A patient with a suspected MRSA infection and acute respiratory distress is being treated in the ICU. Given the initial assessment findings, which intervention is the highest priority for the nurse to perform to address the patient's current condition?

C) Providing supplemental oxygen and preparing for potential intubation due to respiratory distress and low PaO2.

A) Administering prescribed broad-spectrum antibiotics immediately to combat the suspected infection.

B) Initiating aggressive fluid resuscitation to address the elevated serum lactate and potential septic shock.

C) Providing supplemental oxygen and preparing for potential intubation due to respiratory distress and low PaO2.

D) Monitoring coagulation levels closely due to the presence of ecchymoses and potential coagulopathy.

A patient with a suspected MRSA infection and signs of septic shock presents with mixed respiratory and metabolic acidosis. Which of the following interventions should the nurse prioritize to stabilize the patient's condition?

C) Initiating aggressive fluid resuscitation to enhance tissue perfusion

A) Administering sodium bicarbonate to correct the metabolic acidosis

B) Increasing oxygen delivery to address the respiratory component of acidosis

C) Initiating aggressive fluid resuscitation to enhance tissue perfusion

D) Administering diuretics to manage peripheral edema and reduce fluid overload

A patient with suspected MRSA sepsis has developed acute respiratory distress syndrome (ARDS), acute renal failure, and possible disseminated intravascular coagulation (DIC). Which of the following interventions should the nurse prioritize to address the patient's respiratory compromise and ensure adequate oxygenation?

B) Prepare the patient for immediate intubation and mechanical ventilation.

A) Initiate intravenous administration of broad-spectrum antibiotics.

B) Prepare the patient for immediate intubation and mechanical ventilation.

C) Increase the flow rate of the non-rebreather mask to deliver more oxygen.

D) Administer diuretics to reduce pulmonary edema and improve breathing.

A patient with suspected MRSA sepsis has developed acute respiratory distress syndrome (ARDS), acute renal failure, and disseminated intravascular coagulation (DIC). As the nurse, which of the following interventions should be prioritized to address the patient's respiratory deterioration and overall clinical stability?

B) Prepare for intubation and mechanical ventilation while ensuring sedation and analgesia are optimized.

A) Increase the oxygen flow rate on the non-rebreather mask to 15 L/min to improve oxygen saturation.

B) Prepare for intubation and mechanical ventilation while ensuring sedation and analgesia are optimized.

C) Initiate renal replacement therapy to address fluid overload and electrolyte imbalances.

D) Administer fresh frozen plasma to correct coagulopathy and improve platelet count.

A patient with confirmed MRSA bacteremia and possible acute cholecystitis is critically ill, exhibiting high levels of inflammatory markers and sepsis. The medical team plans to proceed with a percutaneous cholecystostomy. What is the nurse's priority action to ensure optimal patient outcomes during this procedure?

B) Monitor the patient's hemodynamic status closely and prepare for potential fluid resuscitation during the procedure.

A) Administer a full dose of vancomycin immediately before the procedure to maximize antibiotic coverage.

B) Monitor the patient's hemodynamic status closely and prepare for potential fluid resuscitation during the procedure.

C) Educate the patient and family about the risks and benefits of the procedure to obtain informed consent.

D) Schedule the procedure during daytime hours when more staff are available for potential complications.

In managing a patient with MRSA sepsis and suspected acute cholecystitis, the interdisciplinary team is considering percutaneous cholecystostomy. What is the primary nursing consideration in preparing the patient for this procedure?

B) Monitoring and optimizing the patient's coagulation status to reduce the risk of bleeding during the procedure.

A) Ensuring the availability of broad-spectrum antibiotics during the procedure to prevent further infection.

B) Monitoring and optimizing the patient's coagulation status to reduce the risk of bleeding during the procedure.

C) Educating the patient and family about the potential need for surgical intervention if the procedure is unsuccessful.

D) Assessing the patient's nutritional status to support recovery post-procedure.

A patient in the intensive care unit is showing signs of septic shock with multi-organ dysfunction. Which of the following interventions should the nurse prioritize to address the patient's deteriorating condition?

