Shock

comprehensive description of septic shock including its management and nursing management, and its complication.

1. Case presentation on
Septic Shock
AnuBajracharya
MN 1
st
year

2. Demographic data
•Patient’s name: Krishna Prasad Sapkota
•Age/sex: 45 years/male
•Marital status: Married
•Education: literate
•Occupation:
•Religion: Hindu
•Address: Pohara-13, Kaski
•Ward: Intensive Care Unit, Western regional Hospital, Pokhara

3. •Bed no: 5
•Inpatient number: 255879
•Provisional Diagnosis: septic Shock, with type 2 Diabetes Mellitus
under medication
•Date of admission: 2074/08/07
•Date of interview: 2074/08/08
•Date of Discharge: 2074/08/22
•Final diagnosis:septic Shock, with type 2 Diabetes Mellitus
•Attending doctor: Dr. MadhavTiwari
•Information obtained from: Patient himself, his wife and patient’s
chart.

4. •Chief complain
•Pain in epigastricregion
•Decreased appetite
•Dry mouth, chest pain, sore throat
•Fever since 8 days.

5. •Complain at present:
•Abdominal pain
•Body ache.
•Unwillingness to eat.
•Tenderness around the abdomen especially in the right
and left hypochondriac region.

6. •Historyofpresentillness:
•Patientisapparentlywellbutsuddenlyhedeveloped
epigastricpainandfeversohevisittolocalpharmacyand
takemedicineforfeverandepigastricpain.Butpainwasnot
subside,decreasedappetiteandalsohenoticedthathis
urinaryoutputisalsodecreased,sohecametoWestern
RegionalHospital,EmergencyDepartmentandgotadmitted
inICUbedNo5withthediagnosisofsepticShock.

7. •History of past illness:
•Immunization taken: he had taken all the immunization as per
EPI schedule
•History of any drug allergy: not known yet
•Around 3 or 4 years ago, he had develop icterus on body,
yellowish eye, loss of appetite and fever, so he admitted in
Saudi Hospital with the diagnosis of Jaundice and he
discharged as per advice by doctor.
•He is under medication of diabetes mellitus since 18 years, he
used AyurvedicMedicine but document not available.

8. •Family history:
•His father is died due to tuberculosis, except it, there is
no any chronic illness of history on maternal family.

9. •Smoking habit-yes, since 14-15 years.
•Alcohol: yes, daily
•Food habit: three times a day/non-vegetarian
•Drug and food allergy: not known
•Bowel and bladder habit: regularly
•Sleeping pattern: 7/8 hours per day.
Personal health history:

10. •Type of family: nuclear
family
•No of family members: 4
•Type of house-cemented
house
•Kitchen: separated
•Fuel used: LP gas
•Drinking water: supply
water
•Toilet: water seal
•Drainage system: closed
drainage
Environmental history

11. •Patient’s reaction to illness: he was worried about the pain
abdomen and diagnostic procedure and prognosis as he is
admitted in ICU so he thought that he had a serious health
problem.
•Patient’s coping pattern: Patient express stress because of
the illness, decreased urinary output and hemodialysis and
whenever he has a stressed, he ventilated it by talking with
his wife, his relatives as well as doctor and sisters.
Psychological history:

12. •Social economic history: farmer
•He is head of the family
•Support system: all the family members’ visit him frequently,
supported him and provided care as needed so he had family
support.
•Recent family crisis or change: there is no any crisis in his family
members beside some financial crisis, but his treatment cost is
under health insurance.
•Leisure time activities: he used to talk with friends, listened news,
chat on Facebook friends.
•Cultural group-he follows Hindu culture.
Socio-economic status:

13. Female death
Female
Patient
Male
Male death
Index
Family tree
Patient’s father is died due to tuberculosis

14. Developmental task
•Developmental task of middle adulthood as described by Havighurst:
Developmental task accordingto bookDevelopmentaltask in patient
Helping teenage childrento become
happy and responsible adults.
He lived with two married sons,
daughter-in law and wife and he
supported his sons decision and helped
in taking responsibility of household.
Achieving adult social and civic
responsibility.
He used his right of vote and also
involved in community’s every activity as
a activemember.
Satisfactory career achievement He stayed aboardfor more than 4-5
years and he is satisfied what he
achieved in aboard.

