Nursing Case Study

1.0 Definitions

Sepsis

It is a fatal medical condition that happens to the response of the elicited by the immune system towards an infection that is in the body. The response can lead to complications other serious clinical conditions including; organ injury or failure, tissue damage, renal failure ischaemia, shock, or multiple organ dysfunction syndromes (MODS). It’s a fatal clinical condition and can cause death (Dellinger et al., 2012).

Severe Sepsis

It is a stage in sepsis infection that causes a condition of poor organ function or abnormalities associated with hypotension. It affects the blood flow and causes an insufficient supply of blood to the body organs and tissue. This condition is usually characterized by low blood pressure and little output of urine (Dellinger et al., 2012). It is a stage in the inflammatory response of the body immune system to infection towards an infection. The conditions usually evolve to septic shock.

Septic shock

It is a condition of severe sepsis due to bacterial infection. It is clinically referred to as the septic shock due to sepsis resulting from an infection. It is defined as sepsis –induced condition of hypotension that is known to persist even after treatment with intravenous fluids (Farris et al., 2013). The shock is a characteristic of low blood pressure, which reduces the perfusion pressure in the organs and tissues resulting in hypoxia condition.

2.0 Evaluation of SIRS with the view of Jessica’s condition. Provide her criteria of showing SIRS

The multiple systems of inflammation because of drastic immune response (SIRS) is a condition of the inflammatory state of the entire body. The patient who is suffering from SIRS exhibit the following symptoms associated with organ failure. Criteria for SIRS evaluation was established in 1992 (Marti‐Caracal et al., 2012). The SIRS signs and symptoms manifestations help in the diagnosis of the condition. These criteria exist for the primary purpose of independently categorizing the serious medical conditions in patients for the easy reproducibility of clinical practices

• Body temperature is a characteristic of the Sirs condition to make body temperature, reduce below 36°C(96.8°F) increase to be over 38°C(100.4°F). The Jessica Simpson body temperature rose to 8°C
• The heart rate that is greater than 90 beats per minute. The patients’ BP was 90/40
• The patients showed a difficulty in breathing with a breathing distress of RR28. Breathing rate greater than 20 breaths per minute is a characteristic for SIRS.
• WBC count for Jessica Simpson was less than 1000. It indicates the condition of SIRS, which is usually described by WBC of less than 4000,
• Increased arterial lactate – blood urea nitrogen tested showed elevated levels of concentration in the blood.

3.0 Defining SIRS

SIRS condition is described as a bodily response to a non-specified insult within the body system. The response could be towards either an infectious or non-infectious condition. It is known that SIRS are not associated with any infections. The concept of SIRS came from the unproven hypothesis that the basic determining factors in the outcome of sepsis is the nature of the response condition due to the general inflammatory responses but not due to the sepsis causes. SIRS can only conditions could only be classified according to the degree of the inflammation (Martí‐Carvajal et al., 2012). There is literature supporting that the concentration of graded level of the disease severity and the consequent mortality can be made attributed to the most severe conditions of SIRS.

Moreover, there have been speculations that if the inflammatory response is inhibited, with anti-inflammatory agents, the body will provide similar responses that are of benefit despite the nature of the underlying condition and the existing causes of sepsis. Several factors contribute to the sepsis conditions. These factors include conditions of a clinical nature, microbiological conditions, and immunologic conditions (Demerol et al., 2012).

4.0 Causative organism for sepsis

Sepsis is usually caused by bacterial infections. In the previous cases, most sepsis conditions were attributed gram-negative bacteria (Singh & Evans, 2012). However, in most of the reported cases, gram-positive bacteria specifically staphylococci are thought to be responsible for over 50% of all the reported cases of sepsis. It could be the organisms responsible for Jessica’s’ condition. Escherichia coli, Streptococcus pyogenes, Klebsiella and Pseudomonas aeruginosa are other species of bacteria which causes sepsis. The condition of fungal sepsis is responsible for about 5% severe conditions of the severe sepsis. These conditions are overwhelming and are caused by fungal yeast species called Candida (Juskewitch et al., 2012).

5.0 Critical Examination and evaluation of the six topics related to patient suffering from septic shock

Antibiotics Therapy

Antibiotics used are broad spectrum antibiotics. They are known to act against a wider range of infections caused bacteria microbes. These antibiotics are known to be having an activity against the growth of both Gram-positive and Gram-negative bacteria. The following discussed antibiotics are commonly used in the management of the bacterial infections due to Gram-positive bacteria.

