Description
Attached is a sample case study provided to me.
In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.
Section
Information to Include
Introduction (patient and problem)
Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What was he/she diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology
Explain the disease (What are the symptoms? What causes it?)
History
Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment
List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments
Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal
Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions
Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation
Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations
Explain what the patient or nurse should do in the future to continue recovery/improvement
Your paper should be 3-4 pages in length and will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following:
Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)
Week 6: Signature Assignment: Topic Name
Student Name
West Coast University
Professor: Dr. Ken Hoang
26 July 2020
Introduction
Joanna Keaton is a 59-year-old Asian American woman from California. Joanna was recently hospitalized after having a Bullectomy. Joanna’s surgery was necessary because she has a history of smoking that developed into COPD. While recovering from her surgery Joanna had become lethargic, she began to experience arrhythmias, tachypnea, chills, emesis, and developed a fever of 103. Based on Joanna’s symptoms she was diagnosed with septic shock. As a nurse, my main focus is to perform early resuscitation therapy. Patients with sepsis who respond to early resuscitation therapy in the emergency department (ED) and show no evidence of end-organ hypoperfusion may be admitted to a general hospital unit while patients who do not respond to initial ED treatment (i.e., who have recurrent hypotension despite adequate fluid challenges) require admission to an ICU for continuous monitoring and continued goal-directed therapy (Kalil, 2019). Since Joanna did not respond to the ED treatment, my next focus is to have her transferred into the ICU and determine which stage of shock she is in.
Determining the stage can be determined through clinical manifestations. Certain stages of septic shock are more severe than others. Based on Joanna’s symptoms she was experiencing at home I would suggest and unresponsiveness she was in the Progressive stage. Progressive stage is the third phase of septic shock is the moment when the infection has become so severe that the body is compensating by igniting an inflammatory process. This inflammatory process is the body’s defense mechanism to fight off the infection. However, in septic shock, the inflammatory process has gone haywire, and it has become widespread and systemic (Linares, 2020). I believe Joanna is in the progressive stage because of her continuous cough, and low body temperature are symptoms of pneumonia. To confirm this, I will order a chest x-ray to see if there is any inflammation in the lungs and a blood test to determine what kind of germ is causing the infection. Chest X-ray helps your doctor diagnose pneumonia and determine the extent and location of the infection. However, it can’t tell your doctor what kind of germ is causing the pneumonia (“Pneumonia- Diagnosis and treatment-Mayo Clinic”, n.d.). Joanna will also have to take a urine analysis, to check the concentration. This is necessary because cloudy concentrated urine is an indicator of the infection.
Pathophysiology
Septic shock is a life-threatening complication of sepsis. Infections that cause sepsis is usually derived from the urinary tract, pneumonia, or abdomen. When the blood pressure drops due to bacteria present in the bloodstream or when gram-positive organism enters the bloodstream it ignites septic shock. Gram-positive organisms (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae) and fungi (Candida species) are also important causes of septic shock. A frequent portal of entry is the genitourinary tract. Other entry sites include the gastrointestinal tract, the respiratory tract, and the skin (Banasik&Copstead, 2017). Septic shock is a possible consequence of bacteremia, or bacteria in the bloodstream. Bacterial toxins, and the immune system response to them, cause a dramatic drop in blood pressure, preventing the delivery of blood to the organs. Septic shock can lead to multiple organ failure including respiratory failure, and may cause rapid death (septic shock, n.d.). There are four stages to the disease: early sepsis, compensatory stage, progressive phrase, refractory stage. Early Sepsis is the initial phase, where the patient has a low MAP. A drop-in mean arterial pressure means that the infection has gone worse than it’s turning off some of the barrel receptors inside the body. Barrel receptors are the receptors in the blood vessels that help regulate the constriction of blood vessels (Linares, 2020). Compensatory stage is when the body is trying to compensate for any type of shock, not just septic shock, it will increase the heart rate and respiratory rate to get more oxygen since there is not enough blood perfusion (Linares, 2020). Progressive phrase is the moment when the infection has become so severe that the body is compensating by igniting an inflammatory process. This inflammatory process is the body’s defense mechanism to fight off the infection. However, in septic shock, the inflammatory process has gone haywire, and it has become widespread and systemic (Linares, 2020). The last stage is refractory has the presence of hypotension, with end-organ dysfunction, requiring high-dose vasopressor support often greater than 0.5 μg/kg/min norepinephrine or equivalent (Nandhabalan et al., 2018).
