A patient with a systemic Staphylococcus aureus infection and poor glycemic control is being treated with broad-spectrum IV antibiotics and fluid resuscitation. The nurse notices the patient's urine output has decreased significantly over the past 6 hours. What should be the nurse's priority intervention?

B) Notify the physician of potential acute kidney injury.

A) Increase the rate of IV fluid administration.

B) Notify the physician of potential acute kidney injury.

C) Measure the patient's blood glucose level.

D) Assess for signs of fluid overload.

A patient with a central line infection caused by Staphylococcus aureus presents with leukocytosis, elevated C-reactive protein, and procalcitonin levels. Given the patient's recent diagnostic results and history of diabetes, what is the nurse's priority intervention to prevent progression to septic shock?

A) Initiate fluid resuscitation and monitor blood pressure closely.

B) Administer insulin to manage hyperglycemia and prevent immune suppression.

C) Educate the patient on signs of infection to report immediately.

D) Prepare the patient for surgical removal of the central line.

A patient with suspected early acute respiratory distress syndrome (ARDS) and signs of septic shock is being considered for transfer to the intensive care unit. Which intervention should the nurse prioritize to optimize the patient's respiratory status prior to the transfer?

C) Position the patient in a high Fowler's position to maximize lung expansion.

A) Increase the oxygen flow rate on the nasal cannula to achieve an oxygen saturation of 95%.

B) Prepare the patient for potential intubation by ensuring all equipment is ready.

C) Position the patient in a high Fowler's position to maximize lung expansion.

D) Administer a bronchodilator to improve airway patency and reduce breath sounds.

A patient with suspected early acute respiratory distress syndrome (ARDS) and signs of septic shock is being considered for transfer to the intensive care unit. Which nursing intervention is most critical to implement immediately for this patient?

B) Initiating vasopressor therapy to manage hypotension.

A) Administering a bronchodilator to improve respiratory function.

B) Initiating vasopressor therapy to manage hypotension.

C) Providing aggressive fluid resuscitation to improve tissue perfusion.

D) Monitoring urine output hourly to assess renal function.

A patient with suspected early acute respiratory distress syndrome (ARDS) is being transferred to the ICU for further management, including the initiation of vasopressor therapy and low tidal volume mechanical ventilation. Which clinical finding would most likely indicate a need for immediate adjustment of the patient's current treatment plan?

C) Persistent hypotension despite norepinephrine infusion

A) Decreased urine output and rising serum creatinine levels

B) Increased bilateral lung infiltrates on repeat chest X-ray

C) Persistent hypotension despite norepinephrine infusion

D) Mild right ventricular strain observed on echocardiogram

A patient with early acute respiratory distress syndrome (ARDS) and signs of sepsis is being transferred to the ICU. The nurse is preparing to implement the care plan, which includes low tidal volume mechanical ventilation and vasopressor therapy. Which of the following nursing interventions is most critical to prioritize upon the patient's arrival to the ICU?

B) Set up continuous pulse oximetry to monitor oxygen saturation levels.

A) Initiate strict intake and output monitoring to assess fluid balance.

B) Set up continuous pulse oximetry to monitor oxygen saturation levels.

C) Prepare for immediate administration of antibiotics as per the revised plan.

D) Monitor the patient's heart rate and blood pressure every 4 hours.

A patient with persistent hypotension and oliguria despite fluid resuscitation is being managed in the ICU. Point-of-care ultrasound shows a flat inferior vena cava, and the patient is on norepinephrine. Which immediate nursing intervention is most appropriate to address the patient's current condition?

D) Monitor for signs of fluid overload before administering additional fluids.

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

B) Administer a bolus of crystalloids to improve intravascular volume.

C) Prepare the patient for renal replacement therapy due to oliguria.

D) Monitor for signs of fluid overload before administering additional fluids.

A patient in the ICU has been receiving norepinephrine for hypotension, yet continues to exhibit labile blood pressure and signs of intravascular volume depletion. After administering additional IV fluids, the patient develops oliguria with rising serum creatinine levels. What is the most appropriate next step in managing this patient's condition?

C) Reassess fluid status and consider diuretics to manage potential fluid overload

A) Increase the dose of norepinephrine to improve blood pressure

B) Initiate renal replacement therapy immediately

C) Reassess fluid status and consider diuretics to manage potential fluid overload

D) Start antibiotics to prevent potential sepsis progression

A patient with suspected acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) is being managed with prone positioning and continuous renal replacement therapy (CRRT). Which nursing intervention is most critical in optimizing the patient's respiratory and renal function?

B) Monitor and adjust fluid balance closely to prevent exacerbation of respiratory distress due to fluid overload.

A) Increase the frequency of position changes to every hour to maximize alveolar recruitment.

B) Monitor and adjust fluid balance closely to prevent exacerbation of respiratory distress due to fluid overload.

C) Administer diuretics to enhance urine output and improve kidney function.

D) Increase the FiO2 to 100% to immediately improve oxygen saturation levels.

