Nursing Assignment Sample
Q1:
Answer :Introduction
Septic shock is a potentially fatal condition that develops as a severe complication of sepsis, resulting in extreme circulatory, cellular, and metabolic derangements. It is defined by the presence of persistent hypotension despite adequate fluid resuscitation, necessitating vasopressor support and frequently resulting in multiple organ dysfunction syndrome (MODS). The intensive care nurse's role in the management of a patient with septic shock is instrumental in early identification, aggressive management, and continued monitoring to enhance survival and avoid complications.
This essay discusses the pathophysiology, clinical presentation, nursing interventions, pharmacological management, and long-term considerations in the management of a patient with septic shock in the ICU.
Pathophysiology of Septic Shock
Septic shock is an evolution of sepsis, which is a life-threatening organ dysfunction due to a dysregulated host response to infection. The most important pathophysiological changes are:
1. Dysregulated Immune Response
Pathogen invasion (bacteria, viruses, fungi) initiates an exaggerated immune response with release of pro-inflammatory cytokines (TNF-α, IL-1, IL-6).
The cytokine storm induces diffuse endothelial dysfunction with increased vascular permeability and leakage of fluid into tissues, resulting in hypotension.
2. Vasodilation and Hypotension
In excess nitric oxide (NO) production leads to extreme vasodilation with decreased systemic vascular resistance (SVR) and resultant hypotension resistant to fluids.
3. Impaired Tissue Perfusion and Hypoxia
Capillary leak results in third-spacing of the fluids, intravascular volume reduction, and hence worsening hypotension.
Compromised cellular oxygen extraction results in anaerobic metabolism, resulting in lactic acidosis.
4. Multiple Organ Dysfunction Syndrome (MODS)
Sustained tissue hypoxia and inflammatory injury lead to multi-organ failure involving:
Cardiovascular system – Myocardial depression and hypotension.
Respiratory system – Acute respiratory distress syndrome (ARDS).
Renal system – Acute kidney injury (AKI) secondary to hypoperfusion.
Neurological system – Altered mental status secondary to poor cerebral perfusion.
Clinical Presentation of Septic Shock
A patient in septic shock will present with:
Early (Hyperdynamic) Phase
Warm, flushed skin (secondary to vasodilation).
Tachycardia and bounding pulses.
Hypotension despite fluid resuscitation.
Fever (>38.3°C) or hypothermia (<36°C).
Altered mental status (restlessness, confusion).
Late (Hypodynamic) Phase
Cold, clammy skin (secondary to deteriorating perfusion).
Weak, thready pulses.
Worsening hypotension with evidence of organ failure.
Oliguria (<0.5 mL/kg/hr urine output).
Metabolic acidosis with increasing lactate.
Hemodynamic Monitoring in ICU
In the ICU, nurses have an important role to play in ongoing hemodynamic monitoring to determine perfusion status and direct treatment.
The main parameters are:
Mean Arterial Pressure (MAP) – Target: ≥65 mmHg.
Central Venous Pressure (CVP) – Directs fluid resuscitation (target: 8–12 mmHg).
Cardiac Output (CO) and Cardiac Index (CI) – Assess myocardial performance.
Lactate Levels – Increased (>2 mmol/L) indicates tissue hypoxia.
Mixed Venous Oxygen Saturation (SvO₂) – Indicates delivery vs. uptake of oxygen.
Nursing Management of Septic Shock
1. Prompt Recognition and Expeditious Management
Take serial vital sign observations and observe for deteriorating signs.
Use Sepsis Screening Tools (e.g., qSOFA score, NEWS).
Draw blood cultures prior to giving antibiotics.
Take strict fluid balance monitoring to inform resuscitation.
2. Fluid Resuscitation
Give crystalloids (Normal Saline or Lactated Ringer's) 30 mL/kg in the first 3 hours.
Measure fluid responsiveness by passive leg raise (PLR) test or stroke volume variation (SVV).
3. Vasopressor Support
If MAP is still <65 mmHg after fluids, initiate norepinephrine (first-line vasopressor).
Vasopressin or epinephrine can be added if refractory shock ensues.
4. Antibiotic Therapy
Administer broad-spectrum antibiotics (e.g., piperacillin-tazobactam, meropenem) within one hour of diagnosis.
De-escalate antibiotics according to culture results.
5. Oxygenation and Ventilation Support
Support SpO₂ > 94% with supplemental oxygen.
Intubation and mechanical ventilation can be needed in ARDS.
Employ lung-protective ventilation techniques (low tidal volume, PEEP).
6. Glycemic Control
Keep blood glucose <180 mg/dL with IV insulin therapy as necessary.
Prevent hypoglycemia with frequent blood glucose monitoring.
7. Kidney Protection and Renal Support
Assess urine output and serum creatinine for early detection of AKI.
Continuous renal replacement therapy (CRRT) can be necessary in severe cases.
8. Nutrition and Gastrointestinal Support
Early enteral nutrition within 48 hours for preventing gut ischemia.
Stress ulcer monitoring and giving proton pump inhibitors (PPIs).
9. Prevention of Complications
Apply DVT prophylaxis (low-molecular-weight heparin, compression stockings).
Prevent pressure ulcers with repositioning frequently.
Prevent ICU delirium by optimizing sleep cycles and reducing sedation.
Long-Term Issues and Outcomes
Post-Sepsis Syndrome (PSS) – Cognitive impairment, muscle weakness, depression.
ICU-Acquired Weakness (ICUAW) – Rehabilitation and physiotherapy critical.
Psychosocial Support – Anxiety and PTSD are frequent post-ICU.
Education and Follow-up – Families and patients ought to get discharged education regarding lifestyle changes and early infection detection.
Conclusion
The management of a septic shock patient in the ICU is a multidisciplinary process involving early identification, aggressive resuscitation, hemodynamic monitoring, and organ support. The intensive care nurse has a key role in minimizing mortality and morbidity through timely intervention and complication prevention. Progress in sepsis protocols and individualized medicine is constantly enhancing patient outcomes, underscoring the need for continuous research and evidence-based practice in critical care nursing.