A patient with suspected acute epiglottitis is exhibiting signs of severe respiratory distress and hypoxemia. Which of the following interventions should the nurse prioritize to prevent complete airway obstruction?

D) Assist in preparing the patient for urgent controlled intubation

A) Administer high-flow oxygen via non-rebreather mask

B) Prepare for an emergency tracheostomy at the bedside

C) Initiate intravenous antibiotic therapy immediately

D) Assist in preparing the patient for urgent controlled intubation

A patient is admitted with suspected acute epiglottitis, displaying signs of respiratory distress and stridor. After a lateral neck X-ray confirms the diagnosis, the healthcare team prepares for airway management. What is the priority nursing intervention while awaiting the arrival of the anesthesiology and otolaryngology teams?

A) Administer high-flow oxygen via face mask.

B) Position the patient supine to ensure airway patency.

C) Prepare for emergency tracheostomy at the bedside.

D) Reassure the patient and encourage them to speak to assess voice changes.

A patient with sepsis due to Haemophilus influenzae type b is being managed in the ICU. The nurse is reviewing the patient's latest lab results and monitoring vital signs. Which of the following interventions should the nurse prioritize based on the current clinical status?

B) Increase intravenous fluid administration and reassess blood pressure.

A) Administer broad-spectrum antibiotics and await further cultures.

B) Increase intravenous fluid administration and reassess blood pressure.

C) Initiate diuretic therapy to manage fluid overload.

D) Prepare for immediate extubation to reduce respiratory rate.

A patient in the ICU with confirmed Haemophilus influenzae type b infection is exhibiting signs of sepsis, including hypotension, tachycardia, and elevated lactic acid levels. After initiating antibiotic therapy specific to the pathogen, which of the following interventions should the nurse prioritize to address the patient's hemodynamic instability?

B) Increase the rate of intravenous fluids

A) Administer antipyretics to reduce fever

B) Increase the rate of intravenous fluids

C) Prepare the patient for immediate dialysis

D) Encourage deep breathing exercises

A patient in the ICU with sepsis shows signs of decreased renal function with a significant drop in urine output and rising serum creatinine levels. Which nursing intervention is most critical to prevent further renal damage?

C) Implement strict monitoring of fluid balance and adjust fluid therapy accordingly

A) Increase the dose of diuretics to enhance urine production

B) Administer nephrotoxic antibiotics as prescribed

C) Implement strict monitoring of fluid balance and adjust fluid therapy accordingly

D) Restrict oral fluid intake to prevent fluid overload

A patient in the ICU with suspected acute kidney injury secondary to sepsis-induced hypoperfusion has decreased urine output and elevated serum creatinine levels. Which nursing intervention is most appropriate to prioritize in managing this patient's condition?

C) Review and adjust medication dosages based on current renal function.

A) Increase the rate of intravenous fluids to 200 mL/hr to improve renal perfusion.

B) Administer a diuretic to promote urine output and prevent fluid overload.

C) Review and adjust medication dosages based on current renal function.

D) Initiate renal replacement therapy immediately to prevent further renal damage.

A patient with suspected septic shock is being treated with norepinephrine infusion and shows signs of respiratory acidosis with a pH of 7.32 and PaCO2 of 52 mmHg. As the nurse caring for this patient, which of the following interventions should be prioritized to address the patient's respiratory status?

B) Collaborate with the respiratory therapist to adjust the ventilator settings to improve ventilation.

A) Increase the norepinephrine infusion rate to improve blood pressure.

B) Collaborate with the respiratory therapist to adjust the ventilator settings to improve ventilation.

C) Administer sodium bicarbonate to correct the acidosis.

D) Prepare the patient for immediate bronchoscopy to assess airway patency.

A patient with septic shock is receiving norepinephrine to maintain hemodynamic stability. The nurse notes a decrease in urine output to 20 mL/hr and serum creatinine levels are rising. What is the most appropriate nursing action to address the patient's renal perfusion concerns?

C) Collaborate with the healthcare team to assess for potential vasopressor-related renal impairment.

A) Increase the norepinephrine infusion rate to improve blood pressure.

B) Initiate a fluid challenge with normal saline to enhance renal perfusion.

C) Collaborate with the healthcare team to assess for potential vasopressor-related renal impairment.

D) Administer diuretics to stimulate urine output and prevent fluid overload.

A patient with epiglottitis complicated by septic shock is being managed in the ICU. Despite norepinephrine infusion, the patient's blood pressure remains unstable, and there are signs of inadequate tissue perfusion, including increased serum lactate levels. Which of the following interventions should the nurse anticipate as the next step to improve the patient's hemodynamic status?

C) Add vasopressin to the current vasopressor regimen.

A) Increase the rate of the norepinephrine infusion.

B) Initiate an intravenous fluid bolus of normal saline.

C) Add vasopressin to the current vasopressor regimen.

D) Start dobutamine to improve cardiac output.