Amphicillin

It is mostly used to manage, treat and prevent a number of known bacterial infections. It is administered by mouth, intra-masculine or intravenous injection. It treats and prevents the diseases caused by streptococci bacteria. Other diseases that are treated with Amphicillin include urinary tract infections, salmonella infections, respiratory tract infections and endocarditic (Yokota et al., 2014). Amphicillin activity of penetration of the cell membrane of Gram-negative bacteria is due to an amino group in its molecule. Once inside the bacteria, it acts as an inhibitor of the enzyme transpeptidase that is responsible for synthesizing the bacterial cell wall ultimately leading to cell wall lysis (Vazquez-Guillamet et al., 2014). However, the antibiotic is associated with side effects. The side effects associated with the antibiotics are; anaphylaxis, diarrhea, rash, and nausea.

Amoxicillin (amox)

It is useful in treating some bacterial conditions. It is the most preferred treatment for all bacterial infections of the middle ear and endocarditic. Can also be used in the management of pneumonia, urinary tract infections, salmonella infections, acute otitis media, skin infections, streptococcal pharyngitis, Chlamydia and strep throat. It is taken orally. The drug has been found to be effective in treatment acne vulgarize conditions that are persistent despite the use of other t antibiotics (Vazquez-Guillamet et al., 2014).

Amoxicillin can work by inhibiting the enzymes that are responsible for synthesizing of bacterial cell wall. It stops the cross-linkage processes that make up major constituents of the bacterial cell wall of both the Gram-negative and the Gram-positive bacteria. However, it has side effects that include; rash, nausea and increased risk of yeast infection

Azlocillin

It is known to possess a broader spectrum of activity against most bacteria. It is mostly similar to other antibiotics like piperacillin and mezlocillin. It is used to manage conditions due to the infections of Pseudomonas origins and enterococci. They can also stop the infection of Gram-negative and Gram-positive bacteria by inhibition of synthesizing of the bacterial cell walls (Vazquez-Guillamet et al., 2014).

Carbapenems

It is classified under the class of β –Lactam antibiotics. Use for treatment of both the Gram-negative and Gram-positive bacteria. Thus, it is very useful in empiric broad-spectrum antibacterial coverage. They work by inhibition of enzymes that are responsible for synthesizing the bacterial cell walls(Vazquez-Guillamet et al., 2014).The known side effects associated with the drug are Gastrointestinal upsets, Nausea, diarrhea, Seizures, Rash, Headache and allergic reactions(Yokota et al., 2014).

IV Fluids – Including Rationale for Colloids/Crystalloids

Intravenous fluids are a management response to drastic changes in the blood pressure, the heart rate and low little urine output in patients. It is done to restore and balance the fluid deficits that are caused by sepsis condition. It should be administered with continuous measurement of the central venous pressure until it is between 8–12mmHg (Demirkol et al., 2012). Colloid and crystalloid solutions are used to boost the blood pressure without using the vasopressor activity.

Crystalloid solutions are preferred in management as they are believed to associate with lesser risk of death. They are used together with albumin, and both have less risk of liver damage as compared to starches.

Blood-glucose control

Significant signs of improvement have been shown when there is a continuous infusion of the insulin and glucose level maintenance. It should be in the range of80 and 110 mg/dl. The use of exogenous glucose and insulin starts simultaneously. The patient blood glucose should be continuously measured. At the start of insulin administration, there greater need to monitor any signs of hypoglycaemia. The process will likely reduce the risks of hypoglycaemia but improve the outcomes (Sursal et al., 2013). It has been shown that the control of blood glucose levels is important than checking the levels of insulin.

Hemodynamic Monitoring – CVP/Arterial MAP

There are intervention methods that are applicable to the conditions of Hemodynamic Monitoring in patients suffering from septic shock. These methods include; BP in arteries, Central Venous Pressure, the catheter in the pulmonary artery, Cardiac muscle pressure measurement and oxygenation in the tissues.

Ventilation management – Invasive Ventilation

Measurements of plateau pressures are recommended for patients having ARDS. Initially, the plateaus’ upper limit pressure in a relaxed lung is less than 30 cm H2O. End-expiratory, that is the positive pressure (PEEP) should be applied to the view of avoiding the collapse of the alveolar at end expiration. The developed strategies that are based on higher PEEP should be used as opposed to the lower PEEP (Demirkol et al., 2012). Prone positioning is up for use by the patient.

