Case study of patient with sepsis
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1) The patient is a 50-year-old female admitted to the ICU with sepsis from an abdominal infection. She presents with fever, chest pain, abdominal distention, and low blood pressure. 2) Diagnostic tests show low white blood cell, red blood cell, and hemoglobin levels. She is started on antibiotics including meropenem, teicoplanin, and other medications to manage her symptoms. 3) The nursing care plan focuses on monitoring her vital signs, administering medications correctly, preventing infection and bedsores, and providing patient education on self-care after discharge.
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Case study of patient with sepsis
- 1. http://www.free-powerpoint-templates-design.com Case study of patient with sepsis Naima adel /Nusrat
- 2. Objective of the sepsis case study understand the pathophysiology about sepsis Identify the medications use to sepsis the management and nursing care plan Identify method of dignostic studied for sepsis Discuss anatomy and physiology about sepsis
- 4. Case study data 40% 50%60%80% 01 02 03 04 Area: ICU Date of submitted: 26-11-2020 Name of student Name of hospital: Bed number: 509
- 5. Patient data Name of patient: XXXX MR: 2961631 Nationality: Gander : F Age: 50 Marital status : married DOA: 16-10-2020 Medical diagnosis : sepsis Reason of admission :abdominal distention with sever pain Chief complaints : Brady cardia -Sunken -Chest pain fever
- 6. General appearance: 1- drowsy 2- pale 3-tired Vital signs: BP:119/57 T: 38.7 P:103 RR: 25 Oxygen: 93 Context: Setting Pain score: 6 History of present illness
- 7. Marital status : married Number of child : 2 Smoker: no Work: none Past medical and surgical history : non History of present illness
- 8. History of present illness Location: chest and abdomen Duration: 2 days before admission Onset : 16/10/2020 Chief complain: Brady cardia -Sunken -Chest pain -fever Characteristics : pain- fever Aggravating factor: non Related symptoms: Illness history upon admission in ER Family history : None Mother obstetric history: None Type of diet: NPO
- 9. Case study data Area Name of hospital Naima adel mubarak Date of submitted Bed number 17-11-2020 ICU Name of student 509EBGH
- 10. Physical assessment Digestive system Stoma – distend abdomen Endocrine system DM Cardiovascular Very week pulse Low pressure Brady cardia Lower peripheral pulse can not palpate Neurological system She have reaction in both pupil Verbal response
- 11. Physical assessment 01 02 03 04 05 Respiratory system Integumentary system Renal system Reproductive system Musculoskeletal system Everything is normal The skin is intact – dry - clammy Bradypnea less than 12 She have good joint – no injury no fracture Decrease the output and with folly catheter
- 14. Anatomy & physiology Right Atrium Tricuspid Valve Right Ventricle Left Ventricle Left Atrium Aortic Valve Mitral ValvePulmonary Valve Pulmonary Artery Coronary Artery Aorta Function of heart : The heart is the main organ in the circulatory system, the structure primarily responsible for delivering the circulation of blood and transportation of nutrients in all parts of the body. the heart has four chambers: two atrium and two ventricles. The right atrium receives oxygen-poor blood from the body and pumps it to the right ventricle. The right ventricle pumps the oxygen-poor blood to the lungs. The left atrium receives oxygen-rich blood from the lungs and pumps it to the left ventricle
- 16. Pathophysiology Definition of sepsis is a potentially life-threatening condition caused by the body's response to an infection. that arises when the body's response to infection causes injury to its own tissues and organs. Risk factor: 1. Are very young or very old. 2. Have a compromised immune system. 3. Have diabetes or cirrhosis. 4. Are already very sick, often in a hospital intensive care unit. 5. Have wounds or injuries, such as burns. 6. Have invasive devices, such as intravenous catheters or breathing tubes
- 17. Causes : Bacterial infections are the most common cause of sepsis. Sepsis can also be caused by fungal, parasitic, or viral infections. The source of the infection can be any of a number of places throughout the body. Common sites and types of infection that can lead to sepsis include: The abdomen: An infection of the appendix (appendicitis), bowel problems, infection of the abdominal cavity (peritonitis), and gallbladder or liver infections. The central nervous system: Infections of the brain or the spinal cord. The lungs: Infections such as pneumonia. The skin: Bacteria can enter skin through wounds or skin inflammation, or through the openings made with intravenous (IV) catheters (tubes inserted into the body to give or drain fluids). Conditions such as cellulitis (inflammation of the skin's connective tissue) can also cause sepsis.
