A CASE STUDY ON SEPTIC SHOCK

SIBAYAN, NICOLEEN MAE D.

SMITH, KATE B.

TANACIO, AULYN B.

TAYAB, HANNAH LHYNE O.

TIANZA, ROSANA L.

TIO-TIO, ABELYN C.

TIWAKEN, KENDRA B.

TONGAB, JAZZYL KETH S.

WAGAWAG, KRISTA DEE D.

WALISEN, SHARALINA

BENGUET STATE UNIVERSITY

LA TRINIDAD, BENGUET

BACHELOR OF SCIENCE IN NURSING

NOVEMBER 2018

A CASE STUDY ON SEPTIC SHOCK |1

 ABSTRACT

Title: A CASE STUDY ON SEPTIC SHOCK

Authors: Nicoleen Mae D. Sibayan, Kate B. Smith, Aulyn B. Tanacio, Hannah Lhyne O. Tayab, Rosana L.
Tianza, Abelyn C. Tio-tio, Kendra B. Tiwaken, Jazzyl Keth S. Tongab, Krista Dee D. Wagawag, Sharalina C.
Walisen, BSN IV

Keywords: septic shock, infection, Non-Hodgkins Lymphoma, stump wound

Overview of the Case: The patient is a known case of Non-Hodgkins Lymphoma in June 2017. The patient
experienced body weakness, anorexia with intermittent pain at his right leg, but he ignored this signs and
didn’t seek for consultation. Until he had experienced severe pain and opted for medical consultation.
Apparently, upon physical examination and laboratory procedures X-ray revealed a new growth on his
right femoral bone. Amputation and chemotherapy was the remedial treatment offered for him. He
started chemotherapy and is now at his eighth cycle. Which prompted him to seek for consultation at
BGHMC on September 25, 2018. Some diagnostic procedures performed were pelvic x-ray, complete
blood count, urinalysis, and creatinine. The creatinine, BUA, BUN test were elevated. While the
hemoglobin and hematocrit were decreased in count. Neutrophils and Lymphocytes were also decreased
in count. Three nursing diagnoses formed were acute pain, hyperthermia, and ineffective tissue perfusion.

Abridged Drug Study: Treatment were given such as antibiotics such as amikacin and ampicillin to treat
serious infection, analgesics such as celecoxib and tramadol however they administered morphine for
breakthrough because in the case of phantom the pain he felt cannot be ease by tramadol and celecoxib
therefore morphine is already needed. Laboratory test such as culture and sensitivity and gram stain was
done before administering antibiotics.

Course in the Ward: September 25, 2018: Patient is a known case of Septic shock secondary to infected
stump wound, accompanied by his mother. The patient was supposed to have his 8th cycle of chemotherapy but
because of his infected stump wound he was then admitted. After admission patient claims to experienced increase in body
temperature, tachycardia, tachypnea and unstable blood pressure. Patient was showed some signs and symptoms
of weakness, cold and clammy extremities. An oxygen via face mask at 2-3LPM was administered and
maintained at high-fowler’s position.

Conclusions: Sepsis is a potential life-threatening due to untreated infection. This can cause multiple
organ dysfunctional and death. Immunosuppression can be caused by the underlying condition such as
diabetes, renal failure, and cancer, or because of previous health care intervention like chemotherapy. In
the case of Phantom the treatment of choice for his cancer is chemotherapy. However, this treatment
increases the chances of infection because of the untreated infection it continues to suppressed the
immune system of the client therefore he had septic shock.

Recommendations: The client should have awareness regarding sepsis and its cause. We suggest that the
client should be more responsible on his health like having well balanced nutrition such as high protein,
high potassium food, and high fiber and having adequate fluid intake. We suggest that proper hygiene
should be regularly done like hand washing, bathing and changing clothes regularly. Adherence to
medication and treatments is a must to prevent the reoccurrence of sepsis. A well balanced activities and
exercises must be prioritized like stretching, and walking. We recommend to always consult the health

A CASE STUDY ON SEPTIC SHOCK |2

care provider if there are symptoms such as high grade fever, low blood pressure, fast heart rate, rapid
breathing, dizziness, and pain, or symptoms that affect their activities of daily living.

A CASE STUDY ON SEPTIC SHOCK |3

 TABLE OF CONTENTS

Title Page……………………………………………………………………………………………………………………………….………..….1

Abstract…………………………………………………………………………………………………………………………………………..…..2

Table of Contents………………………………………………………………………………………………………………………..….……4

Acknowledgements……………………………………………………………………………………………………….……………….…….5

General Profile…………………………………………………………………………………………………………………….………….…….6

Chief Complaint………………………………………………………………………………………………….……………………………..….6

Principal Diagnosis………………………………………………………………………………………………………………….…….……….6

History of Present Illness…………………………………………………………………………………………….……………….…..…….6

Past Medical History………………………………………………………………………………………….……………………….……...….7

Social and Environmental History…………………………………...………………………………………………………..……..…....7

Family History………………………………………………………………………………………………………………………..……………….7

Physical Examination…….……………………………………………………………………………………………………..…….………9-16

Review of Systems..………………………………………………………………………………….………………………………........17-20

Gordon’s Typology Of 11 Functional Health Patterns………………………………….……………………………………21-22

Diagnostic and Laboratory Procedure…………………………………………………………………………………..………….23-31

Case Study………………………….…….……………………………………………………………………..…………………….……..……...32

Pathophysiology…………………………………...…………………………………………………………………………….…………….....33

Treatment………………………………………………………………………………………………………………………………….......34-41

Discharge Plan………………………………………………………………………………………………………….…….…………………….42

Conclusions and Recommendations………………………………………………………………………………………...……...43-44

Nursing Care Plan…………………………………………………………………………………………..……...…………………….....45-50

References………………………………………………...………………………………………………………………….………………..51-52

A C A S E S T U D Y O N S E P T I C S H O C K | 44
 ACKNOWLEDGEMENTS

We, the Group U Level IV nurse learners, would like to express our gratitude to all the people who,
read and offered comments and remarks in editing this case study especially sir Vicente Panagan Jr.

