A patient with complicated cholecystitis is being monitored for potential complications such as sepsis or peritonitis. Which assessment finding should the nurse prioritize as an indication of potential progression to sepsis?

B) Decreased urine output and tachycardia

A) Elevated blood pressure and bradycardia

B) Decreased urine output and tachycardia

C) Increased appetite and stable vital signs

D) Elevated bilirubin and mild right upper quadrant pain

A nurse is caring for a patient diagnosed with complicated cholecystitis and is currently on broad-spectrum intravenous antibiotics and NPO status. Which assessment finding should the nurse prioritize as indicating a potential complication requiring immediate intervention?

B) The patient has a heart rate of 115 beats per minute and blood pressure of 88/60 mmHg.

A) The patient reports increased abdominal pain and tenderness.

B) The patient has a heart rate of 115 beats per minute and blood pressure of 88/60 mmHg.

C) The patient has a temperature of 99.1°F (37.3°C) and mild diaphoresis.

D) The patient reports nausea and has vomited once since admission.

A patient with complicated cholecystitis is showing signs of sepsis, including fever, tachycardia, hypotension, and confusion. Laboratory results indicate an elevated white blood cell count and serum lactate level. Which nursing intervention is the priority to address these clinical findings?

D) Initiating and maintaining aggressive fluid resuscitation

A) Administering prescribed broad-spectrum antibiotics immediately

B) Monitoring urine output and documenting changes

C) Preparing the patient for possible emergent cholecystectomy

D) Initiating and maintaining aggressive fluid resuscitation

A patient with complicated cholecystitis has shown signs of potential sepsis, including fever, tachycardia, hypotension, increased respiratory rate, and confusion. Blood work indicates elevated white blood cell count and serum lactate levels. Which nursing intervention is the priority to address the patient's current condition?

D) Initiate and maintain aggressive intravenous fluid resuscitation

A) Administer prescribed broad-spectrum antibiotics immediately

B) Monitor and record the patient's urine output hourly

C) Prepare the patient for possible emergent cholecystectomy

D) Initiate and maintain aggressive intravenous fluid resuscitation

A nurse is monitoring a patient with sepsis who is experiencing a drop in blood pressure, elevated heart rate, and increased respiratory rate. The patient is scheduled for an emergent cholecystectomy due to suspected gallbladder involvement. Which nursing intervention is the priority to address the patient's deteriorating condition?

A) Administer prescribed vasopressors to stabilize blood pressure.

B) Increase the rate of fluid administration to improve perfusion.

C) Prepare the patient for immediate transfer to the operating room.

D) Monitor urine output closely to assess kidney function.

A patient with sepsis has developed acute kidney injury and is scheduled for an emergent cholecystectomy. Which nursing intervention is most critical to implement prior to surgery to ensure optimal patient outcomes?

B) Increase intravenous fluid rate to correct hypotension.

A) Administer prophylactic antibiotics specific to Escherichia coli.

B) Increase intravenous fluid rate to correct hypotension.

C) Monitor urine output every hour and report decreases immediately.

D) Obtain informed consent for the surgical procedure.

A patient with suspected acute respiratory distress syndrome (ARDS) secondary to sepsis is being prepared for mechanical ventilation. The arterial blood gas analysis shows a pH of 7.28, PaCO2 of 28 mmHg, and PaO2 of 60 mmHg. Which ventilator setting adjustment is most appropriate to improve oxygenation while minimizing barotrauma risk?

B) Increase the positive end-expiratory pressure (PEEP) to enhance alveolar recruitment

A) Increase the tidal volume to 10 mL/kg to improve ventilation

B) Increase the positive end-expiratory pressure (PEEP) to enhance alveolar recruitment

C) Decrease the respiratory rate to reduce respiratory alkalosis

D) Reduce the fraction of inspired oxygen (FiO2) to prevent oxygen toxicity

A patient with sepsis and suspected acute respiratory distress syndrome (ARDS) is exhibiting signs of worsening respiratory distress. The decision to initiate mechanical ventilation has been made. Which of the following ventilator settings is most appropriate to minimize lung injury in this patient?

B) Use a low tidal volume strategy to reduce barotrauma risk.

A) Set a high tidal volume to ensure adequate ventilation.

B) Use a low tidal volume strategy to reduce barotrauma risk.

C) Maintain a high inspiratory pressure to improve oxygenation.

D) Set a low respiratory rate to allow for more expiratory time.

A patient with mechanical ventilation support exhibits a sudden drop in blood pressure, tachycardia, and cool, clammy skin, consistent with distributive shock. The healthcare team decides to initiate prone positioning to manage ARDS. Which of the following is the primary rationale for employing prone positioning in this scenario?