15. Developmental task
cont….
Developing adult leisure time
activities
Heused his leisure time on
watching TV, spending time with
his wife.
Relatingone’s spouse as a
person
Hesupport and care and respect
his wife.
Acceptance the physiological
changesof middle age
He accept the physiological
changes that is occurring in his
body
Adjustingto aging parents He was the eldest member of the
family.

16. Vital signs
•T-99
0
F,
•Pulse-94beats/min
•Respiration-34 breath/min
•Blood Pressure-110/70mm of Hg
•Glasgow Coma Scale-15/15 on admission.
•Weight-60kg

17. Physical examination findings
•General condition of patients: seems poor, drowsy,
lethargic, weakness, puffiness of face.
•Crack lip.
•Icterus bulbar conjunctiva
•Pale in the conjunctiva, oral mucosa.
•Diminish breath sounds in the lower zone.
•Tachycardia.

18. Physical examination findings
•Edema present in lower extremities including ankle
edema.
•Abdominal pain and tenderness in epigastricregion
and right and left hypogastricregion.

19. DEFINITION
Shockistheclinicalmanifestationoffailureofcellular
functionduetoinadequatetissueperfusionand
consequentcellularhypoxiaresultingfromareductionin
theeffectivecirculatingbloodvolume.

20. •Shockcanbestbedefinedasaconditioninwhichsystemic
bloodpressureisinadequatetodeliveroxygenand
nutrientstosupportvitalorgansandcellularfunction.
•Adequatebloodflowtothetissuesandcellsrequiresthe
followingcomponents:adequatecardiacpump,effective
vasculatureorcirculatorysystem,andsufficientblood
volume.

21. •When one component is impaired, blood flow to the tissues is
threatened or compromised. Without treatment, inadequate
blood flow to the tissues results in poor delivery of oxygen and
nutrients to the cells, cellular starvation, cell death, organ
dysfunction progressing to organ failure, and eventual death.
•Shock is a life-threatening condition with a variety of under lying
causes. It is characterized by inadequate tissue perfusion that, if
untreated, results in cell death.

22. Shock: types
•Hypovolemic shock
•Septic shock
•Cardiogenic shock
•Neurogenic shock
•Anaphylactic shock

23. Definition of septic shock
•Septic shock is a medical condition as a result of severe infection and
sepsis, thought the microbe may be systemic or localized to a particular
site.
•It can cause multiple organ dysfunction syndrome (formerly known as
multiple organ failure) and death.
•Its most common victims are children, immune-compromised individuals,
and the elderly, as their immune systems cannot deal with the infection as
effectively as those of healthy adults.
•Frequently, patients suffering from septic shock are cared for in intensive
care units. The mortality rate from septic shock is approximately 25-50%.

24. Clinical spectrum of infections
Infection
Bacteremia
Sepsis
Severe
sepsis
Septic
shock

25. Definition of different terminologies
•Infection: microbial phenomenon characterized by an inflammatory
response to the presence of micro-organisms or the invasion of
normally sterile host tissue by these organisms.
•Bacteremia: the presence of bacteria in the bloodstream.
•Septicemia: no longer used.

26. •Shock-when the cardiovascular system fails to deliver
enough oxygen and nutrients to meet cellular metabolic
needs.
•Sepsis: presence of bacteria in the blood stream.
•Septic shock: begins with the development of septicemia
usually from bacterial infections, but can be viral in origin.
This is the most common type of distributive shock.

27. •Septic shock, the most common type of circulatory shock
is caused by widespread infection. Despite the increased
sophistication of antibiotic therapy, the incidence of septic
shock has continued to rise during the past 60 years.
•It is the most common cause of death in non-coronary
intensive care units in the United States and the 13th
leading cause of death in the U.S. population.