C) Titrate vasopressors to maintain a mean arterial pressure (MAP) above 65 mmHg.

A) Administer a continuous infusion of broad-spectrum antibiotics.

B) Initiate mechanical ventilation to improve oxygenation.

C) Titrate vasopressors to maintain a mean arterial pressure (MAP) above 65 mmHg.

D) Start renal replacement therapy due to acute kidney injury.

A patient with suspected septic shock exhibits a sudden decline in vital signs, including hypotension, tachycardia, tachypnea, and decreased oxygen saturation. Laboratory results indicate thrombocytopenia, elevated lactate levels, and metabolic acidosis. As the nurse, what is the most critical initial intervention to prioritize for this patient?

C) Begin aggressive intravenous fluid resuscitation to improve hemodynamic stability.

A) Administer broad-spectrum antibiotics immediately to address the underlying infection.

B) Initiate mechanical ventilation to improve oxygenation and support respiratory function.

C) Begin aggressive intravenous fluid resuscitation to improve hemodynamic stability.

D) Prepare for hemodialysis to address acute kidney injury and remove metabolic waste.

A patient with a confirmed intra-abdominal abscess and multidrug-resistant organism infection is being closely monitored in the ICU. Despite mechanical ventilation and vasopressor support, she remains hemodynamically unstable. As the primary nurse, what is the most critical next step in managing this patient's care?

B) Advocate for immediate surgical drainage of the abscess to address the source of infection.

A) Increase the vasopressor dose to maintain adequate blood pressure and perfusion.

B) Advocate for immediate surgical drainage of the abscess to address the source of infection.

C) Consult with the infectious disease team to reassess and adjust antibiotic therapy.

D) Initiate continuous renal replacement therapy (CRRT) to prevent renal failure due to nephrotoxic antibiotics.

A patient with a history of cholecystitis has developed an intra-abdominal abscess and is now presenting with sepsis due to a multidrug-resistant organism. The patient is on mechanical ventilation and requires vasopressor support. As the nurse, what is the most critical nursing intervention to prioritize in this situation to prevent further complications?

B) Monitor the patient's hemodynamic status closely and titrate the vasopressors to maintain adequate perfusion.

A) Administer broad-spectrum antibiotics as soon as possible without waiting for infectious disease consultation.

B) Monitor the patient's hemodynamic status closely and titrate the vasopressors to maintain adequate perfusion.

C) Implement strict infection control measures to prevent the spread of the multidrug-resistant organism.

D) Prepare the patient for immediate surgical intervention to drain the abscess.

HAI from long term care facility - Nursing Case Study

Pathophysiology

• Primary mechanism: Disruption of skin and mucosal barriers due to prolonged immobilization and use of invasive devices like catheters, leading to increased susceptibility to colonization by multidrug-resistant organisms (MDROs).

• Secondary mechanism: Impaired host immune response in the elderly or chronically ill patients, often exacerbated by comorbidities and polypharmacy, reducing the ability to clear infections effectively and allowing for proliferation of opportunistic pathogens.

• Key complication: Development of severe infections such as bloodstream infections or pneumonia, which can lead to systemic inflammatory response syndrome (SIRS) and septic shock, significantly increasing morbidity and mortality in this vulnerable population.

Patient Profile

Demographics:

72, female, retired school teacher

History:

• Key past medical history: Type 2 Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and previous Methicillin-resistant Staphylococcus aureus (MRSA) infection

• Current medications: Metformin, Lisinopril, Albuterol inhaler, Fluticasone inhaler, Insulin glargine, and Warfarin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fever and difficulty breathing

• Key symptoms: Persistent cough, increased sputum production, altered mental status, and severe fatigue

• Vital signs: Temperature 102.4°F (39.1°C), Heart rate 128 bpm, Blood pressure 88/54 mmHg, Respiratory rate 28 breaths per minute, Oxygen saturation 82% on room air

Section 1

Initial Assessment Findings:

Upon admission to the acute care setting, a comprehensive assessment was conducted to evaluate the extent of the patient's condition. The patient was found to be in acute respiratory distress, displaying labored breathing with accessory muscle use, while auscultation of the lungs revealed diffuse crackles and wheezing, particularly in the lower lobes. Her skin was noted to be pallid and diaphoretic, with delayed capillary refill time, indicating poor perfusion. Neurologically, she exhibited confusion and lethargy, scoring 14 on the Glasgow Coma Scale, with notable difficulty in maintaining attention during the assessment. Peripheral edema was observed in the lower extremities, and the patient's mucous membranes appeared dry, suggesting possible dehydration. The presence of multiple ecchymoses on the arms and legs raised concern for coagulopathy, possibly exacerbated by Warfarin therapy.

Laboratory results from initial blood investigations revealed a leukocytosis of 18,000/mm³ with a left shift, indicating a potential bacterial infection. Blood cultures were drawn, and preliminary results showed Gram-positive cocci in clusters, raising suspicion for a new MRSA infection. Serum lactate levels were elevated at 4.2 mmol/L, suggesting tissue hypoperfusion and a possible progression toward septic shock. Renal function tests indicated acute kidney injury, with a serum creatinine of 2.1 mg/dL, up from a baseline of 1.0 mg/dL, potentially due to hypoperfusion and dehydration. Arterial blood gases revealed a mixed respiratory and metabolic acidosis, with a pH of 7.28, PaCO2 of 56 mmHg, HCO3- of 18 mmol/L, and PaO2 of 60 mmHg on supplemental oxygen.

These findings prompted immediate intervention, including aggressive fluid resuscitation, initiation of broad-spectrum antibiotics pending culture sensitivities, and critical monitoring in an intensive care setting. The clinical team recognized the need for rapid stabilization to prevent further deterioration, necessitating advanced critical thinking to balance the complexities of her comorbid conditions, potential drug interactions, and the risk of further complications such as acute respiratory failure or disseminated intravascular coagulation. As the scenario unfolds, vigilant assessment and timely response will be crucial in managing this multifaceted case.

Section 2

New Complications:

Despite initial interventions, the patient's condition took a concerning turn, necessitating an escalation in care. Within 12 hours of admission, her respiratory status worsened, with an increased respiratory rate of 36 breaths per minute and persistent use of accessory muscles. Oxygen saturation levels dropped to 85% on a non-rebreather mask, prompting the medical team to consider intubation and mechanical ventilation. A chest X-ray revealed bilateral infiltrates, suggestive of acute respiratory distress syndrome (ARDS), a complication of her suspected MRSA sepsis. This development required the team to reassess her ventilation strategy, fluid management, and sedation needs carefully.

Simultaneously, the patient's renal function continued to decline, with her serum creatinine rising to 3.5 mg/dL, indicating a progression toward acute renal failure. Urine output had significantly decreased to less than 20 mL per hour despite aggressive fluid resuscitation, raising the possibility of initiating renal replacement therapy. Furthermore, her coagulation profile showed a worsening trend, with a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), alongside a drop in platelet count to 75,000/mm³, heightening the suspicion of developing disseminated intravascular coagulation (DIC).

In response to these complications, the clinical team faced challenging decisions regarding the management of her anticoagulation therapy, balancing the need to control the coagulopathy against the risk of thrombotic events. The evolving picture required continuous evaluation and adjustment of her treatment plan, including the potential use of additional supportive therapies such as vasopressors for hemodynamic stability. The complexity of her case underscored the necessity for ongoing interdisciplinary collaboration and dynamic clinical reasoning to navigate the multifaceted challenges presented by her acute health crisis.

Section 3

As the patient's clinical status continued to deteriorate, new diagnostic results emerged that added complexity to her critical condition. A repeat set of blood cultures confirmed the presence of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, solidifying the previous suspicion of MRSA sepsis as the underlying cause of her acute deterioration. In light of this confirmation, the medical team intensified her antibiotic regimen, incorporating linezolid in addition to vancomycin to ensure broad-spectrum coverage and address potential resistance patterns. Despite these adjustments, her inflammatory markers, including C-reactive protein (CRP) and procalcitonin, remained significantly elevated, indicating an ongoing systemic inflammatory response.