This case study wouldn’t be possible without the aid of the following:

To Ma’am Mary Rose B. Catapang who guided us during our clinical duty and selecting a patient
for our case study.

To our parents and guardians who have always been supportive all throughout the start of the
duty until the end.

Lastly, to God, for giving us the strength and wisdom in realizing and fulfilling our duties in the
clinical area.

A CASE STUDY ON SEPTIC SHOCK |5

 GENERAL PROFILE

A. Personal Profile:

Name: Phantom

Age: 24 years old

Sex: Male

Marital Status: Single

Occupation: Construction Worker (welder and painter)

Address: Pangasinan

Educational Attainment: Vocational Graduate of TESDA (welding NC II)

Nationality: Filipino

Religious Affiliation: Roman Catholic

Date of Birth: October 31, 1993

Place of Birth: Pangasinan

A. Chief Complaint
Patient Phantom, a 24-year-old male, was accompanied by her mother for his medical
check-up due to his painful stump with pus discharges and to comply for his eighth cycle
chemotherapy at the hospital on September 25, 2018.

B. Admitting Diagnosis

Septic shock secondary to infected stump wound, NHL, S/P cycle 7 chemotherapy
(RCHOP) S/P hip dislocation (2017) T/C new growth.

A CASE STUDY ON SEPTIC SHOCK |6

C. History of Present Illness
Two years prior to admission, the patient experienced body weakness, anorexia with
intermittent pain at his right leg, but he ignored these signs and did not seek for consultation.
Until he experienced of severe pain, he decided to seek medical consultation at Baguio General
Hospital. Apparently, upon physical examination and laboratory procedures X-ray revealed a new
growth on his right femoral bone. Therefore, this leads him to be diagnosed with Non-Hodgkin’s
Lymphoma. Amputation and chemotherapy was the remedial treatment offered for him. He was
amputated last June 2017 and routinely visits the hospital for chemotherapy. He is now at his
eighth cycle chemotherapy.

D. Past Medical History

Last 2011, he was admitted at a hospital at Pangasinan due to cough and colds. He was
treated accordingly and was given antibiotics. He claims that this is his first hospitalization since
he was a child. He was diagnosed with Non-Hodgkins Lymphoma and was amputated last June
2017 and routinely visits the hospital for chemotherapy. For his chemotherapy sessions
laboratory results revealed immunosuppression and still continue to for eighth cycle of
chemotherapy.

E. Social and Environmental History

Patient Phantom is a vocational graduate of a TESDA course primarily welding NC II at
Pangasinan. Their house is located at Pangasinan and claims that he lives with his family. To
augment his family’s salary, he is a construction worker and worked as a welder and painter in a
ship company at their residency. While working he stayed with his co-workers in a make shift area.
He describes his work place with stagnant water with a hot uncomfortable environment.
He admits that he occasionally drinks liquor and used to be a smoker and can consume 4 packs of
cigarette in a week in the past.

A CASE STUDY ON SEPTIC SHOCK |7

 F. Family History GENOGRAM

8 Stroke 69 68 73
85 Heart failure 3 78
70

Hypertension 42
46

28 24 20

Legend:

Male
Deceased Or

Female

Patient

Patient Phantom is the second of the three siblings and according to him, there were no
cases of cancer in their family except for him. He is not aware of any food and medicine allergies.
He mentioned that his father was diagnosed with hypertension and his grandfather died of a heart
failure. One of his grandmother also died because of stroke.

A CASE STUDY ON SEPTIC SHOCK |8

 PHYSICAL EXAMINATION

ASSESSMENT OF HEAD, FACE, NECK, EYES

HEAD

Shape: Round Size: 56 cm

Lesions: None Type: None Location: None

HAIR:

Distribution: Loosely distributed Color: Black Quantity: Hair is growing and thin

Infestations: None

SCALP:

Lesions: None Type: None Location: None

FACE:

Shape: Round Type: None Location: None

EYES:

Symmetry: Symmetrical Alignment: Aligned

SCLERA: Pale

CONJUNCTIVA: Palpebral: Pale Bulbar: White

PUPILS:

Shape: Round Symmetry: Symmetrical

Pupil reaction to light Pupil has equal reaction to light

Pupil reaction to accommodation Pupil has equal reaction to accommodation

IRIS: Color: Dark brown Symmetry: Symmetrical

VISUAL ACUITY:

Pain: None Tenderness: None Location: None

A CASE STUDY ON SEPTIC SHOCK |9

 Extra ocular movement: Normal

Peripheral Vision: Normal

EYEBROWS:

Symmetry: Symmetrical Distribution: Well- distributed

Lesions: None Type: None

EYELASHES:

Symmetry: Symmetrical Distribution: Well- distributed

EYELIDS:

Color: Brown

Inflammation or presence of edema: None

Adequacy with which the eyelids close: Normal

EARS:

Auricle: Ornamental style Symmetry: Symmetrical Position: Aligned to the Tip of

the Eyebrows

Color: Brown Size: Normal

Lesions: None Tenderness: None

Ear canal patency: Patent

Tympanic Membrane: Visible Contour: Normal Color: Pearly grey

Discharges: None Pain: None

Swelling: None Hearing Problems: None

Rinne test: Normal: Air conduction is better than bone conduction

Webber test: Normal: Heard equal on both ears

Whisper test: Normal: Able to hear on both eras

A C A S E S T U D Y O N S E P T I C S H O C K | 10
NOSE:

Symmetry: Symmetrical Position: Midline Color: Brown

Lesions: None Nasal discharge: None

Patency: Patent Tenderness: None

Nasal cavities: Normal Color: Pinkish Moisture: Moist

Discharge: None

Mass: None Polyps: None

Lesions:None

Nasal septum: Patent Position: Midline Integrity: Normal

MOUTH:

Color: Pale Moisture: Dry Integrity: Normal

Swelling: None Lesions: None Tenderness: None

ORAL CAVITY:

Gums Color: Reddish Hydration: Dry Integrity: Normal

Buccal mucosa Color: Bright pink Hydration: Dry Integrity: Normal

Hard palate Color: Bright pink Hydration: Dry Integrity: Normal

Soft palate Color: Bright red Hydration: Dry Integrity: Normal

Tonsils: Color: Reddish Grade: 2

Uvula: Reddish

Teeth: Natural: Yes Artificial: No Color: White

Orthodontic appliance: None

Position or alignment: Up and Down

Decay: None

Tongue: Symmetry: Position: Rested behind the front teeth

Symmetrical

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NECK:

Color: Brown Symmetry: Symmetrical

Lesions: None Type: None

Lymph nodes: Not palpable Location: N/A

ROM: Able to fully extend and flex Pain/tenderness: None

JVD: none

Trachea: Visible

Thyroid gland Position: Lies between the Consistency: No tenderness

Adam’s apple and along the
windpipe. Grade: NA

ASSESMENT OF THORAX AND LUNGS

Shape of thorax: Side to side symmetric chest shape

Presence of superficial veins: None

Chest wall: Normal chest wall expansion

Respiratory Rate: 20cpm Pattern: Regular with equal Depth: Eupnea

pause between each breath

Symmetry Symmetrical

Audibility of breathing: Audible normal breath sounds

Mode of breathing: Normal

Abnormalities: None

Breath sounds: Normal: Clear lung fields

Pain/tenderness: None

Lesions: None

Position in respiration: Normal

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Lung expansion: Normal

Tactile expansion: Normal

Tactile fremitus: None

Diaphragmatic excursion: 1-2 centimeters

Spine: No abnormalities noted

ASSESSMENT OF THE CARDIOVASCULAR SYSTEM:

Color of nail bed: Pale Capillary refill: 4-5 seconds

Precordial movement: Normal PMI: Heard on the 5th midline intercostal space
on the midclavicular line

Radial pulse: 115 bpm Apical pulse: 89 bpm

Aortic: 2nd intercostal space just right of the Erb’s: Heard on the 3rd intercostal space left
sternum sternal border

Pulmonic: 2nd intercostal space just left of the

sternum

Tricuspid: 4th intercostal space left lower sternal Mitral: 5th intercostal space left mid clavicular
border line

S1: Heard over the apex using the JVD measurement: None
stethoscope’s diaphragm at the beginning of
systolic

S2: Heard during expiration and disappears

during inspiration

ASSESSMENT OF THE ABDOMEN:

INSPECTION: Skin color: Brown

Abdominal symmetry: Symmetrical

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 Lesions/scars: None

Vascularity: none

Abdominal contour: Round

Umbilicus: Midline

AUSCULTATION Bowel sounds: 12

Vascular sounds: Normal

Friction rub: None

Others: None

RLQ sound: Borborygmus sound noted

LLQ sound: Borborygmus sound noted

RUQ sound: Borborygmus sound noted

LUQ sound: Borborygmus sound noted

Liver span MCL: N/A MSL: None

PALPATION: RLQ: No tenderness noted

LLQ: No tenderness noted

RUQ: No tenderness noted

LUQ: No tenderness noted

Others: None

Special procedures: Rebound tenderness: Negative

Rovsing’s sign: Negative

Psoas sign: Negative

Obturator sign: Negative

Murphy’s sign: Negative

Hypersensitivity: None

Abdominal reflex: Normal

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 Others: None

ASSESSMENT OF UPPER EXTREMITIES:

Hands and Appearance: Normal Color: Brown

fingers
Shape: Symmetrical Others: None

Nails: Color: Pale Shape: Round Texture: Firm

Capillary refill: 3-4 Others: None

seconds

Muscles Muscle tone: 0 (Modified Ashworth Muscle strengths: Muscle grade of 5/5
Scale)

Reflexes: +2 Shoulders: +1

ROM: Able to flex

Joints

Posterior tibial: +1

Dorsalispedis: +1

Peripheral pulses: +2

Homan’s sign: Negative

Inflammation: None

Babinski reflex: Negative

Sensation:

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 Light sensation: Normal

Pain sensation: Normal

Vibration: Normal

Position sensation: Normal

Temperature sensation: Normal

ASSESSMENT OF
LOWER
EXTREMITY:

Left Leg and feet Appearance: Normal Skin Temperature: Cold clammy skin

Skin Moisture: Dry Varicosities: None

Right stump amputee

Appearance: With white pus discharges

Color: Dark brown Skin Moisture: Moist

Nails:
Color: Pale Shape: Round Texture: Firm

Capillary refill: 3-4 Others: None

seconds

Muscles Muscle tone: 0 Modified Ashworth Muscle strengths: Muscle grade of 5/5
Scale)

Reflexes: +2

Joints Left ROM: Able to flex ( but not fully flexed)

Posterior tibial: +1

Dorsalispedis: +1

Homan’s sign: Negative

Inflammation: None

Babinski reflex: Negative

Sensation:

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 Light sensation: Normal

Pain sensation: Normal

Vibration: Normal

Position sensation: Normal

Temperature sensation: Normal

REVIEW OF SYSTEMS

SKIN, HAIR AND NAILS Rashes: None

Infestations: None

Deformities, injuries: None

HEENT Head Headaches: None Dizziness: None

Neck Stiffness: None Difficulty with Swallowing: None

Enlarged lymph nodes: Present

Ears Pain: None Tinnitus: None Drainage: None

Difficulty hearing: None

Type of Hearing Aid: None

Date new batteries needed: None

Eyes Pain: None Redness: None Tearing: None

Blurring: None Date of last exam: None

Glasses: None Contact lenses: None

Black spots: None Halos: None Flashes: None

Surgeries: None

Throat, Sore throat: None Hoarseness: None

mouth, nose,
and sinuses Mouth pain: None Lesions: None

Speech difficulties: None Swallowing Difficulties: None

Last dental exam: 2015 Dentures: None

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 Fixtures: None

Allergic rhinitis: None Type of allergen: None

Relief measures: None

Frequency of cold per year: 3

Nose bleeds: None

Sinus problems: None

THORAX AND LUNGS Pain: None DOB: None SOB: None

Orthopnea: None DOE: None PND: None

Cough: None Sputum: None

Hemoptysis: None Last chest X-ray: None

Activity intolerance: None

BREASTS AND REGIONAL Pain: None Lumps: None Dimpling: None

LYMPHATICS
Change in size: None Discharges: None

Swollen lymph nodes in the axilla: None

HEART AND NECK VESSELS Chest pain: None Palpitations: None

Edema: None

Last BP: 100/60 mmHg Last ECG: July 2017

JVD: None

PERIPHERAL VASCULAR Leg or feet pain: Both Swelling of legs or feet: None

Sores: None Numbness: None

Change in color: None Tingling: None

Changes in hair distribution on extremities: None

ABDOMEN Pain: None Indigestion: None N/V: None

Difficulty swallowing: None Gas: None

Appetite: None

Jaundice: None Hernias: None

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GENITALIA Dysuria: None Frequency: None

Hematuria: None Urgency: None

Pyuria: None Hesitancy: None

Nocturia: None Incontinence: None

Anuria; None Dribbling: None

Penile lesions: None Penile pain: None

Scrotal swelling: None Difficulty with erection: None

Difficulty with ejaculation: None

Exposure to STIs: None

Pelvic pain: Present Sexual Pain: unassessed

Age of menarche: N/A Age of menopause: N/A

LMP: N/A GTPAL: N/A

HRT: N/A Birth control methods: N/A

Last PAP smear: N/A Vaginal discharge: N/A

ANUS, RECTUM AND Pain with defecation: None

PROSTATE
Diarrhea: None Constipation: None Hemorrhoids: None

Melena: None Hematochezia: None

Use of laxatives: None Colostomy: None

Ileostomy: None

Prostate problems: None

Last DRE: NA

MUSCULOSKELETAL Pain: Present Redness: Present Swelling: Present

Stiffness: None Strength: Upper Extremity- Left: 5/5 Right: 5/5

Lower Extremity- Left: 5/5 Right: 0/5

Difficulty with ambulating: Present

Ambulation Aids-Present Cane: NA

Crutches: Present

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 Walker: NA

Wheelchair: NA

NEUROLOGICAL Alert: Yes Confused: No Disoriented: No

Mood: Good Behavior: Good Depression: None

Anger: No Headaches: None Concussions: none

Loss of sensation: None

Contusions: none

Loss of strength: None

Difficulty with speech: None

Difficulty with recall or memory: None

Difficulty with learning or reading: None

Strange thoughts: None

Strange voices: None

Strange visions: None

LIFESTYLE AND HEALTH PATTERNS

HABITS Alcohol: Yes Smoking: Yes Drugs: No

Duration of each: Alcohol: Occasionally

Smoking: Everyday, 4 packs in a week : Gradually stopped

NUTRITION 24H diet: Three times a day with snacks in between

EXERCISE Jogging: None Walking: None Gym: None Others: Range of motion
HABITS exercises

SLEEP AND Times asleep: 9PM Time awake: 5AM Sleep problems: None
REST

WORK Nature of work: None Satisfaction: None Stressors: None

PATTERNS

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 GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS
HEALTH PERCEPTION AND HEALTH
MANAGEMENT
NUTRITION AND METABOLISM
ELIMINATION
Prior to admission he admits that he occasionally drinks
liquor and used to be a smoker and can consume 4 packs of
cigarette in a week. He believes that he will soon to be treat
after series of treatment and all he need is patience.
During hospitalization for him health is very important so he
seeks medical consultation if he experiences severe pain and
complies for his scheduled check-up. In compliant to medicine
he takes his medicine on time.
Patient was aware that he would be healed if he will comply
for his medicine and also he gradually stopped his vices
because of his current condition.
Prior to admission he is obese and in favoured in eating junk
foods and soft drinks. He eats nutritious and protein rich
foods. He eats without any problem and claims to have a good
metabolism. He eats his meal three times a day with snack and
between and drinks 5-6 glasses of water per day.
During hospitalization he drinks coffee in the morning and in
the afternoon. He claimed that sometimes he loses his
appetite and skip of his meals.
Patient had change on his appetite by skipping his meals
resulting to least nourished diet.
Prior to admission He urinates 4 times a day presenting
yellowish in color and defecates every day with a consistency
of sausage-like day but lumpy stools.
During hospitalization he defecates every other day or was
being constipated. He also experiences diarrhea.
A C A S E S T U D Y O N S E P T I C S H O C K | 21
 Patient had changes in bowel movement where he experience
alternating constipation and diarrhea.

ACTIVITY AND EXERCISE Prior to admission His leisure activity is watching television
and listening to music. One of his hobbies was jogging every
morning.

During hospitalization he cannot do extraneous exercise like

jogging because of current condition. He does simple exercises
on the upper and lower extremities by means of shaking and
stretching such as flexion and hyper extension, adduction,
abduction on hands and fingers.

Patient had decreased optimal conditioning where he cannot

do extraneous activities because of his current condition.