28. •Astudyconductedin133ICUofdifferent95German
Hospitalsfoundthat,12.6%patientwerediagnosedwith
severesepsisorsepticshock.In860casesi.e.57.2%ofthe
infectionswereofnosocomialorigin.
•ICUmortalityinpatientswithseveresepsis/septicshockwas
34.3%,comparedwith6%inthosewithoutsepsis.Total
hospitalmortalityofpatientswithseveresepsisorseptic
shockwas40.4%.
Source: Incidence of severe sepsis and septic shock in German ICUs: The INSEP study

29. •A CDC evaluation found 7 in 10 patients with sepsis had recently
used healthcare services or had chronic diseases requiring frequent
medical care. In adults, these common infections can lead to sepsis.
•Lung infection such as pneumonia (35%)
•Kidney or urinary tract infection (25%)
•Gut, stomach, or intestine infection (11%)
•Skin infection (11%)
Sepsis Statistics
•More than 1.5 million people get sepsis each year in the U.S
•About 250,000 Americans die from sepsis each year
•One in three patients who die in a hospital have sepsis

30. Causes of septic shock
•Asmentionedanytypeofbacteriainthebloodstream
causessepticshockandthiscanoccurfrommany
infections.
•Healthcareassociatedinfections(infectionsnot
incubatingatthetimeofadmissiontothehealthcare
setting)incriticallyillpatientsthatmayprogresstoseptic
shockmostfrequentlyoriginateinthebloodstream,lung
andurinarytract.

31. •Otherinfectionsincludeintra-abdominalinfectionsand
woundinfections.
•Bacteriemiaassociatedwithintravascularcatheterand
indwellingcatheter.
•Increaseduseofinvasiveprocedureandindwellingmedical
devices.

32. •Increasednumberofantibiotic-resistancemicroorganism
andtheincreasinglyolderpopulation.
•Elderlypatientareparticularriskforsepsisbecauseof
decreasedphysiologicreservesandagingimmune
system.
•Otherpatientsatriskforthoseundergoingsurgicaland
otherinvasiveprocedure,thosewithmalnutritionor
immunosuppressionandthosewithchronicillnesssuch
asdiabetesmellitus,hepatitis,chronicrenalfailureand
immunodeficiencydisorders

33. •Cause in my patient:
•Exact cause is unknown
•Risk factors:
•History of diabetes.
•History of jaundice

34. Gram negative bacteria/ Gram Positive bacteria
Microorganism invade body tissue, patient
exhibit an immune responseActivation of biochemical cytokines and
mediators
Inflammatory response and produces a complex
cascade of physiological events-tissue perfusion
Increased capillary permeability, fluid
seeping from the capillaries and
vasodilation
Activation of coagulation system
Decreased tissue perfusion, nutrients to
the tissue and cells
Begins to form clots whether or not
bleeding is present
Pathophysiology of septic
shock

35. Some characteristics of septic shock
•Systemic vasodilation and hypotension.
•Tachycardia: depressed contractility
•Vascular leakage and oedema; hypovolemic
•Compromised nutrient blood flow to organs
•Disseminated intravascular coagulation
•Abnormal blood gases and acidosis
•Respiratory distress and multiple organ failure

36. Clinical features
•Three major pathophysiologic effects, vasodilation, mal-distribution
of blood flow and myocardial depression.
•Blood flow in the micro-circulation decreased, causing poor oxygen
delivery and tissue hypoxia.
•The combination of TNF and IL-1 is thought to have a role in sepsis
induced myocardial dysfunction.

37. •Theejectionfractionisdecreasedforthefirstfewdaysafterthe
insult.Becauseofdecreasedejectionfraction,theventriclesdilateto
maintainthestrokevolume.Theejectionfractiontypicallyimproves,
andventriculardilationresolveover7-10days.PersistenthighCO
andlowSVRbeyond24hoursisanominousfindingsandisoften
associatedwithanincreaseddevelopmentofhypotensionand
MODs.

38. •As sepsis progresses, tissues become less perfused and acidotic,
compensation begins to fail, the patient begins to show signs of
organ dysfunction. The cardiovascular system also begin to fail, the
BP does not respond to fluid resuscitation and vasoactive agents,
and sigh of end organ damage are evident (renal failure, pulmonary
failure)

39. •As sepsis progress to septic shock, the BP drops, and the
skin becomes cool, pale and mottled. Temperature may be
normal or below. Heart and respiratory rates remain rapid.
Urine production cease, and multiple organ dysfunction
progressing to death occur.