The head of the hospital bed, where the patient is sleeping, should be elevated and maintained at 30-45. Thus reducing the risk of aspiration and preventing the development of ventilator-associated pneumonia. There should be a weaning protocol in place to help the patient undergo breathing trials continuously to assess her ability to stop mechanical ventilation after showing a convincing ability and satisfying the listed guidelines, i) arousal; ii) independent of vasopressor; iii) absence of new medical cases; iv) little ventilator and final expiratory pressure needs; and e) low requirements of Fio2 (Juskewitch et al., 2012). With the successful breathing trial, the patient extubation is considered.

Stress Ulcer Prophylaxis

The intervention practice needs to be administered to SIRS patients. Hydrogen receptors are the agents preferred because they have demonstrated the ability to raise the gastric PH. Although, it is not needed for patients that have been able to meet the nutritional goals established by the clinicians.

6.0 MODS are associated with sepsis. The brief explanations of the system changes in patients in MODS.

Endocrine

During sepsis, conditions affecting the endocrine can manifest as hyperglycaemia, which is characterized by the resistance to insulin or insufficient secretion of both the vasopressin or adrenal corticosteroids (Singh & Evans, 2012). The relative impairments of the adrenocortical reserves are attributed to the pathogenesis of shock which occur during sepsis. There has been observed survival rates, which are improved due to the use of glucocorticoids and mineral corticoids as the doses for patients that showed poor results on secretion of adrenocorticotropin hormone (Farris et al., 2013). The production of vasopressin by the pituitary gland is highly inhibited during sepsis condition.

Primary adrenal functions are highly impaired due to the reduction in production of the cortisol as a result of defects in the production due to a defect in an adrenal cortex. Consequently, secondary adrenal deficiency refers to decreased production of cortisol a result of the dysfunction of the pituitary gland or even the hypothalamus. The serious adrenal deficiency condition is fatal and the characteristic systems associated are; acute abdominal pain, hypovolemia, hypotension, and fever.

Respiratory

The acute condition of respiratory distress syndrome (ARDS) is a fatal medical condition characterized by inflammations in the lungs. The condition is usually as a result of the sepsis infection. It affects the microscopic air sacs affecting the exchange of carbon dioxide and oxygen. It is responsible for several pathological changes. The changes include the body release of inflammatory chemical and consequently leading to breaking down of the cell of the blood vessels in the lungs (Singh & Evans, 2012).These, further causes the high tension in the lungs, fluid accumulation, and formation of fibrous tissues in the lungs.

Gastrointestinal

The gastrointestinal organ plays an important role in the metabolism. The gastrointestinal mucosal lining plays an important protective role (Singh & Evans, 2012). Due to the presence of both immunological and non-immunological layers, they provide the services and the roles of protection. Therefore, sepsis causes the condition of intestinal ischemia as a result of sepsis shock. It brings about the decreased blood flow to the areas of the abdomen. Ischemia development may be attributed to lesser and poor transportation and usage of the nutrient by the intestines despite the proper condition of digestion (Singh & Evans, 2012). During the sepsis, shock condition, insufficiency in blood in the mucus is attributed to the dependent flow tissue that formed. The tissue is called hypoxia; blood flow to the intestines also could be obstruction of the bowels due to atherosclerosis conditions and thromboembolic disease associated with the splanchnic vessels. The injury sustained by the bowels can only relieved through reperfusion.

In conditions where a schema has been relieved by reperfusion, the radicals (derived from oxygen) get generated xanthine oxidase processes and exert more injuries to the to the lipid membranes of the cells.

Renal

Acute renal failure (ARF) is the failure of the kidney due to damage to its tissues or due to decreasing renal blood supply. The causes can be due to low blood pressure, an inflammatory condition due to kidney exposure to harmful substances (Singh & Evans, 2012). It is characterized by conditions such as elevated blood urea nitrogen, low urine production, and creatinine. It can lead to complications that include changes in body fluid balance, metabolic acidosis, and high blood concentration of potassium. These conditions affect other systems and can easily cause death.

Cardiovascular

The implications of impaired functions of the cardiac system in sepsis and MODS are fatal. Due to sepsis, echocardiography research has shown the dysfunctions of both the systolic and diastolic functions of the caddies. These impairments lead to bad outcomes. Sepsis is responsible for myocardial depression and majorly causes the impairments to the regulations of the normal cardiac functions because of the extensive nature of the alterations of the cardiovascular, nervous system (Singh & Evans, 2012). A MODS is characterized by an autonomic response of the innate immune system, resulting on over release of anti-inflammatory mediators resulting in the cardiac cell damage, metabolic breakdown, and neuroendocrine disturbances. It results in the increased heart rate and the reduced HRV.