Each stage has its specific symptoms and signs, the overall symptoms and signs include low blood pressure, arrhythmia, fever, chills, nausea, vomiting, confusion, anxiety, and tachypnea (Medicine net, n.d.). During the early stage, the clinical manifestation is characterized by high cardiac output and warm extremities because of a lack of sympathetic tone, and a widened pulse pressure result. The heart rate and stroke volume increase, and cardiac output is higher than normal, but the patient remains hypotensive (Banasik&Copstead, 2017). The clinical manifestations for the progressive stage include hypothermia- temperature less than 97, pneumonia, decreased urinary output-glomeruli in the kidneys become inflamed. The dilated vessels cause reduced resistance and perfusion that the body compensates by holding on to volume, high specific gravity- dark brown, thick odorous, and very concentrated urine output, bleeding- broken vessels due to the inflammation process (Linares, 2020). The risk factors for the infection are the elderly, patients with chronic health conditions, patients recently hospitalized after surgery, and patients with suppressed immune systems.
History
Joanna has been previously diagnosed with type 2 diabetes and hypertension, she has been taking metformin and lisinopril for 10+ years to treat them. For years she has been having difficulties breathing due to her being a chronic smoker and developing COPD. COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. It’s caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke (“COPD-Symptoms and causes”, n.d.). Her COPD was so severe that she had to receive surgery to remove a bullae from the lung. Bullectomy is a procedure where doctors remove one or more of the very large bullae or blebs from the lungs. Bullae are large air sacs that form from hundreds of destroyed alveoli. These air spaces can become so large that they crowd out the better functioning lung and interfere with breathing. For those people, removing the destroyed air sacs improves breathing.
Joanna’s history with diabetes and her chronic health condition of COPD are risk factors for this infection. Joanna’s recent hospitalization after the Bullectomy made her more susceptible to contracting sepsis and septic shock. Sepsis and septic shock are common after surgeries. Surgery takes a toll on the body and weakens the immune system, even if the procedure is a minor one, which can make infections more likely (Whitlock, 2019).
Nursing Physical Assessment
After taking Joanna’s vitals, her MAP was 59.7 mmHg, due to her blood pressure dropping to 83/48 mmHg. Her heart rate was 106 bpm, respiratory rate was 39 bpm, and had a body temperature of 38.7°C. The patient’s lab results showed her WBC have increased to 15,000/mcL; pH balance was 7.07. Her lactate level increased to 5 mmol/L, which caused her HCO3 to be 20 mEq/L and her urine output was 15mL and was cloudy. Joanna’s results were abnormal because the average normal blood pressure 120/80 mmHg, low BP is 90/60. With that being said if her BP was normal her MAP should be around 93.3 mmHg, Joanna’s was way below that. Lactate levels higher than 2.5 mmol/L are associated with an increase in mortality. The higher the serum lactate, the worse the degree of shock, and the higher the mortality (Kalil, 2019). Joanna also had cloudy urine which is also a symptom for septic shock.
Related Treatments
To stabilize Joanna’s breathing she will be placed on a ventilator and be administered various medications to stabilize her vitals. Treatment for Joanna’s infection will include many medications. The beginning of Joanna’s will start with the early administration of intravenous antibiotics to fight the infection. Appropriate broad-spectrum antibiotic therapy is started as soon as septic shock is suspected and after quickly obtaining appropriate cultures (Banasik&Copstead, 2017).
Since the patient’s BP dropped to 83/48 mmHg, vasopressor medication will need to be administered. Vasopressor medications, which are drugs that constrict blood vessels and help increase blood pressure (Rogers, 2019). Because Joanna’s case is a severe case of septic shock, protein C is also recommended. Activated protein C is currently recommended for those with severe sepsis and a high-risk score for mortality. Protein C has both anti-inflammatory and antithrombotic actions, which may be helpful in sepsis (Banasik&Copstead, 2017).