40. Early sepsis
•Fever or hypothermia
•Rigor, chills
•Tachycardia
•Tachypnea RR more than 35
•Nausea, vomiting
•Hyperglycemia
•Myalgias
•Lethargy, malaise
•Proteinuria
•Hypoxia
•Leukocytosis
•hyperbiliriubinemia

41. Late sepsis
•Lactic acidosis
•Oliguria
•Leukopenia
•Disseminated intravascular
coagulopathy
•Myocardial depression
•Pulmonary edema
•Hypotension
•Hypoglycemia
•Thrombocytopenia
•Acute respiratory distress
syndrome
•GI bleeding

42. Clinical features in my patient:
•Fever-99.6⁰ F
•Pain in epigastricregion, tenderness on abdomen.
•Loss of appetite
•Low urinary output, ceases of urinary output
•Puffiness of face.
•Edema present in lower extremities.
•Difficulty in breathing, decreased oxygen saturation.
•Drowsiness, restlessness, insomnia,

43. •Blood glucose level raised.
•Sreumcreatinine level raise
•Urea level raised.
•USG-mild pleural effusion, mild hepatomegaly, mild splenomegaly

44. Diagnosis of septic shock
•There is no single diagnostic study to determine whether a patient is in
shock.
•Establishing a diagnosis begins with a history and physical examination.
•Obtain a through medical and surgical history and a history of recent
events (e.g, surgery, chest pain, trauma).
•Physical examination-decreased tissue perfusion, elevation of lactate,
blood pressure, pulse, respiration,

45. •Red blood cell count,
hematocrit, hemoglobin
•WBC
•Creatinekinase
•Troponin
•BUN
•Creatinine
•Glucose
•Serum electrolytes
•Arterial blood gases
•Blood culture
•Lactate level
•Liver enzymes
Laboratory study:

46. •Others diagnostic studies:
•ECG
Chest X-ray
•Continuous pulse oxymetry
•Hemodynamic monitor (arterial pressure, central venous
pressure,)

47. Diagnostic test done in patient
•History taking and physical examination
•Laboratory investigation: CBC, Urine R/E, RFT, LFT, sr. Amalyse etc
•Others:
•Chest x-ray
•ECG
USG-mild pleural effusion, mild hepatomegaly and mild
splenomegaly.

48. Lab investigation finding comparison with normal value
Investigation 074/08/07 074/08/08 References
WBC 5400 8500 4000-11,000/mm³
DC N-93, L-06, E-01, N-85, L-10, E-02, M-03
Hb% 12.7% 11.6% 12-14%
Platelets 93,000 90,000 1.5-4ˣ10⁶mm³
MCH 27pg/cell
MCV 76
RBS 281 70-140mg/dl
FBS 176 162 60-110mg/dl
SGPT/ 55 5-42U/L
SGOT 121 5-40U/L

49. Investigation 074/08/09 074/08/10 References
PPBS 201 70-140mg/dl
Urea 88 180 15-40mg/dl
Sr. Creatinine 7.2 6.8 0.6-1.6mg/dl
Sodium 140 129 135-150
Potassium 4.0 4.7 3.5-5
Total Bilirubin 3.6 0.3-1.2mg/dl
Direct/ indirect 2.8/ 0.8 0.1-0.4/0.2-0.8mg/dl
SGOT 108 5-42U/L
SGPT 44 5-40U/L
ALKP 1840 110-310IU/L
Total protein 4.9 6.0-8.09g/dl
Albumin 2.5 3.2-5.5g/dl
Globulin 2.4 2.5-3.0g/dl
A/G ratio 1.0 1.0-1.8
Sr. amylase 72.3 <220U/L

50. Investigation 074/08/10074/08/11074/08/12 08/13 08/14 References
WBC 10,300 8,100 9700 12,000 4000-
11,000/mm³
DC (N, L, E,
M)
82, 15, 01,
02
70, 23, 03,
04
69, 24, 3, 4 65, 29, 03, 03
Hb% 11.7% 11% 10 10.8 12-16%
Platelets 61,000 90,000 1,05,000 1,53, 0001.5-4ˣ10⁶mm³
Urea 180 147 81 45 63 15-40mg/dl
Creatinine 6.8 6.1 11.2 2.7 1 0.5-1.4mg/dl
Sodium 129 129 128 127 135-145meq/l
Potassium 4.7 4.4 3.7 4.1 3.5-5meq/l
FBS 154 173 150 150 207 60-110mg/dl

51. 2074/8/7
Urine R/M/E:
•Colour-yellowish
•Transparency-turbid
•Albumin-Trace
•RBC-Nil
•Pus Cells-2-3
•Epithelia cells-packed
2074/8/8
Urine R/M/E:
•Colour-yellowish
•Transparency-clear
•Albumin-Nil
•Sugar-Nil
•WBC-0.2
•RBC-Nil
•Pus Cells-2-3
•Epithelia cells-packed
08/08-USG-Acute hepatitis, mild splenomegaly, minimal pleural effusion

52. Treatment and management
•Critical factors in the successful management of a patient
experiencing shock relate to the early recognition and treatment of
the shock state. Promote early stage of shock may prevent the
decline to the progressive or irreversible stage.