Hematologic

Sepsis condition can induce changes to the membrane mechanical properties of the blood cells, leading to decrease in their property of deformability. It’s characterized by the membrane damage. Destroying the deformability feature that is essential for blood flow of the red blood cells affects the general circulatory system. The blood will increase in the transit time and consequently reduces flow rate. These alterations impact the delivery of oxygen to tissues and organs negatively. Therefore, these factors contribute to tissues and organ dysfunctions. Sepsis is also responsible for the aggregation of erythrocytes. One characteristic feature is the observed high rates of sedimentations of the red blood cells (Boone et al., 2013).

7.0 Vasopressor.

The vasopressor agent can defined as the type of medication that is used to boost the blood pressure. It can range from antihypertensive drugs that function by the acts of vasoconstriction to increase the peripherals pressure due to resistance (Sursal et al., 2013). Others increase and boost the cardiac muscles’ output, and the other group sensitizes adreno-receptor to catecholamine.

After the surgical procedure on the patient, the preparation to use the vasopressin is made purposely to increase the blood volume should be made. It can be done by using the plasma-substituting solution, for example, colloid solution, and crystalline solution. Thus, it will help raise the blood volume that will consequently boost the blood pressure without using any of the direct methods of vasopressor activity. There are recommendations that other blood products can also be used in boosting blood volume together with the whole blood or the plasma. However, the supplementing products are restricted to be used only, if there is a reduction in the oxygen-carrying capacity of the red blood cells (Boehne et al., 2013).

After sufficiently fluid resuscitating to the patient, and if the mean arterial blood pressure is still below 65 mm Hg, then the vasopressor can be used. The recommended choice for use is the Norepinephrine. In situations where one is not enough others can be used.

References

Boehne, M., Jack, T., Köditz, H., Seidemann, K., Schmidt, F., Abura, M., and Sasse, M. (2013). In-line filtration minimizes organ dysfunction: New aspects from a prospective, randomized, controlled trial. BMC pediatrics, 13(1), 21.

Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., and Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. (2013). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.

Demirkol, D., Yildizdas, D., Bayrakci, B., Karapinar, B., Kendirli, T., Koroglu, T. F., and Carcillo, J. A. (2012). Hyperferritinemia in the critically ill child with secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction syndrome/macrophage activation syndrome: what is the treatment?. Crit Care, 16(2), R52.

Farris, R. W., Weiss, N. S., & Zimmerman, J. J. (2013). Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 14(9), 835-842.

Juskewitch, J. E., Prasad, S., Salas, C. F. S., & Huskins, W. C. (2012). Reliability of the identification of the systemic inflammatory response syndrome in critically ill infants and children. Pediatric Critical Care Medicine, 13(1), e55.

Martí‐Carvajal, A. J., Sol , I., Gluud, C., Lathyris, D., & Cardona, A. F. (2012). Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients. The Cochrane Library.

Singh, S., & Evans, T. W. (2012). Organ dysfunction during sepsis. In Applied Physiology in Intensive Care Medicine 1 (pp. 331-342). Springer Berlin Heidelberg.

Sursal, T., Stearns-Kurosawa, D. J., Itagaki, K., Oh, S. Y., Sun, S., Kurosawa, S., & Hauser, C. J. (2013). Plasma bacterial and mitochondrial DNA distinguish bacterial sepsis from sterile SIRS and quantify inflammatory tissue injury in nonhuman primates. Shock (Augusta, Ga.), 39(1), 55.

Vazquez-Guillamet, C., Scolari, M., Zilberberg, M. D., Shorr, A. F., Micek, S. T., and Kollef, M. (2014). Using the Number Needed to Treat to Assess Appropriate Antimicrobial Therapy as a Determinant of Outcome in Severe Sepsis and Septic Shock. Critical care medicine, 42(11), 2342-2349.

Yokota, P. K., Marra, A. R., Martino, M. D., Victor, E. S., Durão, M. S., Edmond, M. B., and dos Santos, O. F. (2014). Impact of Appropriate Antimicrobial Therapy for Patients with Severe Sepsis and Septic Shock–A Quality Improvement Study.