A 52-year-old male construction worker is being managed for sepsis with complications including Gram-negative bacteremia, elevated lactate levels, and acute kidney injury. Which nursing intervention is most critical to prioritize in the initial management of this patient to address the sepsis-related complications?

A) Administer broad-spectrum antibiotics immediately.

B) Initiate a low-protein diet to minimize renal workload.

C) Start continuous renal replacement therapy (CRRT) to manage acute kidney injury.

D) Provide oxygen therapy to maintain adequate tissue oxygenation levels.

A 52-year-old male construction worker with sepsis has blood cultures positive for Gram-negative bacteria, elevated lactate levels, and signs of acute kidney injury. What is the most appropriate nursing intervention to prioritize in the initial management of this patient?

A) Administer broad-spectrum antibiotics immediately.

B) Initiate a fluid restriction to prevent further renal damage.

C) Prepare the patient for dialysis to address acute kidney injury.

D) Withhold vasopressors until further renal tests are conducted.

A patient with sepsis is being treated with broad-spectrum antibiotics and aggressive fluid resuscitation. Despite these interventions, the patient exhibits signs of confusion and disorientation. Which of the following nursing interventions should be prioritized to address the patient's altered mental status?

B) Initiate a neuroassessment protocol to monitor neurological function.

A) Administer a sedative to reduce agitation.

B) Initiate a neuroassessment protocol to monitor neurological function.

C) Increase the rate of fluid resuscitation to improve cerebral perfusion.

D) Consult with the dietitian to start nutritional support immediately.

A patient with sepsis is receiving broad-spectrum antibiotics and aggressive fluid resuscitation, yet their lactate levels remain elevated, and they show signs of confusion and disorientation. What is the most appropriate nursing intervention to prioritize in this situation?

B) Implement a neuroassessment protocol to monitor for worsening neurological function.

A) Increase the rate of fluid resuscitation to improve perfusion.

B) Implement a neuroassessment protocol to monitor for worsening neurological function.

C) Adjust the antibiotic regimen based on culture and sensitivity results.

D) Initiate continuous renal replacement therapy (CRRT) immediately.

A patient with sepsis is showing signs of acute respiratory distress syndrome (ARDS) with a respiratory rate of 30 breaths per minute and oxygen saturation of 88% on a non-rebreather mask. The arterial blood gas analysis reveals pH 7.28, PaCO2 30 mmHg, and HCO3 18 mEq/L. Which of the following nursing interventions is the priority to improve the patient's respiratory status?

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

A) Administer a sedative to reduce respiratory rate and agitation.

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

C) Increase the flow rate of the non-rebreather mask to improve oxygenation.

D) Initiate a fluid bolus to improve circulation and oxygen delivery.

A patient with sepsis is showing signs of respiratory distress and has been diagnosed with acute respiratory distress syndrome (ARDS). Which nursing intervention is the priority to address the patient's deteriorating condition?

B) Preparing the patient for intubation and mechanical ventilation

A) Administering prescribed broad-spectrum antibiotics immediately

B) Preparing the patient for intubation and mechanical ventilation

C) Initiating continuous renal replacement therapy (CRRT)

D) Performing an electroencephalogram (EEG) to assess for seizure activity

A patient with sepsis and acute kidney injury is being evaluated for continuous renal replacement therapy (CRRT). The patient's blood pressure remains low despite fluid resuscitation and norepinephrine support. Which nursing intervention is most critical to implement to support the patient's hemodynamic stability?

B) Prepare to administer an additional vasopressor

A) Increase the rate of intravenous fluids

B) Prepare to administer an additional vasopressor

C) Monitor and document urine output hourly

D) Educate the family about the need for CRRT

A patient in the intensive care unit is experiencing a decline in renal function and hemodynamic instability 24 hours post-sepsis intervention, with rising creatinine and lactate levels. As a nurse, what is the most appropriate nursing intervention to prioritize in this situation?

B) Monitor and titrate norepinephrine to maintain mean arterial pressure (MAP) above 65 mmHg.

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

B) Monitor and titrate norepinephrine to maintain mean arterial pressure (MAP) above 65 mmHg.

D) Administer a diuretic to promote renal excretion and reduce edema.

A patient undergoing continuous renal replacement therapy (CRRT) shows stabilization in renal function but persistent hemodynamic instability. With fluctuating blood pressure and rising lactate levels, the healthcare team adds vasopressin and dobutamine to the treatment regimen. Which of the following interventions should the nurse prioritize to monitor the patient's response to this adjusted pharmacotherapy?

A) Monitor hourly urine output to assess renal perfusion.

B) Assess for signs of peripheral edema as an indicator of fluid overload.

C) Check blood glucose levels every four hours to detect hyperglycemia.

D) Monitor liver function tests daily to evaluate hepatic involvement.

A patient undergoing continuous renal replacement therapy (CRRT) is experiencing persistent hypotension despite high-dose norepinephrine. Low-dose vasopressin has been added with slight improvement in blood pressure, but lactate levels remain elevated. What is the next best nursing intervention to prioritize in managing this patient's condition?

