Nursing Diagnosis for Septic Shock

Answer the following questions in the case study in complete sentences. Thank you!

N 375
Septic Shock Case Study
At 11 am, Ms. P. L., a 57 year old female, is brought to the Emergency Department of the hospital by her daughter because of weakness and a decreasing level of consciousness. P. L. responds to brief commands to open her eyes and mover her arms and legs, but she does not answer your questions. The daughter tells you that when she stopped at her mother’s house today for a visit, P. L. was complaining about abdominal and back pain. She also reported nausea and had vomited twice. She is lethargic and sleepy. Because of her lethargy and nausea, she has not had anything to eat or drink today. 
Her medical history includes: Hypertension, peripheral arterial disease, diabetes mellitus type 2. Her daughter gives you a list of P. L.’s medications which include: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.
Record the above information on the distributed SBAR form.  What are you thinking as you 
You obtain and document the vital signs as follows:
Blood pressure: 102/38
Heart rate: 102 beats/minute
Oxygen saturation: 76%
Respiratory rate: 40 bpm
Temperature: 102.4 ° F (39.1° C) oral
What is your initial assessment?
What are the priority nursing actions?
Using the form on which you recorded the patient’s information, prepare and give a report in SBAR format to your partner. Critique each other’s reports (strengths and missing information and/or areas needing additional information).
What do you expect the physician to order?
The initial M.D. orders are written as follows:
Insert a Foley catheter and send a urine specimen for C&S
Start oxygen and titrate to maintain oxygen saturation at 90% or higher
Place the patient on telemetry
Check the blood glucose level
What do you think about the orders?
Based on the history and assessment, in which order should you implement the physician orders?
Which method of oxygen administration will best increase P. L.’s oxygen saturation?
Nasal cannula
Nonrebreather mask
Venturi mask
Face mask
Available staffing in the ED includes you and an experienced CNA. Which of the following activities can be delegated to the nursing assistant? Select all that apply. Discuss your rationale(s) that support your decision.
Take vital signs every 15 minutes
Attach the patient to the cardiac monitor
Document a head-to-toe assessment
Check orientation and alertness
Insert an IV
Monitor urine output hourly
Do you have any questions about the above orders? What are they?
The cardiac monitor shows the following rhythm. Analyze the pattern and name the dysrhythmia.
 What action should you prepare to take?
Continue to monitor the cardiac rhythm
Administer lidocaine (Xylocaine) 1 mg/kg IV push
Prepare to perform cardioversion at 50 Joules
Administer adenosine (Adenocard) 6 mg IV push
An arterial blood gas (ABG) sample is obtained by the physician. The results are as follows:
PaCO2: 62 mm Hg
PaO2: 50 mm Hg
HCO3-: 22 mEq/L
O2 saturation: 87%
pH: 7.23
What is your analysis of the ABG sample?
Based on your analysis, which collaborative action do you anticipate happening next?
Administer a sodium bicarbonate (NaHCO3) bolus IV
Insert an endotracheal tube and initiate mechanical ventilation
Continuous monitoring of P.L.’s respiratory status
A nebulized albuterol (Proventil) treatment
You are preparing to assist the ED physician initiate endotracheal intubation of P.L. In which order will the following actions be accomplished? Number each appropriate action in its order of occurrence.
Check end-tidal CO2 level
Tape the ETT in place
Pre-oxygenate with bag valve mask at 100% oxygen
Place the patient in supine position
Briefly explain the intubation procedure to the patient and her daughter
Inflate the ETT cuff
Auscultate breath sounds bilaterally
Obtain a chest X-ray
Insert the ETT orally through the vocal cords
There is discussion about adding PEEP. What is the meaning of this acronym? When is it used and what is its benefit? How would you explain it to P.L. and her daughter?
After successful intubation, you perform a focused assessment of P.L. What is your priority focus? Why?
You document the assessment findings as follows:
“Heart sounds irregular and distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses nonpalpable. Denies chest pain. Breath sounds audible bilaterally with crackles present in left lung base. Grimaces with light abdominal palpation above pelvic bone. Urine is amber and cloudy with red streaks. 100 ml urine output when Foley catheter inserted. Opens eyes and moves to command. Pupils equal, round, and reactive to light”.
The current vital signs are as follows:
Blood pressure: 86/40
Heart rate: 112 bpm
O2 saturation: 93%
Respiratory rate: 32 breaths per minutes
Temperature: 103° F (39.4° C)
What is your interpretation of the patient’s current status?
Which information in your assessment requires the most immediate action?
What do you think the probable medical diagnosis is?
Which data from the health history and physical assessment are significant in developing and confirming the diagnosis?
At 10 pm the patient is to be transferred to the ICU. Prepare an SBAR to give a verbal report to the nurse in the ICU. What are the priorities?