COGNITION AND PERCEPTION No sensory deficits and functions accordingly to his age. He has
normal thought process and oriented to people, time and
place. He responds to stimuli verbally and physically. Severe
pain felt on his right stump amputee and claimed it to be
intermittent.

SLEEP AND REST He sleeps 9 in the evening, and wakes up at 5 in the morning.
He claimed that he is well relaxed and rested after sleep. No
difficulties in going sleep and have straight hours of sleep. He
sometimes takes a nap at noon for about 1-3 hours.

SELF-PERCEPTION AND SELF- He manages to practice healthy lifestyle and hopeful to be

CONCEPT relieved and be treated. He always uses his blanket to cover
his amputated leg and claims to clean it seldom. He regularly
changes his clothes. He also claimed that he is okay with his
clothes and appearance.

ROLES AND RELATIONSHIPS He lives with his family and mostly close to her sister and
mother. In the past he works industriously to support his
family needs but cannot do it nowadays due to his condition.
Sometimes he wants to go home and do things to help his self
and family. He is well supported and loved by her family. He

A C A S E S T U D Y O N S E P T I C S H O C K | 22

SEXUALITY AND REPRODUCTION
COPING AND STRESS TOLERANCE
VALUES AND BELIEFS
considers his family as his life and his motivation to live. Also
claims that he values efforts coming from them.
He does not have a difficulty in sexual functioning. He claims
to be satisfied in his sexual relationship with his girlfriend.
He copes up with stress by eating and taking a nap or sleep. He
copes up with problem by talking it with the family and find
ways to resolve it together. No traumatic events experience
before. He is able to accept situation by cooperating with the
medical advice and procedures.
He is Roman Catholic and has a strong faith with God. He
always prays at night and in the morning. He goes to church
with her mother and siblings to attend the mass every Sunday.
A C A S E S T U D Y O N S E P T I C S H O C K | 23
 DIAGNOSTIC AND LABORATORY PROCEDURES

This section of the study focuses on the diagnostic and laboratory tests ordered by the
physician, vital to the process of understanding the condition of the patient.

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 25, 2018 Complete Blood Count Hemoglobin: 77 g/L Hemoglobin (140-180
helps in detecting any g/L)
abnormal increase or
decrease in blood
Complete Blood Count Hematocrit: 0.24 L/L Hematocrit (0.40-0.54
count. It is also a test
used to screen for L/L)
certain diseases and
disorders that could WBC Count : 8.04 WBC Count (5.0-10.0)
negatively impact
health. Neutrophils (50-70%)
Neutrophils : 76 %
Complete Blood Count
Lymphocytes (20-40%)
(CBC) is a blood test
used to evaluate for Lymphocytes: 2% Monocytes (0-10%)
presence of blood-
related disorders such Monocytes: 9% RBC Count (4.69--6.13 x
as anemia, infection 1012/L)
and leukemia. RBC Count: 2.62
Platelet Count (150-
400 x 109/L)
Platelet Count:195
Table 1.1 Complete Blood Count

Decreased number of Red Blood Cells results to low level of hemoglobin and hematocrit. Thus,
the result implicates that there is decrease ability of the blood in transporting oxygen leading the body to
works much harder to supply tissues which leads the patient to experience fatigue and shortness of
breath. (Forth 2007)
Result of the test shows that Neutrophils are high while Lymphocytes are low. It may indicate
bacterial infection of the patient and presents weakened immune system.
In this patient's case abnormal result is probably affected by his Chemotherapy drugs. Thus,
chemotherapy drugs damages bone marrow where blood cells are made. Hence complete blood count

A C A S E S T U D Y O N S E P T I C S H O C K | 24
was ordered to check blood levels of patient prior to chemotherapy informing the physicians to delay first
the chemotherapy until blood levels returns to normal value and infection is cleared. (National Cancer
Institute,2011) Hence, Blood transfusion was ordered.

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 25, 2018 Prothrombin time is Prothrombin Time: Prothrombin Time: (11-
measured for 15.50 seconds 16 seconds)
determining the cause
Prothrombin Time(PT) of bruising or abnormal
bleeding and to check
blood thinning
medicines will work. It
Activated Partial
is also used to check
Thromboplastin Time
for the factors that
(APTT)
lead to a blood clot,
check levels for low
levels of vitamin K,and
check liver functions.

Partial thromboplastin
time is a measure for
determining the cause Activated Partial Activated Partial
of abnormal bleeding Thromboplastin Time: Thromboplastin Time
and check for factors 24.40 seconds (25-38 seconds)
leading to blood clots
that cause clotting
problems.

Table 1.2 Prothrombin Time/ Partial Thromboplastin

Prothrombin (PT)and Partial Thromboplastin Time (PTT) are both tests used to measure the time
taken for the blood clot. In the result the PT is within normal limit while the APPT is slightly shortened.
Shortened low Activated Partial Thromboplastin time may predict the risk of catheter-associated venous
thrombosis in cancer patient. According to Thromb 2014 increased risk of venous thromboembolism
resulting from host inflammatory response to cancer.

A C A S E S T U D Y O N S E P T I C S H O C K | 25
 However, the wide range of possible causes for abnormal results means that this test alone is not
enough to determine what condition the patient have. An abnormal result will probably prompt the
doctor to order more test. (Michael A. Laffan, 2017)

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 25, 2018 Routine chemistry is Creatinine:215.86 Creatinine:58.00-

the bio chemical 132.00 umol/L
Routine Chemistry analysis of body fluids.
It is done to detect and Sodium:135.0-148.0
Sodium:136 umol/L
quantify different
compounds in blood Potassium:5.2 Potassium:3.5-5.3
and urine. umol/L

Chloride:99.3 Chloride:98.0-107.0
umol/L

Blood Urea
Blood Urea Nitrogen:2.8-7.2
Nitrogen:19.91 umol/L

Blood Uric Acid:815 Blood Uric Acid:208.3-

428.4 umol/L

Table 1.3 Routine Chemistry

The Creatinine, Blood Uric Acid, and Blood Urea Nitrogen is elevated. High creatinine levels may
indicate that kidney function is interrupted or impaired. Since the patient has sepsis, organ failure is its
hallmark. As the body is overwhelmed, its organs begin to shut down, causing even more problems. The
kidneys are often among the first to be affected. According to National Kidney Foundation, one of the
major causes of acute kidney failure is sepsis and some studies have found that between 32 % and 48%
of acute kidney injury cases were caused by sepsis.