C) Prepare for the administration of dobutamine to enhance cardiac output

A) Increase the rate of CRRT to enhance fluid removal

B) Administer a fluid bolus to improve intravascular volume

C) Prepare for the administration of dobutamine to enhance cardiac output

D) Discontinue vasopressin due to lack of significant improvement

sepsis - Nursing Case Study

Pathophysiology

• Primary mechanism: Dysregulated immune response - In sepsis, the body’s immune system overreacts to an infection, releasing excessive inflammatory mediators. This leads to widespread inflammation, damaging tissues and organs.

• Secondary mechanism: Endothelial dysfunction - The inflammatory response causes endothelial cells lining the blood vessels to become dysfunctional, resulting in increased vascular permeability. This allows fluids to leak into tissues, contributing to hypotension and impaired organ perfusion.

• Key complication: Multi-organ dysfunction - As inflammation and endothelial dysfunction progress, the delivery of oxygen and nutrients to organs is compromised, leading to organ failure. Prompt recognition and treatment are critical to prevent severe outcomes.

Patient Profile

Demographics:

52-year-old male, construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin, Metoprolol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: High fever and confusion

• Key symptoms: Chills, increased heart rate, difficulty breathing, fatigue

• Vital signs: Temperature 102.5°F (39.2°C), Heart rate 120 bpm, Respiratory rate 28 breaths per minute, Blood pressure 90/58 mmHg

Section 1

As the healthcare team continues to manage the 52-year-old male construction worker presenting with sepsis, new diagnostic results reveal further complications. Blood cultures return positive for Gram-negative bacteria, indicating a likely source of infection contributing to the sepsis. Concurrently, laboratory tests show elevated lactate levels at 4.5 mmol/L, suggesting significant tissue hypoperfusion. Additionally, the patient's white blood cell count is markedly elevated at 18,000 cells/mm³, further confirming the systemic inflammatory response. Liver function tests reveal a slight elevation in bilirubin and liver enzymes, raising concerns about the early signs of hepatic involvement.

The patient's renal function is also compromised, as evidenced by an increase in serum creatinine to 2.1 mg/dL from a baseline of 1.0 mg/dL, indicating acute kidney injury. Urinalysis shows proteinuria and casts, reinforcing the suspicion of renal impairment secondary to sepsis. Given these findings, the clinical team must prioritize interventions to address the underlying infection, support organ function, and prevent further deterioration.

These diagnostic results necessitate a revision of the treatment plan. Broad-spectrum antibiotics are initiated promptly to target Gram-negative organisms, with adjustments planned based on sensitivity results. Intravenous fluids are administered to improve hemodynamic stability and support renal perfusion, while vasopressors are considered to maintain blood pressure and ensure adequate organ perfusion. Continuous monitoring is crucial to assess the patient's response to these interventions and to detect any further complications, such as worsening organ dysfunction or the development of septic shock. The healthcare team must remain vigilant, using clinical reasoning to adjust the care plan as necessary to optimize patient outcomes.

Section 2

As the healthcare team continues to implement the revised treatment plan, attention turns to the patient's response to the interventions. Within the first 12 hours of initiating broad-spectrum antibiotics and aggressive fluid resuscitation, the patient's vital signs and laboratory values are closely monitored to assess the effectiveness of these treatments. Initially, there is a slight improvement in the patient's mean arterial pressure, which increases to 65 mmHg with fluid resuscitation, although vasopressor support remains necessary to maintain adequate perfusion. The patient's heart rate remains elevated at 110 beats per minute, and his respiratory rate is 24 breaths per minute, indicating persistent tachypnea and the need for careful respiratory support.

Despite these efforts, the patient's lactate level shows only a marginal decrease to 4.2 mmol/L, suggesting ongoing tissue hypoperfusion. Continuous renal replacement therapy (CRRT) is considered to address the acute kidney injury, given the persistently elevated creatinine level of 2.3 mg/dL and ongoing proteinuria. The healthcare team discusses the potential need for more aggressive interventions should renal function continue to decline. Meanwhile, liver function tests show a further increase in bilirubin to 2.5 mg/dL, indicating a progression toward hepatic dysfunction. This necessitates a reevaluation of the patient's overall metabolic status and consideration of additional supportive measures, such as nutritional support and potential adjustments to medication dosages to reduce hepatic strain.

Clinically, the patient exhibits signs of confusion and disorientation, which could be attributed to the combined effects of sepsis, potential hepatic encephalopathy, and renal impairment. This change in mental status prompts the team to initiate a neuroassessment protocol, including regular monitoring for any signs of worsening neurological function. With these developments, the healthcare team remains vigilant, recognizing that timely adjustments to the treatment plan are critical in preventing further deterioration and optimizing the patient's chances of recovery. The plan includes ongoing communication with the patient's family to keep them informed and involved in care decisions as the clinical picture evolves.