A patient with suspected acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) is showing signs of respiratory distress despite mechanical ventilation and prone positioning. The patient is also on continuous renal replacement therapy (CRRT). Which nursing intervention is most appropriate to address the patient's current condition?

C) Collaborate with the respiratory therapist to adjust ventilator settings to improve oxygenation.

A) Increase the FiO2 to 100% to improve oxygen saturation.

B) Administer a diuretic to enhance urine output and reduce fluid overload.

C) Collaborate with the respiratory therapist to adjust ventilator settings to improve oxygenation.

D) Initiate a rapid fluid bolus to improve hemodynamic stability.

CLASBI - Nursing Case Study

Pathophysiology

• Primary mechanism: CLASBI, or Central Line-Associated Bloodstream Infection, primarily occurs when microorganisms, such as bacteria and fungi, gain direct access to the bloodstream via a central venous catheter. This breach in the sterile barrier can result from improper insertion techniques or inadequate maintenance of the catheter site.

• Secondary mechanism: Biofilm formation on the surface of the catheter is a critical factor. Microorganisms adhere to the catheter, creating a protective biofilm that shields them from both the host's immune defenses and antimicrobial agents, enabling persistent infection and complicating treatment.

• Key complication: Systemic infection can arise, leading to sepsis, which is characterized by a systemic inflammatory response that may progress to multi-organ dysfunction. Prompt recognition and management are essential to prevent severe outcomes.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes, previous CLASBI episode 2 years ago

• Current medications: Lisinopril, Metformin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Fever and chills for the past 48 hours

• Key symptoms: Fatigue, redness and tenderness around catheter site, headache

• Vital signs: Temperature 101.3°F, Heart rate 110 bpm, Blood pressure 100/60 mmHg, Respiratory rate 22 breaths per minute

Section 1

New Diagnostic Results:

Following the initial assessment, additional diagnostic tests were performed to determine the extent of the infection and guide treatment. Blood cultures drawn from both the central line and a peripheral vein returned positive for Staphylococcus aureus, indicating a systemic infection. A complete blood count showed leukocytosis with a white blood cell count of 16,000/mm³, and the differential revealed a left shift, suggesting an acute bacterial infection. C-reactive protein and procalcitonin levels were elevated, further supporting an inflammatory response consistent with sepsis. An ultrasound of the catheter site was ordered to assess for any localized abscess formation, which showed increased echogenicity around the catheter, suggestive of early abscess development.

The patient's renal function tests revealed a mild increase in creatinine levels at 1.5 mg/dL, up from her baseline of 1.0 mg/dL, indicating potential renal involvement. Liver function tests remained within normal limits. Due to her history of diabetes, a glycated hemoglobin (HbA1c) test was conducted, revealing poor glycemic control with a value of 9.2%, which could impair her immune response and exacerbate infection risk. Given these results, the clinical team was concerned about the potential for rapid progression to more severe sepsis or septic shock, necessitating close monitoring and aggressive management.

The results of the diagnostics led to an immediate multidisciplinary team meeting to reassess the patient's treatment plan. The team decided to remove the infected central line and initiate broad-spectrum intravenous antibiotics, excluding penicillin due to her allergy, with plans to tailor the regimen based on culture sensitivities. The patient was also started on a fluid resuscitation protocol to address hypotension and was closely monitored for signs of organ dysfunction. With these interventions underway, the focus shifted to vigilant monitoring for any new complications or changes in the patient's status, as the potential for rapid clinical deterioration remained a significant concern.

Section 2

As the patient continued to receive treatment, her clinical status began to exhibit concerning changes. Despite the initiation of broad-spectrum antibiotics and fluid resuscitation, she developed new symptoms indicative of potential complications. The patient reported increased shortness of breath and displayed tachypnea, with a respiratory rate climbing to 28 breaths per minute. Her oxygen saturation dropped to 90% on room air, prompting the healthcare team to supplement her with oxygen via nasal cannula. Auscultation revealed diminished breath sounds and crackles at the bases of both lungs, raising suspicion for the development of pulmonary complications such as early acute respiratory distress syndrome (ARDS).

Concurrently, her hemodynamic status showed signs of worsening. Blood pressure readings, which had initially stabilized, began to trend downwards, with measurements around 88/54 mmHg despite ongoing fluid resuscitation efforts. Her heart rate increased to 118 beats per minute, indicating a compensatory response to hypotension. Repeat laboratory tests revealed a further increase in creatinine levels to 1.8 mg/dL, suggesting worsening renal impairment, while serum lactate levels rose to 3.5 mmol/L, confirming tissue hypoperfusion and indicating a progression towards septic shock.

These developments necessitated an urgent reassessment of the treatment strategy. The clinical team discussed escalating the level of care, considering the transfer to the intensive care unit for closer monitoring and potential initiation of vasopressors to maintain perfusion. Additional diagnostic imaging, such as a chest X-ray, was ordered to further evaluate the respiratory status and guide interventions. The multidisciplinary team emphasized the importance of ongoing re-evaluation of organ function and the need for dynamic adjustments to the patient's care plan to address the rapidly evolving clinical situation.