High Blood Uric Acid may also indicate impaired kidney function and infections. While High Blood
Urea Nitrogen occurs when there is reduced renal blood flow which indicates that kidneys are not filtering
waste properly (Deciphering Diagnostic Tests, 2008).Therefore it implies that high Creatinine, Blood Uric
Acid, and Blood Urea is probably related to impaired renal function which happens because of the septic

A C A S E S T U D Y O N S E P T I C S H O C K | 26
shock. When septic shock occurs the systemic vasodilation increases the renal sympathetic activity and
angiotensin concentration thus resulting to vasoconstriction with sodium and water retention as well as
glomerular filtration rate (W, 2004). And when this happens it affects the renal function of the patient
suffering from septic shock.

PROCEDURE DESCRIPTION RESULT

September 26,2018 Gram staining is a common Pus Cell: Positive one

technique used to
differentiate two large
Gramstain groups of bacteria based on Smear shows: Many Gram Negative Bacili in
their different cell wall singles and in pairs
constituents.

To detect the presence and

identify the general type
of bacteria or
sometimes fungi (microbes)
in a sample taken from the
site of a suspected
infection; to generally
classify bacteria grown
in culture so that further
identification tests can be
performed and appropriate
treatment given.

Table 1.4 Gramstain

The test is done to detect the presence and identify the general type of bacteria in a sample pus
taken from the infected stump. This is to classify bacteria growth in culture so that further identification
tests can be performed and appropriate treatment would be given.

A C A S E S T U D Y O N S E P T I C S H O C K | 27
 PROCEDURE DESCRIPTION RESULT

September26,2018 The anatomic and appearance There is a defined soft tissue

of the pelvis that focuses
X-Ray specifically on the area
Pelvic AP between hips that hold many of
the reproductive and digestive
organ. Pelvis is made up of
three bones, the ilium, ischium,
and pubis, and also forms the
hip joint.
mass density measuring 21 x 10
cm is seen super imposed along
the right pelvic region bony
erosive changes in the right
acetabular region and ischium.
The right femoral head is not
well delineated.

Table 1.5 X-Ray Pelvic AP

Pelvic Xray is done to note the cause of symptoms such as pain, limp, tenderness and swelling of the
amputated and any changes from the stump. Also,it detects the later stage infection in the pelvic bones.

A C A S E S T U D Y O N S E P T I C S H O C K | 28
 PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 29, 2018 Complete Blood Count Hemoglobin: 109 g/L Hemoglobin:140-180
helps in detecting any g/L
abnormal increase or
decrease in blood
Complete Blood Count count. It’s also a test
used to screen for
certain diseases and
disorders that could Hematocrit:0.40-0.54
negatively impact Hematocrit: 0.34 L/L L/L
health.

Complete Blood Count

(CBC) is a blood test
used to evaluate for WBC Count:7.87
presence of blood- WBC Count:5.0-10.0
related disorders such
as anemia, infection
and leukemia.

Neutrophils: 43 % Neutrophils: 50-70%

Lymphocytes: 19%
Lymphocytes:20-40%
Monocytes: 9% Monocytes:0-10%

RBC Count: 3.83 RBC Count:4.69--6.13 x

1012/L

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 Platelet Count: 241

Platelet Count:150-400
x 109/L

Table 1.6 Complete Blood Count

Patient was given blood transfusion therefore repeat CBC was checked 6 hours after first blood.
From the previous result there is an elevation of low RBC, Hematocrit, Hemoglobin, leukocytes and
decreased neutrophils. Thus, it indicates that blood still has decrease ability in transporting oxygen to the
body as previously discussed.

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 29,2018 Anti-HBs is a key mIu/mL <10.00 :

serological marker for Nonreactive
Serology: Anti-Hepatitis
both vaccine-induced
B Surface antibody ( immunity and 0.00 : Non reactive
Anti HBs) immunity due to >10.00:
infection. Reactive

Table 1.7 Serology: Anti Hepatitis B Surface antibody

Nonreactive Anti HBs indicates that no hepatitis B surface antigen is found in the body.
(Hamborsky, Kroger, Wolfe 2015). This test was done to rule out Hepatitis B which occurs to more than
5% of patients with certain diseases other than Hepatitis B such as Non Hodgkin's Disease, Hemophilia,
and Leukemia (Deciphering Diagnostic Tests, 2008)

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

September 29,2018 A blood test that looks

for hepatitis C
Serology: Hepatitis C antibodies in the Non reactive: 0.02 S/CO <1.00
antibody (Anti-HCV) bloodstream. Nonreactive

>1.00 Reactive

Table 1.7 Serology: Hepatitis C antibody (Anti-HCV

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Nonreactive Anti HCV indicates that no hepatitis C antibody is found in the body. (Hamborsky, Kroger,
Wolfe 2015). Septic shock is associated with Hepatitis C, most especially to male patients aging from 50-
59 years old.