B) To enhance oxygenation by improving ventilation-perfusion matching

A) To improve renal perfusion by redistributing blood flow

B) To enhance oxygenation by improving ventilation-perfusion matching

C) To decrease metabolic acidosis by enhancing CO2 elimination

D) To reduce right ventricular strain by lowering pulmonary vascular resistance

A patient diagnosed with ARDS and suspected distributive shock is on mechanical ventilation. The healthcare team observes bilateral infiltrates on a chest X-ray, moderate right ventricular dysfunction, and an elevated lactate level. What is the most appropriate nursing intervention to optimize oxygenation and hemodynamic stability in this scenario?

C) Initiate prone positioning to enhance lung recruitment and improve oxygenation.

A) Increase the tidal volume on the ventilator settings to improve oxygenation.

B) Administer additional vasopressors to maintain blood pressure without adjusting other treatments.

C) Initiate prone positioning to enhance lung recruitment and improve oxygenation.

D) Decrease fluid resuscitation efforts to prevent fluid overload and worsening ARDS.

cholecystitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Cholecystitis primarily occurs due to gallstone obstruction in the cystic duct, leading to bile accumulation, increased intraluminal pressure, and subsequent inflammation of the gallbladder wall.

• Secondary mechanism: The stagnant bile serves as a medium for bacterial growth, commonly involving Escherichia coli and other enteric bacteria, which further exacerbates inflammation and leads to infection.

• Key complication: If untreated, the continued inflammation and infection can result in gallbladder necrosis, perforation, or the formation of a pericholecystic abscess, posing serious risks such as sepsis or peritonitis.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, Hyperlipidemia

• Current medications: Lisinopril 10 mg daily, Atorvastatin 20 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe right upper quadrant abdominal pain

• Key symptoms: Nausea, vomiting, fever, jaundice, worsening pain over past 48 hours, tenderness in the right upper quadrant, positive Murphy's sign

• Vital signs: Temperature 38.5°C (101.3°F), Heart rate 110 bpm, Blood pressure 145/90 mmHg, Respiratory rate 22 breaths per minute

Section 1

As the patient's case progresses, new diagnostic results reveal important insights into her condition. Laboratory tests show elevated white blood cell count at 15,000/mm³, indicating a significant inflammatory response likely due to infection. Liver function tests reveal elevated bilirubin levels at 3.2 mg/dL, elevated alkaline phosphatase, and mildly elevated AST and ALT, confirming the presence of obstructive jaundice and potential liver involvement. An abdominal ultrasound is performed, which shows an enlarged gallbladder with thickened walls and the presence of multiple gallstones. The ultrasound also reveals pericholecystic fluid, suggesting the development of a potential collection or early abscess formation.

These findings prompt the healthcare team to consider the likelihood of a complicated cholecystitis. Given the risk of progression to gallbladder necrosis or perforation, the decision is made to initiate broad-spectrum intravenous antibiotics to target potential bacterial pathogens and reduce inflammation. The patient is also placed on nothing by mouth (NPO) status to prepare for possible surgical intervention and to prevent further gallbladder stimulation. Fluid resuscitation is continued to maintain hemodynamic stability and address dehydration from vomiting.

Clinical reasoning at this stage involves anticipating complications such as sepsis or peritonitis and monitoring for changes in the patient’s status. The healthcare team must assess for signs of systemic infection, such as persistent tachycardia, hypotension, or altered mental status, which would necessitate urgent surgical consultation and intervention. The focus remains on stabilizing the patient while planning for cholecystectomy, either laparoscopic or open, depending on the surgical evaluation and the patient’s response to medical management.

Section 2

As the healthcare team continues to manage the patient with complicated cholecystitis, they observe a change in her clinical status. Despite initial treatment efforts, the patient develops a fever of 101.8°F, accompanied by increased heart rate at 115 beats per minute and a slight drop in blood pressure to 98/62 mmHg. Her respiratory rate has increased to 24 breaths per minute, and she reports feeling more fatigued and confused. These changes raise concerns about the development of sepsis, prompting further evaluation and immediate reassessment of her condition.

Repeat laboratory tests are ordered, and results show a further increase in white blood cell count to 18,000/mm³, indicating a worsening inflammatory response. Blood cultures are drawn to identify the specific bacterial pathogen responsible for the infection. The serum lactate level is elevated at 3.5 mmol/L, suggesting tissue hypoperfusion and an increased risk of septic shock. Given these findings, the healthcare team intensifies fluid resuscitation efforts and adjusts the antibiotic regimen to ensure broad-spectrum coverage while awaiting culture results.

The clinical reasoning now focuses on recognizing the signs of systemic infection progressing to septicemia. The team is vigilant for any further decline in hemodynamic stability or changes in mental status that may prompt urgent surgical intervention. The patient is closely monitored, with frequent reassessments of vital signs, mental status, and urine output to evaluate the effectiveness of the interventions and detect any new complications early. The primary goal is to stabilize the patient while preparing for possible emergent cholecystectomy, prioritizing interventions that address both the infection and potential gallbladder complications.

