Pasadena City College Shock & Multiple Organ Dysfunction Syndrome Case Study

Clinical Case StudyFor Advanced Med-surg
“Shock and
Multiple Organ
Dysfunction
Syndrome”
(as referenced from Hinkle & Cheever, 2014)
Prepared by Kathleen Rosales, PhD, RN
Page 1 of 5
Important Note: You must earn a minimum of 75% on this case study as your remediation for
four (4) of your missed clinical hours. Failure to achieve this minimum grade will necessitate
further assigned case studies to adequately compensate for your missed clinical hours. Please
use your text book as your primary source of information and other appropriate nursing
resources(which must be referenced) to thoroughly answer the case study questions. The rubric
for evaluation and grading of this case study is as follows:
90% of the
case study
grade
Rubric that will
be applied to
each
case study
question:
10% of the
case study
grade will be
based on
Grammar,
syntax, and
APA format,
including a
cover page and
reference
sheet.
Grammar,
syntax, and
APA formatting
rubric that will
be applied to
the overall
case study:
1 point
The student
demonstrates
incorrect or minimal
knowledge in
response to the
question asked in
the case study.
2 points
The student
demonstrates only
partial
comprehension
and/or provides an
inadequate
response to the
question asked in
the case study.
3 points
The student
demonstrates the
use of application
and analysis in
response to the
question asked in
the case study.
4 points
The student
demonstrates the
ability to assess,
compare and
contrast, prioritize,
and/or evaluate in
response to the
question asked in
the case study.
1 point
The student’s
written responses
and APA formatting
contain 10 or more
grammar,
punctuation, and/or
spelling errors.
2 points
The student’s
written responses
and APA formatting
contain 7-9
grammar,
punctuation, and/or
spelling errors.
3 points
The student’s
written responses
and APA formatting
demonstrate correct
and consistent use
of the rules of
grammar usage,
punctuation, and
spelling. There are
only 3-6 minor
grammar,
punctuation, and/or
spelling errors
noted.
4 points
The student’s
written responses
and APA formatting
demonstrate
correct and
consistent use of
the rules of
grammar,
punctuation, and
spelling. There are
not more than 2
minor errors noted.
Please attach this page to the end of your completed case study
for evaluation and grading purposes.
Page 2 of 5
Clinical Presentation
A 79 year-old Hispanic male is admitted to the ICU from a SNF with new onset ALOC. The
patient arrives from the ER with a Foley catheter connected to a drainage bag that contains
cloudy, foul-smelling urine. Initial vital signs are: Temp 96.7๐F; Radial pulse 1+ at 108 bpm; RR
36 and shallow; Pulse ox 88% on a non-rebreather mask; BP 86/44 (MAP 58). Preliminary lab
tests come back as follows:
o ABGs: pH 7.30 PaCO2 65 mmHg HCO3 32 mmHG PaO2 256 with 100% Fio2 via
non-rebreather mask.
o Serum lactate 5.9 mmol/L
o K 3.3; BUN/Cr 58/1.9; Glucose 298
o CRP 5 mg/L; BNP 1347; Troponin I 1.9 ng/mL
o H/H 9/27; WBC 21K; Platelets 95K
o Serum bilirubin 4.8 mg/dL
o Blood cultures show gram-positive cocci in clusters
o Additional focused physical assessment findings: Neuro: GCS 10; PERLA, +gag reflex,
admitted with ALOC; Pulmonary: breath sounds diminished bilaterally with crackles in
anterior and posterior fields; Cardiovascualr: S1, S2, grade 2 systolic murmur, +3 pitting
edema in lower extremities, +1 pedal pulses, EKG as noted below
GI: hypoactive bowel sounds x4 quadrants; Renal: urine output 20 mL/hr; Skin: no
breakdown, extremities cool to touch.
Medical History
Early dementia, CHF, CAD, MVR, DM II, renal insufficiency
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Initial Medical Interventions
o 12 Lead EKG
o 2-D echo
o Right subclavian triple lumen central line with CVP
o CXR (confirming pulmonary edema and central line placement)
o Intubation with the following vent settings: AC 20 Vt 500 PEEP 5 FiO2 40%
o Arterial line
o IV infusions
o
norepinephrine (Levophed) 2 mcg/min, to be titrated to keep the greater than 100
mm Hg.
o Propofol 10 mcg/kg/min and tritrate to sedation
Case Study Questions
1. Explain the pathophysiology of septic shock and MODS.
2. Compare clincal presentations for bacterial sepsis between the gerontologic population as
compared to the adult non-geri population.
3. Which clinical findings indicate that the patient has developed sepsis and/or MODS?
Provide rationales.
4. Explain the significance of each of the patient’s lab results.
5. Explain the rationale for each medical intervention.
6. Explain the nursing management and responibilites for each ordered test.
7. The family have been notified and are at the bedside. They are distressed and anxious
about the deteriorating condition of the patient’s condition. What could the RN aay
and/or do to comfort and calm them?
8. What is the interpretation of the patient’s EKG? Why is it abnormal and why?
9. What bacterial organism do you think has affected this patient?
10. What would be considered first line antibiotic treatment for this bacteria?
11. Based on implementation of each of the medical interventions ordered, what potential
complications could the patient develop that the RN would need to assess/monitor for?
12. What is the importance of verifying placement of a subclavian central line by CXR?
13. Your textbook calls for NS boluses in the presence of sepsis. Why might this be
contraindicated with this patient?
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14. The norepinephrine concentration is 16 mg in 250 mL in 0.9% normal saline (NS).
Present your calculations for determining the IV rate for the ordered dose.
15. Based on new ABGs, the physician has increased the FiO2 and the PEEP. What potential
complications could the patient develop that the RN would need to assess/monitor for?
16. Explain the mechanics of the cardiac cycle as it relates to the waveforms of an arterial
line, as seen below. Label each part of the waveform.
17. The RN notes that the arterial waveform has changed, as seen below. What is causing this
and how could it be corrected?
Page 5 of 6
References
Hinkle, J.L. & Cheever, K.H. (2014). Brunner & Suddarth’s textbook of medical surgical
nursing (14th ed.). Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams &
Wilkins.
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