53. •Successful management of a patient in shock includes the
following:
•Identification of patients at risk for developing shock.
•Integration of the patient's history, physical examination,
and clinical findings to establish a diagnosis.
•Interventions to control or eliminate the cause of the
decreased perfusion
•Protection of target and distal organs from dysfunction
•Provision of multisystem support care.

54. •Patient in septic shock require large amount of fluid replacement
volume.
•Resuscitation of 30 to 50ml/kg is usually done with isotonic crystalloid
to achieve a target central venous pressure of 8-12 mm hg.
•To optimize and evaluate large volume fluid resuscitation
hemodynamic monitoring with in minimum of central venous catheter
is necessary.

55. •Albumin0.5to1g/kg/dosemaybeaddedwhenpatients
requiressubstantialvolume.
•OncetheCVPis8mmHgormore,vasopressormaybeadded.
Thefirstdrugofchoiceisnorepinephrine.
•VasodilationandlowCardiacoutputorvasodilationalone,
causelowBPinspiteofadequatefluidresuscitation.
Vasopressinmaybeaddedforpatientsrefractoryto
vasopressortherapy.VasopressordrugmayincreaseBPbut
mayalsodecreasestrokevolume.

56. •IV corticosteroids may be considered for patient in septic shock who
cannot maintain an adequate BP with vasopressor therapy despite
fluid resuscitation.
•Antibiotics are important and early component of therapy. They should
be started within the first hour of septic shock.
•Obtain cultures (e.g., blood, wound exudate, urine, stool, sputum)
before antibiotics are started.
•Broad spectrum antibiotics are given first, followed by antibiotics that
are more specific once the organism had been identified.

57. •Glucose level should be maintained below 180mg/dl for patient in shock.
Frequently monitor glucose levels in all patients in septic shock.
•Stress ulcer prophylaxis with proton pump inhibitor.
•For patient with bleeding risk factors and venous thromboembolism
prophylaxis e.g., heparin, enoxaparin are also recommended.
•Nutritional supplementation should be initiated within the first 24 hours
after ICU admission and continuous infusion of insulin are used to control
hyperglycemia.

58. Treatment done in my patient
•ICU admission.
•NPO followed by soft diet
•Regular monitoring of liver function test, kidney function
test and blood glucose level.
•Strictly monitoring vital signs and intake and output.

59. •Insulinedextrose salaine10 drops/min.
•Inj. Dopamin4mcg/kg/min through infusion pump.
•Dialysis is done due to acute renal failure.

60. Drugs used in my patient
•Inj. Montaz1gm IV BD
•Inj. Levoflox500mg IV OD
•Inj. Pantop40 mg IV BD
•Inj. Fevastin1gm IV SOS
•Tab. Medomol1tab PO SOS
•InjBuscopan1am IV SOS
InjOndem4mg IV TDS
•Inj. 10% dextrose + Insulin 10 unit + KCL 10 MCq10 drops/ min
•Inj. Orinda 500 mg IV OD
•Inj. Ketrolac30mg IV Stat BD

61. Date Instruction followed General condition
074/08/07
(Thursday)
•Admitted in ICU from emergency at
3.30pm, patient is came on wheel chair.
•patient’s general condition is poor,
difficulty in breathing so SPO2 was
maintained through 2lit/min oxygen via
nasal cannula.
•T-99
0
F,
•Pulse-94beats/min
•Respiration-24 breath/min
•Blood Pressure-110/70mm
of Hg
•Glasgow Coma Scale-15/15
on admission.
•Patient is in NPO,
•intake-600ml and output-
Nil.
Daily progress report

