma Scale score decreasing to 10. This change in neurological status, coupled with the elevated lactate levels and persistent hypotension, suggests ongoing systemic hypoperfusion and potential septic encephalopathy.

The patient's urine output has also decreased significantly to less than 20 mL/hour, indicating potential acute kidney injury. Serum creatinine levels, drawn as part of routine monitoring, have risen to 2.1 mg/dL from an initial baseline of 1.0 mg/dL. This combination of findings highlights the possibility of progression towards multiple organ dysfunction syndrome (MODS). The interdisciplinary team must now focus on optimizing hemodynamic support, adjusting antibiotic therapy as needed based on culture results, and closely monitoring organ function to tailor further interventions. The complexity of the patient's condition necessitates continuous reassessment and adjustment of the treatment plan to prevent further deterioration.

Section 3

As the team continues to manage the patient's complex clinical picture, they note a further decline in her respiratory status despite the initiation of non-invasive positive pressure ventilation (NIPPV). Her respiratory rate remains elevated at 36 breaths per minute, with oxygen saturation persistently low at 85% on NIPPV. An urgent arterial blood gas analysis shows worsening respiratory acidosis, with a pH of 7.25, PaCO2 of 58 mmHg, and PaO2 of 55 mmHg. These findings indicate that NIPPV may no longer be sufficient, prompting the team to consider intubation and mechanical ventilation to ensure adequate oxygenation and ventilation.

Simultaneously, the patient's hemodynamic status shows signs of further compromise. Despite the ongoing administration of vasopressors, her blood pressure remains low at 84/50 mmHg, and her heart rate increases to 118 beats per minute, suggesting compensatory tachycardia. Repeat lactate levels have risen to 4.5 mmol/L, reinforcing concerns about ongoing tissue hypoperfusion. The interdisciplinary team discusses the potential need for additional vasopressor support or inotropic agents to stabilize her cardiovascular status while reviewing culture results to refine antibiotic therapy.

In addition, there is a worsening trend in renal function, with urine output now less than 10 mL/hour and serum creatinine climbing to 2.6 mg/dL. This confirms a progression towards acute kidney injury, necessitating consideration of renal replacement therapy options such as continuous renal replacement therapy (CRRT) if urine output fails to improve. The team must carefully balance fluid management to avoid exacerbating pulmonary edema while ensuring adequate perfusion to vital organs. These developments require an urgent reassessment of the patient's evolving condition and a recalibration of the treatment strategy to address the intertwined respiratory, cardiovascular, and renal challenges she faces.

Section 4

The team decides to proceed with intubation and mechanical ventilation due to the patient's worsening respiratory status and inadequate response to non-invasive measures. Post-intubation, the ventilator settings are adjusted to achieve better oxygenation and ventilation, with the patient now on a FiO2 of 60%, a tidal volume of 6 mL/kg, and a PEEP of 10 cmH2O. Initial post-intubation arterial blood gases reveal slight improvement, with a pH of 7.30, PaCO2 of 52 mmHg, and PaO2 of 68 mmHg. Despite these modest improvements, her oxygenation remains a concern, necessitating further fine-tuning of ventilator parameters. The team closely monitors her for signs of ventilator-associated complications and adjusts sedation to ensure patient comfort and synchrony with the ventilator.

Concurrently, the patient's cardiovascular status remains precarious. With blood pressure persistently low despite increased doses of norepinephrine, the team initiates an infusion of dobutamine to enhance cardiac output and support tissue perfusion. This dual approach aims to optimize her hemodynamic stability while avoiding excessive fluid administration that could worsen pulmonary edema. Although her lactate levels stabilize slightly at 4.2 mmol/L, indicating a marginal improvement in perfusion, her heart rate remains elevated at 122 beats per minute, reflecting ongoing compensatory mechanisms.

Renal function continues to deteriorate, with serum creatinine rising to 3.0 mg/dL and urine output decreasing further to 5 mL/hour. Given the lack of response to conservative measures, the team prepares to initiate continuous renal replacement therapy (CRRT) to manage fluid overload and support renal function. As they navigate these complex challenges, the team remains vigilant for potential complications such as electrolyte imbalances, ventilator-associated pneumonia, and further hemodynamic instability. The patient's condition requires ongoing assessment and a dynamic treatment strategy, emphasizing the critical need for interdisciplinary collaboration and precise clinical reasoning to guide her care journey.

Section 5

As the team continues to manage the patient's complex clinical picture, new complications arise. Overnight, the patient develops a fever of 38.9°C (102°F), along with an increase in white blood cell count to 16,000/µL, suggesting the onset of an infectious process. These changes prompt concerns about ventilator-associated pneumonia (VAP), a common complication in patients requiring prolonged mechanical ventilation. A chest X-ray is ordered and reveals new infiltrates in the right lower lobe, consistent with pneumonia. Sputum cultures are obtained, and empiric broad-spectrum antibiotics are started to address the suspected infection while awaiting culture results.

Simultaneously, the patient's hemodynamic status shows signs of further instability. Despite the ongoing norepinephrine and dobutamine infusions, her blood pressure drops to 82/48 mmHg, and her heart rate increases to 130 beats per minute. The team faces the challenge of balancing the need for vasopressors to maintain perfusion with the risk of further compromising her already strained cardiac and renal function. This necessitates a careful reassessment of her fluid status and vasopressor requirements, as well as a potential adjustment in her sedation regimen to reduce metabolic demands.

In light of these developments, the interdisciplinary team convenes to reassess the patient's treatment plan, focusing on optimizing her respiratory and hemodynamic support while preventing further complications. CRRT is initiated to manage her fluid overload and support renal function, with the goal of improving her overall stability. The team also considers additional diagnostic tests, such as echocardiography, to evaluate cardiac function and guide further therapeutic decisions. Throughout this process, continuous monitoring and adjustment of interventions remain crucial, underscoring the importance of a dynamic and coordinated approach to her care.