Nursing Management of Deteriorating Patients Case Study

In this case scenario, Jedda Merindah, a 33-year-old male of Indigenous heritage has been admitted after a post-medical emergency for hypotension. He was receiving induction phase chemotherapy for his Acute Myeloid Leukemia (AML). According to Merindah’s self-monitoring, he reported that he was afebrile. Blood culture taken 1 week ago did not grow any pathogen. His past medical history indicates Acute Rheumatic Fever during childhood with no structural heart abnormalities, mild left ventricle dilation, and normal ejection fraction based on the previous echocardiogram. Other past medical history includes depression and hypercholesterolemia. which he is taking Citalopram 10mg daily and Atorvastatin 40mg respectively. In addition, Merindah attempted suicide in 2003 via drug overdose. On assessment, his sign and symptoms are heart rate 118 beats/min with atrial fibrillation, Blood pressure 92/65mmHg, febrile 38.8°C, Hb 89, WBC 3.4, creatinine 138, BGL 9.6mmol, tachypneic 28 breaths per minute, using accessory muscles, anxiety and restless, diaphoretic, decreased nutritional intake and decreased urinary output. This paper will discuss the identification of the presented case-patient deterioration due to septic shock and the evidence-based practice of clinical interventions that can be put in place to ensure the patient is regaining good health.

The early recognition of the clinical deterioration gives room for the health care providers to look for the best means possible to adequate and evidence-based interventions to the patient (Fisher & King, 2013, pp. 2378-2381). Therefore, Registered Nurses must possess knowledge on physiological changes that occur during septic shock and the possible interventions that can help the patient.

Sign and symptoms: Decreased BP, Increased respiratory rate and effort, decreased WBC and platelets

The patient blood pressure is 92 mmHg Systolic which according to definition is not considered hypotensive shock (Dellinger, 2013, p. 583). However, the increase in HR shows the body’s attempt to increase the cardiac output to preserve the oxygen delivery to cells and tissues (CO = HR X SV). This was possibly caused by the release of adrenaline which is another attempt to increase the BP to preserve the organ perfusion. Another assessment data which confirms this assumption is the cold peripheries secondary to peripheral vasoconstriction caused by the release of angiotensinogen which is part of the renin-angiotensin -aldosterone system (RAAS) (Corrêa, Takala, & Jakob, 2015).

In addition, the blood test confirmed the potential hypotension perfusion of the kidneys because the creatine level was 138 and urea is 11.2 which both are about the reference ranges. The cause for the suspected infective reaction is likely viral-induced septic shock as the blood culture when negative however a septic screen is recommended to identify the potential source of infection, in particular, because the patient is febrile and diaphoretic. According to the blood test result, the white cell count was below the reference range which increases the susceptibility of the patient to infection. However, the hemoglobin and platelet are also decreased. This is likely caused by chemotherapy which affects all myeloid lineage cells, resulting in pancytopenia. This increases the risk of coagulopathy, indicated by deranged APTT and INR.

Priority: Kidney Perfusion

Based on the information above, the highest priority is to support the body’s attempt to compensate for the decreased blood pressure and to improve organ perfusion, particularly in the kidneys (Benedict, 2015, p. 140). The inability of the body to compensate can lead to a multiorgan failure. This is caused by cell hypoxia, leading to anaerobic respiration and later lactic acidosis and decreasing blood pH, which consequently increases mortality rates (Benedict, 2015, p. 141). It has been shown that lactic acid is a rather strong vasodilative agent that would further decrease blood pressure. The Surviving Sepsis Campaign identifies a lactic acid level of more than 4 mmol/L as potentially dangerous for the entire metabolism.

Collaborative Intervention: Fluid Resuscitation

The Registered nurse has to assess the IV access for patency and signs of infection before connecting the infusion. Also, the regular assessment of the IV access is recommended to recognize a potential tissuing of the fluid, which might cause pain and discomfort to the patient. Most of the current guideline recommends an initial fluid resuscitation with isotonic crystalloids and the fluid of choice is mostly the 0.9%NaCl (Bark, Persson, & Grände, 2013, p. 862; Winters, Sherwin, Vilke, & Wardi, 2017, p. 593). The reason for this choice is the fact that it is cheap, available, and well-tolerated. A volume of 2 liters is ad