Nursing Diagnosis & Patient Goal
The patient is experiencing deficient fluid volume related to constant emesis and a fever of 103. Ineffective breathing pattern due to the patient’s arrhythmias and tachypnea. Ineffective tissue perfusion related to the progression of septic shock with decreased cardiac output of 15mL, vasodilation which decreased Joanna’s BP to 83/48 mmHg.The patient will have a systolic blood pressure above 100 mmHg by tomorrow. Joanna’s breathing pattern will return to normal resting rate after the administration of calcium channel and beta-blockers. The patient’s tissue perfusion will increase, and she will be given medication to get rid of the infection.
Nursing Interventions
According to Rochester.edu, the principle of adult sepsis treatment is to measure lactate level, administer broad-spectrum antibiotics, administer 30 ml/kg crystalloid intravenous fluids (IVF) for hypotension, or lactate ≥ 4mmol/L. Timely vasopressor administration to maintain MAP (Rochester, 2018). To accomplish my nursing goals, I will assess the patient’s vital signs frequently, administer oxygen, and administer intravenous antibiotics to decrease the inflammation. Norepinephrine will be given to maintain a MAP of 65mmHg. Lastly, to stabilize the Joanna’s lactate and hypotension, I will administer crystalloid to increase the lactate to 4mmol/L.
Evaluation
The intervention was unsuccessful, even though I measured the patient’s lactate levels and administer the antibiotics and crystalloid within the three hours and retook her vitals, they did not improve. Doing these treatments promptly was supposed to decrease the infections and stabilized the lactate and serum bicarbonate levels. Administrating the vasopressor did not help increase Joanna’s blood pressure, and her MAP stated the same. Joanna is still lethargic and is emesis.
Recommendations
Because my goal of stabilizing Joanna was unsuccessful, I plan on consulting with my hospital staff to choose the next best course of action. I will continue to assess and monitor Joanna’s symptoms and signs and increase her IV fluids.
References
Banasik J. L. &Copstead, L. C. (2019). Pathophysiology (6th ed.). Elsevier, Inc.
COPD – Symptoms and causes. Mayo Clinic. Retrieved from
https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes
Kalil, A. (2019). Septic Shock Treatment & Management: Approach Considerations, General
Treatment Guidelines in Septic Shock, Goals of Hemodynamic Support.
Emedicine.medscape.com. Retrieved from https://emedicine.medscape.com/article/168402-treatment.
Linares, M. (2020). Septic Shock: Diagnoses and Nursing and Medical Management – Simple
Nursing. Simple Nursing. Retrieved from https://simplenursing.com/septic-shock-
diagnoses-and-nursing-and-medical-management/.
Nandhabalan, P., Ioannou, N., Meadows, C., &Wyncoll, D. (2018). Refractory septic shock: our
pragmatic approach. Critical care (London, England), 22(1), 215. https://doi.org/10.1186/s13054-018-2144-4
Pneumonia – Diagnosis and treatment – Mayo Clinic. Mayoclinic.org. Retrieved 27 July 2020,
from https://www.mayoclinic.org/diseases-conditions/pneumonia/diagnosis-
treatment/drc-20354210.
Rogers, G. (2019). Septic Shock: Symptoms, Causes, Diagnosis, Treatment & More. Healthline.
Retrieved from https://www.healthline.com/health/septic-shock#symptoms.
septic shock. (n.d.) Medical Dictionary for the Health Professions and Nursing. (2012).
Retrieved from https://medical-dictionary.thefreedictionary.com/septic+shock
Septic Shock Symptoms, Definition, Treatment, Signs & Causes. MedicineNet. (2020). Retrieved
from https://www.medicinenet.com/septic_shock/article.htm.
Whitlock, J. (2019). Know the Difference Between a Sepsis Infection and Septic Shock. Verywell
Health. Retrieved from https://www.verywellhealth.com/sepsis-and-septic-shock-3156848.