Section 3

Following the initial assessment and the concerning developments in the patient's condition, new diagnostic results provided further insights into her deteriorating status. The chest X-ray revealed bilateral infiltrates consistent with early acute respiratory distress syndrome (ARDS), confirming the team's suspicions based on the physical examination and respiratory symptoms. This finding underscored the significance of addressing her respiratory compromise promptly. Additionally, an echocardiogram was performed to assess cardiac function, which showed normal left ventricular ejection fraction but signs of mild right ventricular strain, possibly as a result of increased pulmonary pressures and hypoxia.

The laboratory workup was expanded to include a comprehensive metabolic panel and coagulation profile. Results indicated a worsening metabolic acidosis with a bicarbonate level of 18 mEq/L, an anion gap of 16, and an elevated prothrombin time of 18 seconds, suggesting the onset of coagulopathy, a common complication in severe sepsis and septic shock. These findings emphasized the potential need for blood product support and further hemodynamic stabilization.

Given these developments, the clinical team prioritized the escalation of care by transferring the patient to the intensive care unit (ICU). This move enabled continuous monitoring and the initiation of vasopressor therapy with norepinephrine to counteract persistent hypotension. The patient's care plan was adjusted to include low tidal volume mechanical ventilation to support her respiratory function while minimizing ventilator-induced lung injury. The multidisciplinary team, including critical care specialists, nephrologists, and infectious disease experts, convened to reassess antibiotic coverage, considering the possibility of multidrug-resistant organisms contributing to her condition. With these coordinated efforts, the focus remained on stabilizing the patient's condition, preventing further complications, and closely monitoring her response to the intensified treatment regimen.

Section 4

The patient's response to interventions over the following 24 hours was mixed, necessitating ongoing clinical vigilance and adaptive management. Despite the initiation of norepinephrine, her blood pressure remained labile, with readings fluctuating between 85/50 mmHg and 95/60 mmHg. This persistent hypotension highlighted the need for further evaluation of her fluid status. A point-of-care ultrasound was conducted, revealing a flat inferior vena cava suggestive of intravascular volume depletion, prompting the team to cautiously administer additional intravenous fluids while monitoring for signs of fluid overload.

Respiratory support with low tidal volume mechanical ventilation showed initial improvement in her oxygenation status, with arterial blood gases now demonstrating a PaO2 of 70 mmHg on 60% FiO2 and a PaCO2 of 45 mmHg, indicating adequate ventilation but ongoing hypoxemia. Despite this, the patient's oxygenation index remained borderline, warranting consideration of adjunctive therapies such as prone positioning or inhaled nitric oxide to enhance pulmonary function. Her metabolic acidosis persisted, though there was a slight improvement in bicarbonate levels to 20 mEq/L, suggesting a partial response to the interventions aimed at correcting her acid-base balance.

However, the emergence of a new complication became evident as the patient's urine output decreased significantly over the past few hours, with total output dropping to less than 200 mL in 24 hours despite adequate fluid resuscitation. This oliguria, coupled with rising serum creatinine levels now at 2.5 mg/dL from a baseline of 1.0 mg/dL, suggested the onset of acute kidney injury (AKI). The nephrology team was consulted to evaluate the need for renal replacement therapy, as the risk of fluid overload versus the necessity of maintaining adequate perfusion became a critical balancing act. The multidisciplinary team continued to prioritize a comprehensive approach, integrating these new developments into the ongoing assessment and adjustment of the patient's treatment plan.

Section 5

As the clinical team closely monitored the patient's condition, a critical change in her status emerged. Over the next 12 hours, the patient's respiratory function began to deteriorate despite ongoing mechanical ventilation and the consideration of adjunctive therapies. Her oxygen saturation dropped to 85% on an FiO2 of 70%, and her PaO2 decreased to 60 mmHg. This change prompted the team to implement prone positioning to improve alveolar recruitment and oxygenation. Despite these efforts, the patient continued to exhibit signs of respiratory distress, with an increased respiratory rate and use of accessory muscles. The potential for acute respiratory distress syndrome (ARDS) was considered, necessitating a reevaluation of her respiratory management strategy.

In parallel, the patient's renal function showed further decline, with serum creatinine rising to 3.2 mg/dL and continued oliguria. The nephrology team performed a thorough assessment, including a review of fluid balance and medication history, to determine contributing factors to the worsening AKI. The decision was made to initiate continuous renal replacement therapy (CRRT) to address the dual concerns of fluid overload and electrolyte imbalances, while also ensuring adequate removal of potential nephrotoxins. This intervention aimed to provide renal support while maintaining hemodynamic stability, a critical consideration given her ongoing hemodynamic lability.

The multidisciplinary team remained vigilant, integrating these new developments into the overall treatment plan. They continued to prioritize a balanced approach, carefully adjusting interventions to optimize organ function while avoiding complications. Regular team huddles were conducted to review the patient's progress, evaluate response to interventions, and explore additional therapeutic options. This dynamic and adaptive management approach underscored the complexity of the patient's condition, emphasizing the need for ongoing clinical reasoning and collaboration to navigate her challenging clinical course.