62. Date Instruction followed General condition
074/08/08
(Friday)
•First day of hospitalization.
•General condition of patient seem poor,
difficulty in breathing as well as talking.
•Complaining of nausea and abdominal
pain, abdominal tenderness (+).
•FBS, CBC, LFT, Amylase send and
report collected.
•On morning round, doctor ordered DIK
drip 10drops/min
•T-98.2
0
F
•pulse-74 beats/min
•Respiration-26breaths/min,
Blood pressure-110/70 mm
of Hg
•Glasgow Coma Scale-
15/15.
•Diet: NPO
•Intake: 1200 ml
•Output: 15ml
Daily progress report

63. Date Instruction followed General condition
074/08/09
(Saturday)
•Second day of hospitalization.
•General condition of patient is poor
(puffiness of face, swelling of lower
extremities, vomiting +),
•patient’s BP is falling down (80/40) so
dopamine 4mcg/kg/min added in
morning round,
•after that patient’s BP is rise within
normal range i.e. 110/60, so dopamine
drip is hold in evening round.
•Patient is in soft diet.
•SPo
2is maintained in room temperature
(92%).
•Temp-97.4
0
F
•Pulse-80beats/min
•Respiration-26 breaths/min
•Blood Pressure-110/60 mm of
Hg
•Glasgow Coma Scale-15/15.
•Intake-1500ml and output-
750ml.
Daily progress report

64. Date Instruction followed General condition
074/08/
10
(Sunda
y)
•Third day of hospitalization.
•General condition of patient is still poor.
•Decreased urinary output, level of serum
creatinine and serum urea is high
(creatinine-7.2, urea-180mg/dl)
•so hemodialysis done by jugular vein
(jugular venous catheter-duration of
hemodialysis is 2 hours, ultrafiltration 1 liter
and fluid used in hemodialysis is
bicarbonate).
•FBS, RFT was sent and report collected-
(urea-180 creatinine-6.8).
•Vital signs-T-98.40F,
•Pulse-80 beats/min,
•Respiration-26 breath/min,
•Blood pressure-100/60 mm of
Hg, Glasgow Coma Scale-
15/15 SPO2 is maintained in
room air-96%.
•Patient is in soft diet,
•Intake-1200 ml, and output is
940 ml.
Daily progress report

65. Date Instruction followed General condition
2074/08/11
(Monday)
•Fourth day of hospitalization.
•General condition of patient is poor but
he feels better than yesterday.
•Today also done hemodialysis
(duration-3 hours, ultrafiltration 1.5 liter,
blood flow rate-250ml/minute and fluid
used is bicarbonate).
•FBS, CBC, RFT was sent and report
collected. (Urea-147, creatinine-6.1).
•Temperature -98
0
F
•Pulse-82beats/minute
•Respiration-24 breath/minute
•blood pressure-120/70mm of
Hg
•SPO
2-96% on room air and
Glasgow Coma Scale-15/15.
•Intake-1750ml and output-
940ml
Daily progress report

66. Date Instruction followed General condition
2074/08/12
(Tuesday)
•Fifth day of hospitalization.
•General condition of patient is fair.
•Hemodialysis was done and 1.5 liter
fluid removed. DIK fluid stop and insulin
added.
•CBC, FBS RFT send and report
collected. (FBS-150, Blood Urea-81,
Creatinine-11.2).
•Patient is in soft diet
•Temperature-98
0
F
•Pulse-80 beats/minute
•Respiration-26 breaths/minute
•Blood pressure-110/80 mm of
Hg, Glasgow Coma Scale-
15/15 SPO
2-96%.
•Intake-1400ml and output-
1000ml.
Daily progress report

67. Date Instruction followed General condition
2074/08/1
3
(Wednes
day)
•Sixth day of hospitalization.
•General condition of patient seems to
be poor. (Puffiness of face, swelling of
lower extremities and difficulty in
breathing.)
•Complain of unwillingness to eat and
drowsiness.
•Insulin is hold on morning round. RFT
send and report collected (urea-45 and
creatinine 2.7).
•SPO
2-96% with 2lit oxygen through nasal
cannula.
•Temperature-98⁰F
•pulse-80beats/min
•Respiration-22breaths/min
•Blood Pressure-110/70 mm of
Hg and Glasgow Coma Scale-
15/15.
•diet-soft diet.
•Intake-1250ml and output-
1360ml
Daily progress report

