A patient with a rapidly deteriorating perineal wound is showing signs of systemic involvement with a fever of 101.9°F, heart rate of 120 bpm, and a blood pressure of 130/85 mmHg. The patient's laboratory results indicate leukocytosis and elevated lactate levels. Which nursing intervention is the priority in managing this patient's condition?

C) Initiate broad-spectrum intravenous antibiotics.

A) Administer oxygen at 2 liters per minute via nasal cannula.

B) Prepare the patient for immediate surgical debridement.

C) Initiate broad-spectrum intravenous antibiotics.

D) Monitor blood glucose levels every 4 hours and administer insulin as needed.

A patient with a rapidly deteriorating perineal wound and systemic signs of infection, including fever, tachycardia, and elevated lactate levels, is being treated for suspected septic shock. Which nursing intervention is most critical in the initial management of this patient?

B) Start a continuous IV infusion of normal saline to maintain perfusion

A) Initiate a high-protein diet to promote wound healing

B) Start a continuous IV infusion of normal saline to maintain perfusion

C) Administer antipyretics to control the patient's fever

D) Encourage deep breathing exercises to improve oxygenation

A patient with sepsis is experiencing altered mental status, fever, tachycardia, hypotension, and decreased oxygen saturation despite receiving broad-spectrum antibiotics and fluid resuscitation. Blood cultures show a polymicrobial infection, and serum lactate levels are elevated. What is the priority nursing action to address the patient's condition?

C) Collaborate with the healthcare team to review and adjust the antibiotic regimen.

A) Increase the rate of IV fluids to improve tissue perfusion.

B) Administer antipyretics to reduce the patient's fever.

C) Collaborate with the healthcare team to review and adjust the antibiotic regimen.

D) Increase the oxygen flow rate via nasal cannula to improve oxygen saturation.

A patient with sepsis is being prepared for urgent surgical debridement. The nurse notes that the patient's oxygen saturation has decreased to 88% on room air, and there is an increase in serum lactate levels. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Adjust the oxygen delivery system to a non-rebreather mask to improve oxygenation.

A) Increase the rate of the intravenous fluid infusion to improve tissue perfusion.

B) Adjust the oxygen delivery system to a non-rebreather mask to improve oxygenation.

C) Contact the physician to request an increase in antibiotic dosage based on culture results.

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

A patient with a severe polymicrobial infection is receiving a revised antibiotic regimen including an aminoglycoside and a carbapenem. The patient also exhibits elevated serum lactate levels and declining renal function. Which nursing intervention is the most appropriate to prioritize in this scenario?

A) Monitor the patient's serum creatinine and urine output closely to assess renal function.

B) Educate the patient and family about the potential side effects of the antibiotic therapy.

C) Encourage the patient to increase oral fluid intake to support renal clearance of antibiotics.

D) Administer oxygen therapy to maintain oxygen saturation levels above 95%.

A patient with a polymicrobial infection is receiving a new antibiotic regimen including an aminoglycoside and a carbapenem. The patient also undergoes aggressive fluid resuscitation due to elevated serum lactate and declining renal function. Which assessment finding would most likely indicate that the treatment plan is effective in improving the patient's hemodynamic stability?

A) Decreased serum lactate level

C) Persistent confusion and lethargy

D) Oxygen saturation of 85% on room air

A patient in the ICU is being prepared for emergent surgical debridement due to septic shock. The patient is on norepinephrine to maintain a target mean arterial pressure of at least 65 mmHg. The nurse notes the patient's urine output is less than 0.5 mL/kg/hr, and the creatinine level is 2.2 mg/dL. What is the most appropriate nursing intervention to address the patient's renal perfusion status?