At 11 pm In the ICU, new orders are written. They are as follows:
Acetaminophen (Tylenol) 650 mg rectally
Draw blood for cultures from three separate sites
Infuse 1 Liter of normal saline over 30 minutes
Start a dopamine (Intropin) drip at 15 mcg/kg/min
Administer gentamycin (Gentacidin) 60 mg IV
Number the above actions in the order in which they should be implemented and explain your rationale.
The following bags of fluid are in the med room:
500 ml of 0.45 NaCl
1000 ml of 0.45 NaCl
1000 ml of 0.9 NaCl
500 ml of D5.45 NaCl
 Which do you select?
How do you administer the IV fluid? What are the volume and rate?
When you are infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid infusion of fluid?
Palpate P.L. for peripheral edema Monitor P.L.’s urine output Listen to P.L.’s lung sounds Check for JVD
You are preparing to administer the dopamine (Intropin) drip as ordered at 15 mcg/kg/min. The medication is available in an ampule containing 40 mg/ml or premixed 400 mg/250 ml NaCl. If you were to use the ampule, what equipment do you need?
If the patient weighs 140 lbs., and you decide to use the premixed solution of dopamine, what are the pump volume and rate settings?
When you recheck the dopamine drip, you notice that you have miscalculated the dopamine dose and have set the rate too high. 
What do you do? List the nursing actions in priority order.
Which patient finding is most important to report to the physician regarding the error in dopamine infusion? -The noninvasive BP monitor shows a BP of 102/48 mm Hg -The data screen on the ventilator indicates a respiratory rate of 44 breaths/min -Pulse oximitry is 90% -The cardiac monitor indicates a heart rate of 156 beats/min.
You are preparing to administer 60 mg of gentamycin IV. The bag has been delivered from the pharmacy: 60 mg in 250 ml of NS to run in over 1 ½ hours. 
What are the volume and rate settings?What symptoms do you monitor for that can indicate a potentially serious side effect of the medication?If the medication is to be administered every 8 hours and the first dose was administered at 6 am today, when should the blood specimens for peak and trough be drawn. Why?
P. L.’s medical diagnosis is septic shock. Identify the three major goals in treating septic shock (also referred to as Early Goal-Directed Therapy EGDT) 
What are expected nursing interventions for each goal?What are other nursing responsibilities in caring for a patient with septic shock?
Utilizing the data, develop a priority nursing diagnosis, an expected outcome, and three interventions for P.L.
The results from initial lab work are: Na 130 mEq/L Cl 95 mEq/L BUN 38 mg/dLCreatinine 1.6 mg/dLGlucose 190 mg/dLWBC 17,000 mm3Hct 29%Hgb 9.9 g/dLPlatelets 120,000
What laboratory value requires immediate attention? Why?
 P. L. is ordered to begin TPN via a triple lumen central venous catheter (TLCVC). What are the major nursing responsibilities/actions in initiating and administering TPN to this patient?
P. L. is also to receive 2 units of packed red blood cells (PRBCs). 275 mls are in each unit and the order says to administer them over a total of 3 hours. The patient has the triple lumen catheter. TPN is running in one lumen, dopamine is in the other, and the other one is heparinized but not accessed.
Into which lumen should the blood product be administered?
What nursing actions are needed prior to administering the blood?
What is the rate of administration of the PRBCs?
It is change of shift at 7 am the next morning. Which of the following RNs in the ICU is best prepared to care for this patient?- A “traveler” with 5 years of ICU experience who has been working in this unit for 4 months.- A new graduate RN who worked on the unit as a CNI and has just completed orientation.- An experienced ICU nurse who has been called in from his day off to work the first four hours of the shift.- A “float” RN from PACU.- There is also an experienced LPN on the unit. Which nursing activities should be delegated to the LPN? (Select all that apply) -Document the nasogastric tube drainage and urinary output on the ICU flowsheet -Notify the laboratory after giving gentamycin to that peak and trough levels can be drawn -Monitor the dopamine infusion site for signs of extravasation -Administer sliding-scale insulin lispro subcutaneously every 6 hours -Complete and document a head-to-toe assessment every 4 hours -Monitor blood pressure and titrate dopamine to keep systolic pressure at 100 mm Hg
Over the next week, P.L.’s condition continues to deteriorate. She is determined to be experiencing Multiple Organ Dysfunction Syndrome (MODS). 
What are the early warning signs of MODS?What are the other clinical manifestations of this syndrome?
P.L.’s daughter is aware of her mother’s deteriorating condition and requests a team meeting. P.L. has an advance directive and designated her daughter as Power of Attorney. She asks what will change in her mother’s care if the status is changed to Comfort Measures/DNR. The medical resident looks to you to answer the question.What is your response?
P.L.’s daughter asks if she should tell her mother that she is dying.What is your response?
P.L.’s daughter also asks how she will know when her mother’s death is imminent.What is your response?
What actions can you suggest to P.L.’s daughter to comfort her mother in the dying phase?
What is the nurse’s role in caring for the dying person? The family member(s)?
After her mother’s death, her daughter thanks you and the ICU team for your help and support in making the difficult time a little easier.