68. Date Instruction followed General condition
2074/08/14
(Thursday)
•Seventh day of hospitalization.
•General condition of patient is fair.
Puffiness of face and swelling of face is
decreased than yesterday.
•SPO2 is maintained with 2 liter of
oxygen through nasal cannula. TC, DC,
BSF and RFT send and report
collected.
•Urinary output is also cleared and
adequate in comparison to intake.
•Temperature-98⁰F
•pulse-80beats/min
•Respiration-22breaths/min
•Blood Pressure-110/70 mm of
Hg and Glasgow Coma Scale-
15/15.
•Patient is in soft diet.
•Intake-1500ml and output-
1600ml.
Daily progress report

69. Nursing Theory Application
The Henderson has focused on individual care for maintenance of
health, for recovery and for peaceful death as well. She has
emphasized 14 basic needs to achieve for the optimum health of
an individual which are as follows:
1.Breathe normally
2.Eat and drink adequately.
3.Eliminate body wastes
4.Move and maintain desirable posture

70. 5.Sleepandrest
6.Selectsuitableclothes–dressandundress
7.Maintainbodytemperaturewithinnormalrangebyadjusting
clothingandmodifyingenvironment.
8.Keepthebodycleanandwellgroomedandprotectthe
integument.
9.Avoiddangerousinenvironmentandavoidinjuringothers.

71. 10.Communicate with others in expressing emotions, needs, fears,
or opinion.
11.Worship according to one's faith.
12.Work in such way that there is a sense of accomplishment.
13.Play and participate in various forms of recreation
14.Learn, discover or satisfy the curiosity that leads to normal
development and health and use the available health facilities.

72. Assessment of the patient
Health history of
patient.
Physical examination: Vital
signs, General appearance
Fever, Pain
Loss of appetite
Drowsy
Decreased urinary
output
Tachycardia,
decreased cardiac
output
Heart sound, breathing sound
Signs of acute organ
dysfunction. Assess for
presence of hypotension,
tachypnea, tachycardia,
decreased urine output, clotting
disorder, and hepatic
abnormalities.

73. Nursing Diagnosis
Ineffectivebreathingpatternrelatedtorapid
respirationandprogressionofsepticshock
Riskforfluidvolumedeficitrelatedtofever,vomiting,andnothing
peroralandshiftofintravascularvolumetointerstitialspace.
Risk for decreased cardiac output related to decreased preload.
Ineffectivetissueperfusionrelatedtoprogressionofsepticshock
withdecreasedcardiacoutput,hypotensionandmassive
vasodilation.
Riskoffurtherinfectionrelatedtocatheterization

74. Imbalancenutritionlessthanbodyrequirement
relatedtovomiting,NPOandunwillingnesstointake.
Deficientknowledgerelatedtocognitivelimitation.
Risk for impaired skin integrity.

75. Planning & Goals: Healthcare team members should be prepared
with a care plan for the patient for a more systematic and detailed
achievement of the goals.
•Patient will display hemodynamic stability.
•Patient will verbalize understanding of the disease process.
•Patient will be free from infections.
•Patient’s will demonstrate to eating the food.

76. Implementation
Improve breathing pattern:
•Assess breathing pattern
•Administer oxygen @ 2lit/min with the face mask
•Keep patient in semi fowler’s position
•Monitor Vital signs frequently(every hourly)
•Administer prescribed medicines

77. Maintain fluid balance:
•Prevent IV fluid overload, which may worsen cerebral oedema.
•Monitor intake and output closely.
•Encourage for oral care.
•Maintain clean ward environment
•Serve food which patient likes
•Give frequent small food.
•To provide family member to feed the patient.
•Weight daily.

78. Promoting Cardiac output:
•Assess the condition
•Assess for the signs of shock
•Administer IV fluid and medications as prescribed
•Ensure that the correct fluids are administered at the prescribed
rate.
•Monitor intake and output
•Monitor vital signs frequently

79. Preventing Infection:
•Assess the condition of the patient
•Give perineal care as well as catheter care daily.
•Change catheter in every 15 days.
•Change the IV cannula every 72 hours.
•Watch for sign and symptoms of infection
•Maintain aseptic techniques.
•Minimize the visitors in ward.
•Monitor vital signs to rule out the signs and symptoms of shock.

80. Reducing fever:
•Keep patient without pillow and slightly elevate bed in head
side. (Comfortable position).
•Remove all extra cloths and blankets from the body.
•Maintain the cross ventilation by opening windows and
door and open fan.
•Apply the cold sponge for 30 min.
•Encourage to drink oral fluid.
•Administering antimicrobial agents on time to maintain
optimal blood levels.

