Case study: Shock and Multiple Organ Dysfunction Syndromes

1. Adam Smith, 77 years of age, is a male patient who was admitted from a nursing
home to the intensive care unit with septic shock secondary to urosepsis. The patient
has a Foley catheter in place from the nursing home with cloudy greenish, yellow-
colored urine with sediments. The nurse removes the catheter after obtaining a urine
culture and replaces it with a condom catheter attached to a drainage bag since the
patient has a history of urinary and bowel incontinence. The patient is confused,
afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is
28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician
ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO 2 greater than 90%.
The patient responded to 2 L of oxygen per nasal cannula with an SaO 2 of 92%. The
patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood
count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The
patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed)
beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100
mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for
correct placement. An arterial line was placed in the right radial artery to closely monitor
the patient’s blood pressure during the usage of the vasopressor therapy.

a. What predisposed the patient to develop septic shock?

 In the case of the patient he has Foley Catheter in place which contributes
to infections or microorganisms or Foley is the portal of infection. The
patient has urinary and bowel incontinence which predisposed to the
development of septic shock. Presence of infection determined by color of
urine, concentrations and sediments.

b. What potential findings would suggest that the patient’s septic shock is
worsening from the point of admission?
 BP of 82/44 mmHg indicate hypotension
 RR of 28 b/m
 Low oxygen saturation which determined insufficient circulatory perfusion
or may lead to necrosis of some cells
 High blood glucose 160 mg/dl may indicates organ problem
 High WBC count of 15,000 which indicate infections.

c. The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS).

Explain how the nurse should administer the medication. What nursing
implications are related to the usage of a vasoactive medication?
 The norepinephrine should be given at 2 mcg per minute. The solution
should be added in small, measured quantities to a known volume of a
standard solution until a reaction occurs, as indicated in color or pH of the
product. Also, Levophed is given to increase the strength of myocardial
contractility.
 Nurse implication includes: Obtain history, including drug and known allergies.
Monitor Vital signs as well as ECG. BP every 2 minutes from the time of
Case study: Shock and Multiple Organ Dysfunction Syndromes

administration until desired BP is obtained. Observe for cyanosis which may

indicate ineffective tissue perfusion. It should not be given with Normal Saline
alone because it may cause degradation; administer with D5W or D5 saline. Use
infusion pump, enter on a large vein. Discard solution after 24 hours. Advise
patient to notify nurse if IV site feels cool or painful. Instruct patient to report the
following symptoms: dizziness, nausea, syncope, abdominal and chest pain, as
well as confusion, the adverse effects of Levophed.

d. Explain why the effectiveness of a vasoactive medication decreases as the septic

shock worsens. What treatment should the nurse anticipate to be obtained to
help the patient?
 The condition has already worsened in the next stage. There are
compromise organs which contributes to tissue perfusion. For these
stages, the doctor may order blood transfusion, high-flow of oxygen,
removal of cellular waste products with severely altered tissue perfusion,
and insulin administration to control the increase in blood glucose. Bowel
and bladder training may be arranged for urinary and bowel incontinence.
 Maximize antibiotics and fluid resuscitation and preventing ABG gas
worsening

e. Explain the importance for nutritional support for this patient and which type of
nutritional support should be provided?
 Nutritional support may be given to facilitate the delivery of nutrients to
systemic tissue. Foods high in iron may be given to help increase the
amount of oxygen-carrying cells in the body. Low-calorie and low-
carbohydrate could also be ordered to prevent further increase in blood
glucose. Nutritional support will provided in a form of TPN and careful
balancing necessary nutrients’, electrolytes and hand in hand with fluids.

2. Carlos Adams was involved in a motor vehicle crash and suffered blunt trauma to his
abdomen. Upon presentation to the emergency department, his vital signs are as
follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min;
and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the
umbilicus. He is alert and oriented, but complains of dizziness when changing positions.
The patient is admitted for management of suspected hypovolemic shock.

The following prescriptions are written for the patient:

● Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/line

● Obtain complete blood count, serum electrolytes
● Oxygen at 2 L/min via nasal cannula
● Type and cross for 4 units of blood
● Flat plate of the abdomen STAT
Case study: Shock and Multiple Organ Dysfunction Syndromes

a. Describe the pathophysiologic sequence of events seen with hypovolemic shock.

 Initial stage – no visible changes, but changes are occurring at the cellular
level
 Compensatory – measurable increase in heart rate, vasoconstriction of
arterial bed to increase cardiac output
 Progressive – compensatory mechanism begin to fail
 Refractory – Irreversible shock, total body failure.

b. What are the major goals of medical management in this patient?

 The goals of medical management are to controlling the homeostasis of
the body and restore tissue perfusion and oxygenations.

c. What is the rationale for placing two large-bore IVs?

 Two large bore IVs will be used in rapid administration of blood and for
administration of medications in need of bolus or fast drips.

d. What are advantages of using 0.9% NS in this patient?

 0.9% Normal Saline is the safest solution to use during this time because
some electrolytes might not need to be replace as well as the RBCs in
order to increase the plasma volume

e. What is the rationale for placing the patient in a modified Trendelenburg position?
 To increase the blood pressure and not having to use too much of effort.