B) Consult with the healthcare provider to consider adding low-dose dopamine to enhance renal blood flow

A) Increase the norepinephrine infusion rate to improve renal perfusion

B) Consult with the healthcare provider to consider adding low-dose dopamine to enhance renal blood flow

C) Administer a diuretic to increase urine output and relieve fluid retention

D) Monitor fluid balance closely and report any significant decrease in urine output

A patient in the ICU with septic shock is being prepared for surgical debridement. The patient's vital signs are unstable, with low blood pressure, elevated heart rate, and fluctuating oxygen saturation levels. Laboratory results show metabolic acidosis and elevated serum lactate. Norepinephrine has been started to stabilize blood pressure. As the nurse, which action is the most critical to prioritize before the patient is transported to the operating room?

A) Ensure a patent airway and adequate oxygenation

B) Re-evaluate the patient's fluid status and administer additional fluids

C) Review and adjust the antibiotic regimen with the healthcare provider

D) Monitor and document urine output every 30 minutes

A patient with sepsis is showing signs of acute respiratory distress syndrome (ARDS) and is currently on high-flow nasal cannula. The patient's blood cultures confirm persistent bacteremia, and the creatinine level is rising, indicating acute kidney injury. Which intervention should the nurse prioritize to address the patient's respiratory compromise?

B) Prepare for potential intubation and mechanical ventilation.

A) Administer a diuretic to reduce fluid overload.

B) Prepare for potential intubation and mechanical ventilation.

C) Increase the rate of norepinephrine infusion to improve blood pressure.

D) Re-evaluate the current antibiotic regimen with the infectious disease team.

A patient in the ICU is diagnosed with acute respiratory distress syndrome (ARDS) secondary to sepsis and is currently receiving high-flow nasal cannula oxygen therapy. The patient remains oliguric with an upward trending creatinine level. As the nurse, what is the most appropriate intervention to prioritize when planning care for this patient?

A) Prepare for potential intubation as respiratory status may deteriorate.

B) Increase the dose of norepinephrine to improve mean arterial pressure.

C) Initiate fluid restriction to prevent worsening of acute kidney injury.

D) Administer diuretics to enhance urine output and reduce oliguric status.

Fournier gangrene wound on perineum - Nursing Case Study

Pathophysiology

• Primary mechanism: Fournier gangrene is caused by polymicrobial infection that rapidly progresses due to synergistic activity between aerobic and anaerobic bacteria, leading to tissue necrosis. This synergy enhances bacterial growth and toxin production, resulting in extensive tissue destruction.

• Secondary mechanism: The infection compromises microvascular blood supply in the perineum and adjacent areas. Ischemia ensues, exacerbating tissue necrosis and creating an anaerobic environment that further fuels bacterial proliferation.

• Key complication: If untreated, the rapid spread of infection can lead to systemic sepsis, characterized by severe hypotension, organ failure, and potentially death, necessitating urgent surgical debridement and broad-spectrum antibiotics.

Patient Profile

Demographics:

56-year-old male, construction worker

History:

• Key past medical history: Type 2 diabetes mellitus, hypertension

• Current medications: Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain and swelling in the perineal region

• Key symptoms: Fever, foul-smelling discharge, erythema, and necrosis in the perineum

• Vital signs: Temperature 101.5°F (38.6°C), Heart rate 112 bpm, Blood pressure 145/90 mmHg, Respiratory rate 24 breaths per minute, Oxygen saturation 94% on room air

Section 1

As the medical team proceeds with the initial assessment of the patient, they note the rapidly deteriorating condition of the perineal wound. The area of necrosis has expanded, with clear demarcation of necrotic tissue surrounding the erythematous zone. Palpation reveals crepitus, indicating the presence of subcutaneous emphysema. The foul odor remains pronounced, confirming the aggressive nature of the infection. In addition to the severe localized symptoms, the patient exhibits signs of systemic involvement: his fever persists at 101.9°F (38.8°C), and his heart rate has increased to 120 bpm. The blood pressure has dropped to 130/85 mmHg, suggesting the onset of sepsis. His respiratory rate remains elevated at 26 breaths per minute, and his oxygen saturation has decreased slightly to 92% on room air.