Concurrently, further imaging studies were conducted to explore potential sources of infection and guide targeted interventions. An abdominal ultrasound revealed an enlarged, edematous gallbladder with pericholecystic fluid, suggesting acute cholecystitis as a possible source of her systemic infection. Given her critical condition and the risk of further complications, the surgical team was consulted to evaluate the feasibility of percutaneous cholecystostomy as an interim measure to manage the gallbladder inflammation and reduce sepsis progression.

These new findings necessitated a nuanced approach to her management plan, balancing the urgency of addressing multiple organ dysfunctions against the potential risks of invasive procedures. The interdisciplinary team recognized the need for continuous reassessment and close monitoring, particularly concerning her hemodynamic stability and organ perfusion. The focus remained on supporting her failing organs while addressing the infectious source, requiring advanced critical thinking to prioritize interventions and anticipate further complications in this challenging case.

Section 4

As the multidisciplinary team grappled with the patient's complex condition, a sudden change in her status prompted immediate reevaluation of her management plan. The patient's vital signs showed a concerning trend: her blood pressure had dropped to 78/45 mmHg, her heart rate was elevated at 128 beats per minute, and her respiratory rate had increased to 30 breaths per minute. Oxygen saturation had decreased to 88% on a non-rebreather mask, indicating potential respiratory compromise. Additionally, she exhibited altered mental status, becoming increasingly lethargic and less responsive to verbal stimuli.

Laboratory results revealed a precipitous drop in her platelet count to 50,000/μL, raising the suspicion of disseminated intravascular coagulation (DIC). Her lactate level had increased to 6 mmol/L, further suggesting worsening tissue hypoperfusion and a possible transition to septic shock. Arterial blood gas analysis showed a pH of 7.25, indicating metabolic acidosis. The patient's kidney function deteriorated, evidenced by a rising creatinine level of 3.2 mg/dL and reduced urine output, pointing towards acute kidney injury.

In response to these alarming developments, the medical team initiated aggressive resuscitation measures, including intravenous fluid boluses and vasopressor support to stabilize her hemodynamics. The critical care team deliberated the addition of mechanical ventilation support to address her respiratory insufficiency. Intensifying the search for underlying complications, a repeat CT scan of the abdomen and pelvis was ordered to reassess the gallbladder and identify any other potential sources of infection. These acute changes necessitated a rapid reassessment of the therapeutic priorities, with a focus on stabilizing her condition while preventing further escalation of her multi-organ dysfunction.

Section 5

As the medical team continued their efforts to stabilize the patient, they were met with new diagnostic results that provided further insights into her deteriorating condition. The repeat CT scan of the abdomen and pelvis revealed a significant finding: the presence of an intra-abdominal abscess adjacent to the previously noted cholecystitis. This abscess was likely contributing to the patient's systemic inflammatory response and was identified as a possible source of ongoing sepsis. The presence of this abscess necessitated urgent surgical consultation to evaluate the need for percutaneous drainage or surgical intervention.

Concurrently, blood cultures drawn prior to the initiation of broad-spectrum antibiotics returned positive for a multidrug-resistant organism, compounding the complexity of the patient's management. The infectious disease team was immediately consulted to tailor antibiotic therapy, balancing the need to cover resistant pathogens while minimizing the risk of further renal impairment due to nephrotoxic drugs. The identification of the resistant organism highlighted the importance of infection control measures in preventing further spread within the long-term care facility, prompting a review of current protocols.

Despite ongoing aggressive resuscitative efforts, the patient's clinical status remained precarious. Although vasopressor support had temporarily stabilized her blood pressure, her oxygenation continued to decline, warranting the initiation of mechanical ventilation. The team faced the challenge of addressing her acute respiratory failure without exacerbating her already compromised hemodynamics. These developments underscored the urgency of a multidisciplinary approach, integrating surgical, infectious disease, and critical care expertise to navigate the evolving complexities of the patient's condition. The situation called for continuous monitoring and swift adaptation of the management plan to prevent further deterioration and to optimize her chances for recovery.