Section 3

As the healthcare team continues intensive monitoring, they observe further changes in the patient's status that raise additional concerns. Within a few hours, the patient's blood pressure drops further to 90/58 mmHg, despite aggressive fluid resuscitation efforts. Her heart rate remains elevated at 120 beats per minute, and her respiratory rate has increased to 28 breaths per minute, suggesting respiratory compensation for metabolic acidosis. The patient's mental status deteriorates; she becomes increasingly lethargic and difficult to rouse, indicating worsening encephalopathy secondary to sepsis.

Repeat laboratory tests reveal a further escalation in serum lactate levels to 4.2 mmol/L, reinforcing the suspicion of tissue hypoperfusion and inadequate response to fluid therapy. Additionally, her creatinine level has risen to 2.1 mg/dL from a baseline of 0.9 mg/dL, suggesting acute kidney injury potentially due to sepsis-related hypoperfusion. Blood cultures return positive for Escherichia coli, allowing the team to tailor the antibiotic regimen to provide more targeted therapy, adjusting from broad-spectrum antibiotics to those specifically effective against this pathogen.

Given the patient's deteriorating condition and the development of acute kidney injury, the healthcare team considers the urgent need for surgical intervention alongside continued medical management. The decision is made to expedite preparations for an emergent cholecystectomy, as the gallbladder is likely contributing to ongoing sepsis. The anesthesiology and surgical teams are consulted to assess the patient's surgical risk and optimize her condition for the procedure. Throughout, the team remains vigilant, monitoring vital signs, urine output, and mental status closely to guide further interventions and ensure timely responses to any additional complications that may arise.

Section 4

As preparations for the emergent cholecystectomy are underway, the patient's condition continues to evolve, presenting a new set of challenges for the healthcare team. Despite targeted antibiotic therapy, the patient exhibits signs of worsening respiratory distress. Her respiratory rate has further increased to 32 breaths per minute, accompanied by shallow breathing and the use of accessory muscles. Arterial blood gas analysis reveals a pH of 7.28 with a PaCO2 of 28 mmHg and a PaO2 of 60 mmHg, indicating a mixed respiratory and metabolic acidosis. The team suspects the development of acute respiratory distress syndrome (ARDS) as a complication of sepsis, necessitating immediate intervention.

In response to the patient's declining respiratory function, the decision is made to initiate mechanical ventilation to support oxygenation and ventilation. The anesthesiology team adjusts the ventilator settings to achieve appropriate oxygenation goals while being mindful of the patient's hemodynamic instability. Concurrently, continuous renal replacement therapy (CRRT) is considered to manage her acute kidney injury and remove accumulated toxins, as evidenced by the rising creatinine levels and reduced urine output to less than 20 mL per hour.

The team remains focused on optimizing the patient's status before proceeding to the operating room. They closely monitor her hemodynamic parameters, aiming to maintain mean arterial pressure above 65 mmHg with vasopressor support if necessary. Her lactate levels are reassessed every two hours to gauge the effectiveness of resuscitation efforts and guide fluid management. The healthcare team's multidisciplinary approach, incorporating critical care, nephrology, and surgical expertise, reflects the complexity of the patient's condition and underscores the importance of timely, coordinated interventions to address the multifaceted challenges presented by sepsis and its complications.

Section 5

As the healthcare team continues to manage the patient's complex condition, they observe a change in her status that prompts further investigation. Four hours into mechanical ventilation and supportive therapies, the patient exhibits a sudden drop in blood pressure to 85/50 mmHg, despite ongoing vasopressor support. Her heart rate increases to 120 beats per minute, and her skin becomes cool and clammy, suggesting the development of distributive shock. The team responds by titrating vasopressors to maintain her mean arterial pressure and initiates an aggressive fluid resuscitation strategy, mindful of the risk of fluid overload given her compromised respiratory status.

To gain a clearer understanding of the patient's worsening condition, additional diagnostic tests are performed. A repeat chest X-ray reveals bilateral infiltrates consistent with the progression of ARDS, while an echocardiogram shows moderate right ventricular dysfunction, raising concerns of right heart strain due to increased pulmonary pressures. Laboratory tests indicate worsening metabolic acidosis with a lactate level now elevated to 5.6 mmol/L, highlighting inadequate tissue perfusion and oxygenation. Despite CRRT, the patient's renal function continues to decline, with serum creatinine reaching 3.2 mg/dL, reflecting ongoing acute kidney injury.

These findings prompt the healthcare team to reassess their intervention plan, considering the need for adjustments in ventilatory strategies and hemodynamic support. The team deliberates the potential benefits of advanced therapies, such as prone positioning for ARDS and adjustments to the CRRT regimen to optimize fluid balance and metabolic clearance. This evolving scenario underscores the critical importance of continuous monitoring and dynamic clinical reasoning to address the relentless challenges posed by sepsis and its complications, as the team works diligently to stabilize the patient for her impending cholecystectomy.