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

October 3, 2018 Complete Blood Count Hemoglobin:109 g/L Hemoglobin:140-180

helps in detecting any g/L
abnormal increase or
decrease in blood
Complete Blood Count Hematocrit:0.33 L/L Hematocrit:0.40-0.54
count. It also a test
used to screen for L/L
certain diseases and
disorders that could WBC Count:5.58 WBC Count:5.0-10.0
negatively impact
health.
Neutrophils:57 % Neutrophils:50-70%
Complete Blood Count
(CBC) is a blood test
used to evaluate for
presence of blood- Lymphocytes:16% Lymphocytes:20-40%
related disorders such
as anemia, infection Monocytes:0-10%
and leukemia. Monocytes:8%
RBC Count:4.69--6.13 x
RBC Count :3.74 1012/L

Platelet Count:150-400
Platelet Count:303 x 109/L

Table 1.8 Complete Blood Count

Patient was given blood transfusion therefore repeat CBC was checked 6 hours after first blood.
From the previous result there is an elevation of low RBC, Hematocrit, Hemoglobin, leukocytes and
decreased neutrophils. Thus, it indicates that blood still has decrease ability in transporting oxygen to the
body as previously discussed.

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 PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

October 4,2018 Routine chemistry is Sodium:140.9 Sodium:135.0-148.0

the bio chemical umol/L
Routine Chemistry analysis of body fluids.
It is done to detect and Potassium:3.5-5.3
Potassium:3.48 umol/L
quantify different
compounds in blood
and urine
Blood Urea Blood Urea
hypernatremia
Nitrogen:10.03 Nitrogen:2.8-7.2
umol/L

Creatinine:111.17 Creatinine:58.00-
132.00 umol/L

Table 1.9 Routine Chemistry

Septic shock has higher risk for lethal hypokalemia. Hence potassium is being checked. The
Potassium is slightly low while Blood Urea Nitrogen is elevated. Low potassium levels indicate that his
kidney is not functioning well.

High Blood Urea Nitrogen occurs when there is reduced renal blood flow which happens when
there is dehydration (Deciphering Diagnostic Tests, 2008). It indicates kidney function being impaired
because of the infection.

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 PROCEDURE DESCRIPTION RESULT

October 4,2018 Urinalysis is a set of screening Physical Examination:

test that can detect some
Urinalysis common diseases. It may be Light Yellow, Slightly Turbid
used or help diagnose condition
such as a urinary tract infection, Chemical Examination
kidney disorders, liver problems,
diabetes or other metabolic Specific gravity:1.010
conditions
pH: 6.0

Leukocyte Esterase: Negative

Nitrates: Negative

Protein: Negative

Microscopic Examination

Pus cells: 2-4/hpf

Red Blood Cells: None

Yeast Cells: None

Bacteria: Rare

Epithelial Cells: None

Mucus threads: Few

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 Amorphous Materials: Occasional

Table 1.11 Urinalysis

Urinalysis shows low pH which may indicate a high protein diet – produces turbidity, and
formation of oxalate, cysteine, leusine, tyrosine, amorphous urate, and uric acid crystal. Turbid indicates
that urine may contain red or white blood cells, bacteria, fat or chyle, and may reflect renal infection.
Fixed specific gravity, in which values remain 1.010 regardless of fluid intake, occurs in chronic
glomerulonephritis with severe renal damage. Bacteria, yeast cells and parasites in urinary sediment
reflect genitourinary tract infection or contamination of external genitalia.

PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

October 5, 2018

Serology:

Hepatitis B surface HBsAg is normally Non reactive: 0.02 S/CO

Antigen (HBsAg) produces as a part of
normal immune < 1.00: Nonreactive
response to infection. >1.00: Reactive

Reactive: 431.02 S/CO

< 1.00: Nonreactive

>1.00: Reactive

Table 1.12 Serology

A reactive HBsAg may indicate that there is immunity from hepatitis B virus infection.
(Hamborsky, Kroger, Wolfe 2015). This test was done to rule out Hepatitis B which occurs to more than
5% of patients with certain diseases other than Hepatitis B such as Non Hodgkin's Disease, Hemophilia,
and Leukemia, wherein it was done to check for presence of immunity from Hepatitis B that could
increase risk of liver failure. (Deciphering Diagnostic Tests, 2008)

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 PROCEDURE DESCRIPTION RESULT REFERENCE RANGE

October 7,2018 The levels of creatinine Creatinine:124.53 Creatinine: 64-

in the blood are 104umol/L
Routine Chemistry measured to check for
Creatinine kidney function.

Table 1.8 Routine Chemistry

The Creatinine is elevated. Creatine is excreted by the kidney and elevated creatinine is due to
poor clearance by the kidneys. Therefore it indicates renal impairment.(Deciphering Diagnostic Tests,
2008). Sepsis is the systemic inflammatory response to infection, and one of the most common
contributing renal impairment of critical illness. Previous studies of septic shock noted that 60% patient
with septic shock developed renal impairment and found higher mortality and longer duration of hospital
stay.

A C A S E S T U D Y O N S E P T I C S H O C K | 35
 CASE STUDY

Comprehensive Pathophysiology

RISK FACTORS:

SMOKING ALCOHOL Age Exposure to

chemical: Paint

DNA
Changes

Formation of tumour on Diagnosis of Non-Hodgkin

Lymphoma: Lymphoma
Enlargement of lymph nodes
particularly femoral lymph nodes
Failed to observe
Amputation of right leg wound condition and
(2017) seldom cleans the
wound

CHEMOTHERAPY
Infection of stump
wound

Immunosuppression Perforation of Infection

Failure of natural defense of

mechanism; Toxins are released
into blood stream
Vasodilation, edema, leukocytosis

Signs and Symptoms:

A C A S E S T U D Y O N S E P T I C S H O C K | 36
Shortness Of breath, Fever, Tachycardia,
Sweaty and clammy skin
 SEPTIC SHOCK

Medical Diagnosis

Septic shock secondary to infected stump wound, NHL, S/P cycle 7 chemotherapy (RCHOP) S/P
hip dislocation (2017) T/C new growth

Septic Shock

Septic shock is a medical condition as a result of severe infection and sepsis, though the microbe
might be systematic or localized to a particular site. This can cause multiple organ dysfunction syndrome
and death. The most common cases are seen with children, elderly, and immunosuppressed clients just
as patient Phantom.

