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Nursing Care Plan | NCP Septic Shock

Septic shock is a clinical syndrome associated with severe systemic infection. It is a sepsisinduced shock with hypotension despite adequate fluid replacement. Patients have perfusion abnormalities, including lactic acidosis, oliguria (urine output 400 mL/day), or an acute alteration in mental status. Often septic shock is characterized by decreased organ perfusion, hypotension, and organ dysfunction. Septic shock is the major cause of death in intensive
care units; the mortality rate is as high as 50% to 80% depending on the patient population. The incidence has increased during the last 50 years in North America probably owing to an increased number of patients who are immunocompormised, the increased use of invasive devices, and a longer life span for the elderly. It occurs in 2 cases per each 100 hospital discharges, and approximately 70% of the patients who develop septic shock need intensive care.

Septic shock is part of the continuum associated with the systemic inflammatory response syndrome (SIRS), defined by two or more changes in the following four factors: body temperature, heart rate, respiratory function, and peripheral leukocyte count. Sepsis, on the other hand, is defined as systemic host response to infection with SIRS plus a documented infection, and severe sepsis is defined as sepsis with hypotension, despite fluid resuscitation, and evidence of inadequate tissue perfusion.

The syndrome usually begins with the development of a local infectious process. Bacteria from the local infection enter the systemic circulation and release toxins into the bloodstream. Gram-negative bacteria release endotoxins from their cell membrane as they lyse and die, whereas gram-positive bacteria release exotoxins throughout their life span. These toxins trigger the release of cytokines (proteins released by cells to signal other cells) such as tumor necrosis factor and the interleukins (ILs). They also activate phagocytic cells such as the macrophages. The complex chemical reactions lead to multiple system effects. As the syndrome progresses, blood flow becomes more sluggish, tissues become hypoxic, and acidosis develops. Ultimately, major organ systems (such as the lungs, kidneys, liver, and blood coagulation) fail, which leads to multiple organ dysfunction syndrome.

Although any microorganism may cause septic shock, it is most often associated with gramnegative bacteria such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas, and Serratia. Gram-positive bacteria such as Staphylococcus aureus can also cause septic shock and, in past years, have led to outbreaks of toxic shock syndrome. A fungal infection causes septic shock in less than 3% of the cases. Lower respiratory infections cause 25% of the cases of septic shock, urinary tract infections cause 25%, and soft tissue infections cause 15% of the cases.

Common factors or conditions that are associated with septic shock include diabetes mellitus, malnutrition, alcohol abuse, cirrhosis, respiratory infections, hemorrhage, cancer, and surgery. People with traumatic injuries with either peritoneal contamination, burns, prolonged intravenous (IV) cannulation, abscesses, or multiple blood transfusions are at particular risk as
well.

Nursing care plan assessment and physical examination
Patients appear critically ill and may have already been intubated and on mechanical ventilation for adult respiratory distress syndrome (ARDS). Because of the severity of the patient’s condition, you may not be able to interview him or her for a complete history. You may obtain a great deal of information from the family and from other healthcare providers when the patient is transferred to your care. Because patients with septic shock are among the most critical of all patients treated in a hospital, they are admitted to a critical care unit for management.

Patients often have a history of either an infection or a critical event, such as a traumatic injury, perforated bowel, or acute hemorrhage. Some patients may also have a long-standing IV catheter or a Foley catheter. Determine the cause for the patient’s admission to the hospital and any history of a chronic disease such as cancer, diabetes mellitus, or pneumonia. Note any brief periods of decreased tissue perfusion such as hemorrhage, severe hypotension, or cardiac arrest that may demand emergency management before the development of septic shock. Take a thorough medication history, with particular attention to recent antibiotic administration or total parenteral nutrition. Ask if the patient has been exposed to any treatment—such as organ transplantation, radiation therapy, or chemotherapy—that would lead to immunosuppression.