A patient with a diagnosis of epiglottitis complicated by septic shock is being managed with norepinephrine infusion and is displaying signs of inadequate tissue perfusion and reduced urine output. The team is considering adding vasopressin to the treatment plan. What is the primary reason for adding vasopressin in this clinical scenario?

C) To enhance systemic vascular resistance and stabilize blood pressure

A) To directly increase cardiac output by enhancing myocardial contractility

B) To improve renal perfusion by causing selective vasodilation of renal arteries

C) To enhance systemic vascular resistance and stabilize blood pressure

D) To reduce the risk of metabolic acidosis by decreasing lactate production

epiglotitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Epiglottitis is primarily caused by bacterial infection, most commonly Haemophilus influenzae type b (Hib), which leads to inflammation and swelling of the epiglottis and surrounding tissues. This inflammation can rapidly progress, causing airway obstruction.

• Secondary mechanism: The inflammatory response results in increased vascular permeability, leading to edema of the supraglottic structures. This swelling can significantly narrow the airway passage, creating a critical risk for respiratory distress and compromise.

• Key complication: Without prompt intervention, the swelling can cause complete airway obstruction, necessitating emergency airway management to prevent hypoxia and potential respiratory arrest.

Patient Profile

Demographics:

34-year-old male, teacher

History:

• Key past medical history: History of seasonal allergies, no prior episodes of epiglottitis

• Current medications: Loratadine for allergies

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe sore throat and difficulty swallowing

• Key symptoms: High fever, muffled voice, drooling, stridor, and difficulty breathing

• Vital signs: Temperature 101.8°F (38.8°C), heart rate 112 bpm, respiratory rate 24 breaths per minute, blood pressure 128/76 mmHg, oxygen saturation 91% on room air

Section 1

As the healthcare team initiates the initial assessment, the patient's condition begins to deteriorate further, prompting immediate clinical concern. The patient's respiratory distress intensifies, evidenced by increased stridor and a more pronounced use of accessory muscles for breathing. His oxygen saturation has dropped to 88% on room air, indicating significant hypoxemia. On auscultation, inspiratory stridor is clearly audible, and the patient is visibly anxious and restless. The patient's voice is becoming progressively more muffled, and he is unable to lie flat due to increased airway obstruction, which is a classic sign of escalating epiglottitis.

In response to these alarming assessment findings, the team quickly performs a lateral neck X-ray, which reveals the classic "thumbprint sign," indicative of a swollen epiglottis. This confirms the diagnosis of acute epiglottitis. Blood cultures and a complete blood count are obtained to identify the causative organism and assess the extent of systemic involvement. The CBC shows leukocytosis with a left shift, suggesting a bacterial etiology. Despite antibiotic therapy being initiated, the immediate priority is securing the airway.

Given the rapid progression of symptoms and risk of complete airway obstruction, the decision is made to proceed with an urgent controlled intubation in a controlled environment, such as the operating room, where equipment for a potential tracheostomy is readily available. The team prepares for advanced airway management, ensuring that all necessary personnel, including anesthesiology and otolaryngology, are at hand to manage this critical situation. This scenario underscores the importance of prompt and coordinated intervention in preventing further complications, such as acute respiratory failure, while also highlighting the need for ongoing monitoring and adjustment of the treatment plan based on the patient's evolving clinical status.

Section 2

As the healthcare team proceeds with the urgent controlled intubation, the patient's condition temporarily stabilizes, allowing for a more comprehensive evaluation of systemic involvement. However, within a few hours post-procedure, the patient begins to exhibit signs of sepsis, a new complication that demands immediate attention. His heart rate has increased to 120 beats per minute, and his blood pressure has dropped to 90/60 mmHg, indicating the onset of hemodynamic instability. The patient is febrile, with a temperature of 39.2°C (102.6°F), and his respiratory rate remains elevated at 28 breaths per minute despite the mechanical support. These findings suggest a systemic inflammatory response, likely secondary to the underlying infection.

Blood culture results return, identifying Haemophilus influenzae type b (Hib) as the causative organism, confirming the need for targeted antibiotic therapy. Despite the initial broad-spectrum antibiotics, the patient's clinical picture necessitates the adjustment of the antimicrobial regimen to specifically cover this pathogen. Furthermore, lactic acid levels are elevated at 3.5 mmol/L, reinforcing the diagnosis of sepsis and highlighting the need for aggressive fluid resuscitation and close monitoring of fluid balance.

The healthcare team quickly implements a sepsis management protocol, administering intravenous fluids to address the patient's hypotension and initiating vasopressor support as needed to maintain adequate perfusion. The patient is transferred to the intensive care unit for continuous monitoring and advanced supportive care. This critical phase underscores the importance of dynamic clinical reasoning, as the team must continually reassess and adjust the treatment plan based on the patient's evolving condition. The focus now shifts to stabilizing the patient and preventing further organ dysfunction, while closely monitoring for any additional complications that may arise.