81. Evaluation
•After implementation of the interventions, the nurse must evaluate
their effectiveness.
•Patient displayed hemodynamic stability.
•Patientverbalized understanding of the disease process.
•Breathing Pattern was improved
•Fluid balanced was maintained
•Cardiac output was promoted
•Further infection was prevented
•Temperature was reduced to normal.

82. Prognosis
•Overallmortalityinpatientswithsepticshockisdecreasingandnow
averages30to40%(range10to90%,dependingonpatient
characteristics).Pooroutcomesoftenfollowfailuretoinstituteearly
aggressivetherapy(e.g.,within6hofsuspecteddiagnosis).Once
severelacticacidosiswithdecompensatedmetabolicacidosisbecomes
established,especiallyinconjunctionwithmulti-organfailure,septic
shockislikelytobeirreversibleandfatal.

83. Complications
•severe sepsis. Sepsis could progress to severe sepsis with symptoms
of organ dysfunction, hypotension or hypoperfusion, lactic acidosis,
oliguria, altered level of consciousness, coagulation disorders, and
altered hepatic functions.
•Multiple organ dysfunction syndrome. This refers to the presence of
altered function of one or more organs in an acutely ill patient requiring
intervention and support of organs to achieve physiologic functioning
required for homeostasis.

84. •Acute respiratory distress syndrome
•Acute renal failure (ARF) occurs in 40-50% of patients
with septic shock. ARF complicates therapy and worsens
the overall outcome.
•Disseminated intravascular coagulation(40%)
•Chronic renal dysfunction,
•Mesenteric ischemia.

85. •Myocardial ischemia and dysfunction
•Liver failure
•Complications related to prolonged hypotension and
organ dysfunction
•Prolonged tissue hypo perfusion can lead to long-term
neurologic and cognitive squeal as well.

86. Prevention
•Strict infection control practices. To prevent the invasion of
microorganisms inside the body, infection must be put at bay
through effective aseptic techniques and interventions.
•Prevent central line infections. Hospitals must implement efficient
programs to prevent central line infections, which is the most
dangerous route that can be involved in sepsis.

87. •Early debriding of wounds. Wounds should be debrided early so
that necrotic tissue would be removed.
•Equipment cleanliness. Equipment used for the patient, especially
the ones involved in invasive procedures, must be properly cleaned
and maintained to avoid harboring harmful microorganisms that can
enter the body

88. Discharge planning
Diet
Rest and Sleep
Personal hygiene
Exercises
Medications
Safety and security
Bowel and bladder care
Follow up visits

90. References
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products/medical-equipment/airway-management/tips/422245-A-basic-
overview-of-shock/on dated 4th December 2017.
•Black, J. M. & Hawks, J. N. (2009). Medical-surgical nursing (8
th
ed.).New
Delhi: Elsevier India Pvt. Ltd.
•Chaurasia, B.D. (2004). Human Anatomy. (4
th
ed.). India: CBS publishers
and distributors.
•Kozier, B. Erb, G. Berman, A. Burke, K. (2005). Fundamentals of nursing
Concepts, Process, and Practice. (7
th
ed.). India: Pearson Education Pte.
Ltd.

91. •Nettina, S. M. (2010). Lippincott Manual of Nursing Practice.(9
th
ed.). New Delhi;
WoltersKluwer (India) Pvt. Ltd.
•Saxton F., Nugent M., PelikanK. (2006). Comprehensive Review of Nursing for
the NCLEX-RN Examination, (18
th
ed.), Mosby Elsevier, Inc.
•Sepsis and septic shock-critical care management retrieved from
http://www.msdmanuals.com/professional/critical-care-medicine/sepsis-and-
septic-shock/sepsis-and-septic-shockon dated 4th December 2017
•Septic shock, symptoms, causes and diagnosis retrieved from
https://www.healthline.com/health/septic-shock#risk-factorson dated 4th
December 2017.
•Shock, retrieved from http://interestingmedfacts.blogspot.com/2013/01/shock-
hypovolemic-cardiogenic-septic.htmlon dated 4th December 2017.
•Smeltzer, S. C. , Hinkle, J. L., Bare, B. G. & Cheever, K. H. (2009). Brunner
Suddarth’sTextbook of Medical Surgical Nursing,(11
th
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