Laboratory results arrive, providing further insight into the patient's condition. The complete blood count reveals leukocytosis with a white blood cell count of 18,000/µL and a left shift, indicating an acute inflammatory response. Blood cultures are pending, but preliminary results show elevated lactate levels at 3.5 mmol/L, suggesting inadequate tissue perfusion and anaerobic metabolism. Renal function tests show a slight elevation of serum creatinine to 1.4 mg/dL, hinting at early renal involvement likely due to the systemic inflammatory response. The glucose level is significantly elevated at 250 mg/dL, reflecting poorly controlled diabetes, which may be contributing to impaired wound healing and increased susceptibility to infection.

The medical team prioritizes aggressive intervention, acknowledging the patient's condition is evolving towards septic shock. Immediate surgical consultation is obtained for urgent debridement of necrotic tissue. Broad-spectrum intravenous antibiotics are initiated, specifically avoiding penicillin-based drugs due to the patient's allergy. The clinical team recognizes the critical need for meticulous monitoring of vital signs, blood glucose control, and supportive care to address the developing complications and prevent further systemic deterioration. As the patient's journey progresses, the focus will be on evaluating the efficacy of interventions and anticipating any further complications that may arise.

Section 2

Following the initiation of the broad-spectrum intravenous antibiotics and fluid resuscitation, the medical team continues to monitor the patient closely for any changes in his condition. Despite initial efforts, the patient's status evolves with concerning developments. Approximately 12 hours post-intervention, the patient's fever has risen to 103.1°F (39.5°C), and his heart rate has increased further to 130 bpm. Blood pressure now reads 110/70 mmHg, indicating a possible progression towards septic shock. His respiratory rate remains elevated at 28 breaths per minute, and oxygen saturation has decreased to 88% on room air, necessitating supplemental oxygen via nasal cannula.

New diagnostic results arrive, providing additional insight into the patient's systemic challenges. Blood cultures have returned positive for a polymicrobial infection, including both aerobic and anaerobic bacteria, necessitating a review and potential adjustment of the antibiotic regimen to ensure comprehensive coverage. Additionally, the serum lactate level has increased to 4.2 mmol/L, a troubling sign of worsening tissue hypoperfusion and ongoing anaerobic metabolism. The renal function continues to decline, with serum creatinine now at 1.8 mg/dL, suggesting acute kidney injury likely exacerbated by the systemic inflammatory response.

The patient exhibits new complications, including altered mental status characterized by confusion and lethargy, underscoring the severity of the sepsis. The need for urgent surgical debridement becomes even more critical to remove the source of infection and prevent further systemic deterioration. The clinical team must now engage in complex clinical reasoning to optimize fluid management, tailor antibiotic therapy based on culture results, and address the multi-organ dysfunction that is emerging. As the patient is prepared for surgery, the team remains vigilant for any signs of further deterioration, recognizing that timely surgical intervention and continued intensive care are crucial to improving the patient's prognosis.

Section 3

After careful consideration of the patient's deteriorating condition and the latest diagnostic results, the medical team decides to focus on the response to interventions, particularly the adjustment of the antibiotic regimen and fluid management. The initial broad-spectrum antibiotics are reevaluated in light of the polymicrobial nature of the infection revealed by blood cultures. The team collaborates with infectious disease specialists to tailor a more targeted antibiotic therapy, incorporating both an aminoglycoside and a carbapenem to ensure comprehensive coverage of the identified aerobic and anaerobic bacteria. This revised regimen aims to curb the systemic spread of infection and mitigate the progression towards septic shock.

In parallel, the patient's fluid management plan is critically reassessed. The elevated serum lactate level of 4.2 mmol/L and declining renal function with a creatinine level of 1.8 mg/dL indicate ongoing tissue hypoperfusion and possible fluid imbalance. The team initiates a more aggressive fluid resuscitation strategy, carefully balancing the risk of fluid overload, given the patient's marginal respiratory status with an oxygen saturation of 88% on room air. Close monitoring of urine output and repeated serum lactate measurements will guide the titration of fluids, aiming to restore hemodynamic stability and improve organ perfusion.