Section 3

As the patient stabilizes in the intensive care unit, the healthcare team remains vigilant, continuously monitoring his hemodynamic status and organ function. Within the next 24 hours, there is a noticeable change in the patient’s renal status, which prompts further investigation. Urine output has decreased significantly to less than 0.5 mL/kg/hr, raising concerns about acute kidney injury potentially secondary to sepsis-induced hypoperfusion. Serum creatinine levels have risen from 1.0 mg/dL to 2.2 mg/dL, substantiating the suspicion of renal involvement. The calculated glomerular filtration rate (GFR) has decreased, indicating diminished kidney function.

In response to these findings, the team enhances fluid resuscitation efforts, ensuring meticulous attention to fluid balance and avoiding fluid overload. Nephrology is consulted to provide insight into potential causes and management strategies, considering the contributions of both pre-renal and intrinsic factors. The alteration in renal function necessitates a review of the patient’s medication regimen to avoid nephrotoxic agents and adjust dosages of antibiotics according to renal clearance. This development underscores the complexity of managing sepsis, as multiple organ systems can become compromised, requiring a dynamic and integrated approach to care.

Meanwhile, the patient’s respiratory function remains a priority, with close monitoring of ventilator settings and arterial blood gases to assess for any signs of respiratory acidosis or hypoxemia from potential pulmonary complications. The team continues to reassess the effectiveness of the current interventions, remaining prepared to escalate care if necessary. The evolving clinical picture emphasizes the critical need for ongoing assessment and adjustment of the treatment plan, highlighting the interplay between different organ systems and the importance of a coordinated, multidisciplinary approach in managing severe systemic infections like epiglottitis complicated by sepsis.

Section 4

As the healthcare team continues to manage the patient's complex condition, a new complication emerges that requires immediate attention. Despite aggressive fluid resuscitation, the patient's blood pressure remains borderline low, with systolic readings consistently around 90 mmHg. This persistent hypotension, alongside the rising serum lactate levels now at 3.5 mmol/L, suggests inadequate tissue perfusion and raises concerns about progressing septic shock. The team initiates a low-dose norepinephrine infusion to support hemodynamic stability while carefully monitoring for any potential side effects such as peripheral vasoconstriction, which could further impact renal perfusion.

In parallel, the respiratory team notes subtle changes in the patient's ventilatory requirements. Arterial blood gases reveal a pH of 7.32 and a PaCO2 of 52 mmHg, indicating a developing respiratory acidosis. This prompts a reassessment of the ventilator settings to optimize oxygenation and ventilation, while ensuring the airway remains secure given the initial epiglottitis diagnosis. The team debates the potential need for bronchoscopy to rule out any additional airway obstructions or secretions that could be contributing to the respiratory compromise.

These developments highlight the interconnectedness of the patient's organ systems and underscore the importance of a coordinated response. The clinical team, including intensivists, nephrologists, and respiratory therapists, collaborates closely to adjust the treatment plan. They prioritize maintaining adequate perfusion and oxygenation while minimizing further renal insult, anticipating that these interventions will stabilize the patient's condition. The case now pivots towards evaluating the effectiveness of these strategies, with careful monitoring to detect any further complications that may arise as the patient continues to recover from this severe systemic infection.

Section 5

The team's vigilant monitoring reveals a change in the patient's status overnight. Despite the norepinephrine infusion, the patient's blood pressure remains unstable, with systolic readings occasionally dipping to 85 mmHg. Concurrently, the urine output has decreased to less than 0.5 mL/kg/hr, raising concerns about acute kidney injury (AKI) secondary to both the hypotension and potential vasoconstrictive effects of the vasopressor. Repeat serum lactate levels show a slight increase to 3.8 mmol/L, reinforcing the suspicion of ongoing inadequate tissue perfusion. These findings necessitate a careful reassessment of the patient's fluid status and vasopressor management, prompting the team to consider adding vasopressin to the regimen to achieve more effective hemodynamic support.

On the respiratory front, an urgent bronchoscopy is performed after further evaluation of the patient's respiratory acidosis and potential airway obstruction. The procedure reveals moderate airway edema and the presence of thick secretions partially obstructing the lower airways. These findings prompt the respiratory team to initiate aggressive airway clearance strategies, including mucolytics and chest physiotherapy, alongside adjustments to the ventilator settings to enhance ventilation and prevent further CO2 retention. The patient's arterial blood gases show a slight improvement post-intervention, with a pH of 7.34 and PaCO2 of 48 mmHg, suggesting a positive response to the revised respiratory management plan.

These developments illustrate the complexity of managing a multifaceted condition like epiglottitis complicated by septic shock. The team's multidisciplinary approach is crucial in navigating the interplay between the cardiovascular and respiratory systems, ensuring that each intervention is tailored to address the evolving clinical picture. As the patient stabilizes, albeit slowly, the team remains vigilant for any signs of further deterioration, ready to pivot their strategies to support the patient's recovery trajectory. The next phase of care will focus on monitoring for any new complications and refining the treatment plan to facilitate the patient's gradual improvement.