Three stages have been identified, but all patients do not progress with the same pattern of symptoms. In early septic shock (early hyperdynamic, compensated stage), some patients are tachycardic, with warm and flushed extremities and a normal blood pressure. As shock progresses, the diastolic blood pressure drops, the pulse pressure widens, and the peripheral pulses are bounding. The patient’s temperature may be within normal limits, elevated, or below normal, and the patient may be confused or agitated. Often, the patient has a rapid respiratory rate, and peripheral edema may develop. In the second stage (late hyperdynamic, uncompensated stage), widespread organ dysfunction begins to occur. Blood pressure falls, and the patient becomes hypotensive. Increased peripheral edema becomes apparent. Respirations become more rapid and labored; you can hear rales when you auscultate the lungs; and the patient’s sputum may become copious, pink, and frothy. In late septic shock, the blood pressure falls below 90 mm Hg for adults, the patient’s extremities become cold, and signs of multiple organ failure (decreased urinary output, abdominal distension, absence of bowel sounds, bleeding from invasive lines, petechiae, cardiac dysrhythmias, hypoxemia, and hypercapnia) develop.

As the syndrome progresses, patients may develop symptoms that change their behavior and appearance and situations that increase their anxiety and that of their family members. Ultimately, the family may be faced with the death of a loved one. Continuously assess the coping mechanisms and anxiety levels in both patients and families.

Nursing care plan primary nursing diagnosis: Infection related to exposure to bacteria from trauma, invasive instrumentation, or contamination.

Nursing care plan intervention and treatment plan
The primary goals of treatment in septic shock are to maintain oxygen delivery to the tissues and to restore the vascular volume, blood pressure, and cardiac output. IV fluids are administered to increase the volume within the vascular bed; crystalloids (normal saline solution or lactated Ringer’s injection) are usually the fluids of choice. Vasopressors, such as dopamine or norepinephrine (Levophed), may also be required to maintain an adequate blood pressure. The patient is also placed on broad-spectrum IV antibiotics. If the patient’s hemoglobin and hematocrit are insufficient to manage oxygen delivery, the patient may need blood transfusions. A pulmonary artery catheter is inserted to monitor fluid, circulatory, and gas exchange status.

An aggressive search for the source of sepsis is an essential part of the treatment. Any indwelling catheters, whether they are urinary, intravascular, intracerebral, or intra-arterial, are discontinued if possible or moved to another location. A surgical consultation may be performed to search for undrained abscesses or to d├ębride wounds. If complications such as ARDS develop, more aggressive treatment is instituted. Intubation, mechanical ventilation, and oxygenation are required for severe respiratory distress or failure. Patients often need ventilator adjuncts, such as positive end-expiratory pressure, pressure-control ventilation, or inverse inspiration-to-expiration ratio ventilation.

Total parenteral feeding or enteral feedings may be instituted for patients who are unable to consume adequate calories. Monitor the success of nutritional therapy with daily weights. During supportive care, the entire healthcare team needs to monitor the patient’s condition carefully with serial cardiopulmonary assessments, including vital signs, physical assessment, and continuous hemodynamic monitoring. Patients should be attached to a pulse oximeter for continuous assessment of the arterial oxygen saturation. The patient’s level of consciousness is important. In children, monitor the child’s activity level and the response to parents or significant others.

Priorities of nursing care for the patient with septic shock include maintaining airway, breathing, and circulation; preventing the spread of infection; increasing the patient’s comfort; preventing injury; and supporting the patient and family. Monitor the patient continuously for airway compromise and prepare for intubation when necessary. Maintain strict aseptic technique when you manipulate invasive lines and tubes. Use universal precautions at all times. Unless the patient is endotracheally intubated, place patients with a decreased level of consciousness in a side-lying position, and turn them every 2 hours to protect them from aspiration. To increase the intubated patient’s comfort, provide oral care at least every 2 hours.

Maintain skin integrity by placing the patient on an every-2-hour turning schedule. Post the schedule at the head of the bed to increase the visibility of the routine. Implement active and passive range of motion as appropriate to the patient’s condition. Provide the family with information about diagnosis, prognosis, and treatment. Expect the patient and family to have high levels of anxiety and fear, given the grave nature of septic shock. Support effective coping strategies, and provide adequate time for the expression of feelings.

Nursing care plan discharge and home health care guidelines
Instruct patients who have been identified as high risk to call the healthcare provider at the first signs of infection. Teach high-risk individuals to avoid exposure to communicable diseases and to use good hand-washing technique. Reinforce the need for immunizations against infectious diseases such as influenza. Encourage patients to consume a healthy diet, get adequate rest, and limit their alcohol intake. Instruct patients and families about the purpose, dosage, route, desired effects, and side effects of all medications. Explain that it is particularly important that the patient take the entire antibiotic prescription until it is finished.
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