Section 3

As the healthcare team continues to monitor the patient, a new complication arises approximately 18 hours after the initial intervention began. The patient's respiratory status begins to deteriorate, with the respiratory rate increasing to 30 breaths per minute and oxygen saturation dropping to 88% on a non-rebreather mask. Arterial blood gas analysis reveals a worsening metabolic acidosis with a pH of 7.28, PaCO2 of 30 mmHg, and HCO3 of 18 mEq/L, indicating that compensatory mechanisms are being overwhelmed. This suggests the evolution towards acute respiratory distress syndrome (ARDS), likely secondary to the systemic inflammatory response associated with sepsis. The team decides to intubate the patient to protect the airway and ensure adequate ventilation, considering the increased work of breathing and risk of respiratory failure.

Simultaneously, further laboratory results return, showing a rising white blood cell count of 18,000/mm³, indicating a persistent or worsening infection despite the broad-spectrum antibiotics. Blood cultures drawn at the time of admission have now identified the presence of Escherichia coli, leading to the adjustment of antibiotic therapy to more targeted coverage. Despite these adjustments, the patient's neurological status remains concerning, with ongoing episodes of confusion and agitation. An electroencephalogram (EEG) is performed to rule out any seizure activity, given the potential for hepatic encephalopathy and sepsis-associated encephalopathy.

In light of these developments, the healthcare team discusses the need for enhanced multidisciplinary care, including respiratory therapy, infectious disease consultation, and potential nephrology input for CRRT initiation. The family is updated on the patient's condition, emphasizing the seriousness of the situation and the need for close monitoring and rapid intervention to address the evolving complications. The clinical team remains focused on stabilizing the patient's condition, understanding that careful management of respiratory, renal, and hepatic functions is crucial to prevent further deterioration and to optimize the potential for recovery.

Section 4

As the healthcare team continues to closely monitor the patient, a new complication emerges 24 hours after the initial interventions. The patient's renal function begins to decline, evidenced by a significant rise in serum creatinine from 1.2 mg/dL to 2.8 mg/dL and blood urea nitrogen (BUN) climbing to 45 mg/dL. Urine output has also decreased to less than 20 mL/hour, raising concerns for acute kidney injury (AKI) secondary to both sepsis and potential nephrotoxic effects of medications. This decline prompts the nephrology team to evaluate the patient for continuous renal replacement therapy (CRRT) to manage fluid overload and support renal function.

Meanwhile, the patient's hemodynamic status remains unstable. Blood pressure readings continue to trend downward, with systolic pressures dropping to the low 80s mmHg despite aggressive fluid resuscitation and vasopressor support with norepinephrine. Lactate levels, which had previously shown a slight decrease, now rise again to 4.5 mmol/L, signaling ongoing tissue hypoperfusion and a failure to achieve adequate hemodynamic resuscitation. The team discusses the possibility of introducing additional vasopressors or inotropes to improve cardiac output and tissue perfusion.

These developments necessitate a reevaluation of the current management plan. The healthcare team collaborates to refine the patient's treatment strategy, incorporating insights from nephrology and infectious disease specialists. The priority is to stabilize renal function, ensure adequate oxygenation and perfusion, and address the persistent infection. The patient's response to these interventions will be critical in determining the next steps, as the team remains vigilant for further complications such as multi-organ dysfunction syndrome (MODS) or persistent septic shock. The family is kept informed of the evolving situation, with a focus on the complexity and critical nature of the patient's condition.

Section 5

Response to Interventions

Following the initiation of continuous renal replacement therapy (CRRT), the healthcare team monitors the patient closely for signs of stabilization in renal function and hemodynamic status. Within the first few hours of CRRT, there is a notable improvement in fluid balance, as evidenced by a gradual increase in urine output to approximately 30 mL/hour. Additionally, serum creatinine levels show a slight decrease to 2.5 mg/dL, indicating a positive initial response to renal support. However, despite these encouraging signs, the patient's hemodynamic instability persists, with blood pressure readings fluctuating between 75-85 mmHg systolic, requiring continued high-dose norepinephrine.

In response to the persistent hypotension and rising lactate levels, the team initiates low-dose vasopressin as an adjunct to norepinephrine to enhance vasopressor efficacy. The addition of vasopressin leads to a modest improvement in blood pressure, with systolic readings stabilizing around 85-90 mmHg and diastolic pressures slightly improving. However, lactate levels remain elevated at 4.2 mmol/L, indicating ongoing tissue hypoperfusion. The attending intensivist decides to add dobutamine to the regimen, aiming to augment cardiac output and further improve tissue oxygenation.

As the team continues to address the critical issues of renal support and hemodynamic stability, they maintain vigilance for any signs of multi-organ dysfunction syndrome (MODS). The patient’s liver function tests, which had been stable, now show a mild increase in AST and ALT levels, raising concerns for potential hepatic involvement. This development prompts further collaboration with the infectious disease and hepatology teams to reassess the patient's antimicrobial regimen and consider potential hepatotoxicity or progression of sepsis-related complications. The family remains updated on the evolving situation, with emphasis on the complexity of managing such a critically ill patient and the need for ongoing, dynamic adjustments to the treatment plan.