- 18. Disease process: The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems sign and symptom of sepsis I. Fever and chills II. Fast heartbeat. III. Nausea and vomiting. IV. Diarrhea. V. Fatigue or weakness. VI. Blotchy or discolored skin
- 19. Diagnostic Studies ImplicationsResultsNormal ValuesName of diagnostic Low2.62 McL4.5 – 11.5WBC Low2.9 McL4.60 – 6.00RBC Low7.6 gmd L14.0 – 18.0Hemoglobin
- 20. ActionIndicationClassificationName of drug Chemical effect: antibacterial activity by binding to the d-alanyl-d- alanine moiety and sequestration of the lipid II substrate, resulting in inhibition of bacterial peptidoglycan synthesis Therapeutic effect : treat serious infections, such as septicemia, endocarditis, bone and joint infections caused by Gram- positive bacteria resistant to other drugs, cystitis due to multidrug-resistant enterococci and catheter- associated staphylococcal infections in neutropenic patients Treatment of infections caused by susceptible gram- positive bacteria AntibioticGeneric name: teicoplanin Brand name: targocid Dosage: 400 MG Route: IV frequency: once daily
- 21. Nursing considerationsContraindicationAdverse reaction 1- vital sings 2- check for any allergy 3-observe any side effect Appear hypersensitivity to vancomycin, as crossed hypersensitivity reactions, including fatal anaphylactic shock 1-Rashes 2-fever 3-diarrhea 4-nausea 5-vomiting
- 22. OngoingDate DCRouteFrequencyDosageGeneric nameBrand name 7 DAYS23-10-2020IVBID1 GMeropenemArchifar 7 DAYS23-10-2020NGTBID5 MGIvabradineProcoralan 7 DAYS23-10-2020IVOnce daily1 AMPTrace elementTracutil
- 24. PlanningNursing diagnosisAssessment After 8 hours of my shift Pt will be improve HR Improve BP Decrease the chest pain Improve oxygen saturation Decrease the fever Risk for infection and coma related to sepsis SUBJECTIVE: Patient said: ”my heart is sunken feeling tired something happened with me” after 10 min patient become unconscious OBJECTIVE: She is pale – tired – chest pain and pain score 4 – brady cardia – bradypnea Patient transferer to ICU V/S: BP:119/57 T: 38.7 P:103 RR: 25 Oxygen: 93
- 25. EvaluationRationaleIntervention After the end of my shift the patient 1-Increase the V/S including O2 saturation and blood pressure with normal range 2-The fever is reduced 3- The pain is reduced 4- the heartburn is decreased 5- patient still on ventilator 1- decrease the fever 2- prevent the patient from bedsores 3- to monitors oxygenation and ventilation status. 4-To determine if there is hypoxia 5-to determine the breath pattern if improved or not 6- to prevent from infection 7- to treat the infection 8- to reduce the heartburn 9- to decrease the clotting ability 10- for DM 11- to reduce the pain and fever 1-i will applying cold compresses in the underarm ,neck and forehead 2-change every hour the position 3- assess the ABG status 4-check the Pao2 5- observe for breathing pattern 6-clean the stoma Medical mangment: 1-targocid 2-omecure 3- multiparin 4- actrapid 5- perfalgan Health teaching: Clean the stoma bag and before that wash the hand and wear gloves- Eat a healthy diet-Drink enough fluids- Call your healthcare provider if you have new or worsening sign and symptoms- not driving
- 27. THANK YOU