Despite these interventions, the patient's clinical status continues to pose challenges. The altered mental status remains a concern, with persistent confusion and lethargy suggesting cerebral hypoperfusion or direct septic encephalopathy. The urgency for surgical intervention becomes even more pronounced as a means to eliminate the infectious source and halt the cascade of systemic inflammation. As the patient is prepped for urgent surgical debridement, the interprofessional team stays vigilant, ready to address any intraoperative and postoperative complications, recognizing that successful surgical management, alongside optimized medical therapy, is pivotal in improving the patient's overall trajectory.

Section 4

As the surgical team prepares for the emergent debridement, the patient's status is closely monitored in the intensive care unit. Despite the tailored antibiotic regimen and fluid resuscitation efforts, the patient's vital signs remain concerning. Blood pressure is persistently low at 85/50 mmHg, and heart rate has increased to 120 beats per minute, indicating a compensatory tachycardia. Oxygen saturation fluctuates between 86-89% despite supplemental oxygen via nasal cannula. The patient's respiratory rate is elevated at 28 breaths per minute, suggesting increased respiratory effort and potential respiratory compromise.

New laboratory results show a worsening metabolic acidosis with a bicarbonate level of 18 mmol/L, and the serum lactate has risen to 5.1 mmol/L, underscoring the severity of the tissue hypoperfusion. Additionally, the white blood cell count has escalated to 18,000/µL, further indicating an overwhelming inflammatory response. The renal function continues to decline, with creatinine now at 2.2 mg/dL and urine output decreasing to less than 0.5 mL/kg/hr over the past six hours, raising concerns for acute kidney injury secondary to septic shock.

In light of these developments, the team intensifies their focus on optimizing hemodynamic support, incorporating vasopressor therapy to stabilize blood pressure and maintain adequate perfusion. Norepinephrine is initiated to achieve a target mean arterial pressure of at least 65 mmHg. The altered mental status persists, with the patient remaining disoriented and minimally responsive, heightening the suspicion of ongoing cerebral hypoperfusion. The immediate goal is to stabilize the patient sufficiently for safe transport to the operating room, where surgical debridement can be performed to control the source of infection. The team remains alert to the potential for further complications, including intraoperative hemodynamic instability and postoperative recovery challenges, emphasizing the need for meticulous perioperative care and continuous reassessment.

Section 5

As the team prepares for the surgical intervention, further diagnostic results reveal additional concerns. A chest X-ray indicates new bilateral infiltrates, suggestive of acute respiratory distress syndrome (ARDS), likely secondary to sepsis. The patient's respiratory status is markedly compromised, correlating with the observed hypoxemia and increased work of breathing. Given these developments, the decision is made to escalate the respiratory support to high-flow nasal cannula, and preparations for potential intubation are discussed should the patient's respiratory condition deteriorate further.

Simultaneously, a repeat blood culture confirms persistent bacteremia, despite the broad-spectrum antibiotics. This finding raises the possibility of antibiotic resistance or inadequate source control, necessitating a re-evaluation of the antibiotic regimen in consultation with infectious disease specialists. The multidisciplinary team considers the addition of antifungal coverage, given the high risk of invasive fungal infections in this critically ill patient.

Clinically, the patient's hemodynamics show partial improvement with norepinephrine, achieving a mean arterial pressure of 65 mmHg. However, the patient remains oliguric, and the creatinine continues to trend upwards, now at 2.8 mg/dL, reinforcing the diagnosis of acute kidney injury. The nephrology team is consulted to discuss the potential for renal replacement therapy as part of the management plan. As the situation evolves, the team remains vigilant, understanding that successful surgical intervention and close postoperative monitoring will be crucial in navigating the patient's complex clinical trajectory.