Signs and symptoms

Signs and symptoms vary from one client to another and the following were manifested by patient
Phantom:

 Shortness of breath
 Fever
 Tachycardia
 Sweaty and clammy skin

Patient Phantom was a painter which means he was exposed to different kinds of chemical.
Furthermore, Phantom also smokes and can consume 2 packs f cigarette per day and drinks alcohol every
other day which adds up as a risk factor for him to be diagnosed with Non-Hodgkin’s Lymphoma. One of
the study revealed that smoking and obesity increases the risk of developing non-Hodgkin’s
lymphoma while alcohol has lower risk. (Susan M. Geyer, 2010).This factors could lead changes
in DNA where it causes normal lymphocytes to become lymphoma cells. Most non-Hodgkin
lymphomas are B-cell lymphomas, and either grow quickly (high-grade) or slowly (low-grade)
which he had also to have a tumour growth on his right femoral bone. Due to new growth he had
a right hemipelvectomy surgery last 2017. On his diagnosis, he opted to accept the treatment for his
condition hence he had 6 cycles of chemotherapy since then. Moreover, when patient Phantom had been
amputated he was unable to clean his stump and with the minimal assistance of his family and forgets to
clean the wound at the most appropriate times. Because of the lack of assistance and time to clean the
stump, this caused the stump to be infected leading to perforation of infection which released toxins all
throughout his body. Due to the inflammatory process, vasodilation occurred which caused the increased
heart rate and low blood pressure to compensate for the body’s needs. Leukocytosis also occurred that

A C A S E S T U D Y O N S E P T I C S H O C K | 37
was seen through laboratory results with an increase in white blood cell which caused the edema on the
patient’s stump. Considering the case of the patient who is diagnosed with NHL and had been going in
and out of the hospital for chemotherapy, he was susceptible to infection because of also of failure of
natural defense of mechanism thus, gave him the greater risk to have sepsis that lead to his diagnosis,
Septic Shock.

TREATMENT

This section shows the treatment given to patient Phantom. This includes the drugs, intravenous
fluids, and blood transfusion with the description, purpose and nursing intervention of each treatment
given.

Drug Description and Purpose Nursing Interventions

Piperacillin- Piperacillin and Tazobactam 1. Determine previous hypersensitivity

Tazobactam 4.5 gm IV combination is an antibiotic that
q6 (-) ANST works by killing bacteria and
preventing growth. Piperacillin
Date and time ordered: works best when combined with
September 25, 2018 tazobactam to treat moderate-
to-severe infections (Truven
3: 30 pm
Health Analytics Incorporated,
2018).Piperacillin-Tazobactam
was given to kill the bacteria that
caused the infection.
Tazobactam is in a class called
beta-lactamase inhibitor that
works by preventing bacteria
from destroying
piperacillin(Ogbru, 2017).
reactions to penicillins, and other
allergens prior to therapy.
2. Lab tests: Baseline culture and
sensitivity tests prior to initiation of
therapy; start drug pending results.
3. Monitor patient carefully during the
first 30 min after initiation of IV
therapy for signs of hypersensitivity
and anaphylactoid reaction. Serious
anaphylactoid reactions require
immediate use of emergency drugs
and airway management.
4. Monitor I&O ratio and pattern.
Report dysuria, urine retention, and
hematuria.

5. Report chills, wheezing, pruritus

(itching), respiratory distress, or
palpitations to physician immediately.

Table1. Piperacillin- Tazobactam

A C A S E S T U D Y O N S E P T I C S H O C K | 38
 This medication is used to treat skin infections caused by bacteria on the stump wound area of
the patient. Antibiotic testing was performed because it is a useful procedure for identifying patient’s
hypersensitivity to pain (So Hee Lee, 2015). The medication was to be given every six hours to keep the
amount of drug in his system. Not taking the drug at the right time may keep the medications from
working properly (Lo, 2016). Piperacillin-tazobactam 4.7 mg at 10 ml + 90 ml of PNSS was given via soluset
with a drop factor of 100 micro drops per minute in hour. It was given via soluset to prevent pain in the
IV site.

Drug Description and Purpose Nursing Interventions

Gabapentin 300 mg 1 Gabapentin was initially 1. Note any signs of allergic reactions.
tab ODHS developed as an antiepileptic
drug but was later discovered to 2. Monitor patient on possible episodes
Date and Time be an effective treatment of of seizure or pain during the shift.
Ordered: neuropathic pain (Ad, 2010).
3. Advise patient to take medication
September 25, 2018
exactly as directed.
3:30 pm
4. Instruct patient to rest or sleep after
the medication is given. Drowsiness,
dizziness, loss of coordination,
tiredness, blurred/double vision,
unusual eye movements, or shaking
(tremor) may occur.
Table 2. Gabapentin

This medication affects chemicals and nerves in the body that are involved in the cause of seizures
and some types of pain. Gabapentin was given to patient Phantom because of nerve pains on the right
stump wound and to prevent seizure occurrence although, the patient did not show any episodes of
seizure.

Drug Description and Purpose Nursing Interventions

Tramadol 50mg IV q8 Tramadol is an opioid analgesic 1. Assess for hypersensitivity to drug.

for pain that is used to relieve moderate
to severe pain. 2. Measure and record regular weights
Date and Time to monitor fluid changes.
Ordered:

A C A S E S T U D Y O N S E P T I C S H O C K | 39
 September 25, 2018 3. Administer drug early in the day so
increased urination will not disturb
3:30 pm sleep.

4. Monitor serum electrolytes,

hydration, and liver functioning during
long-term therapy.

5. Provide diet rich in potassium.

Table 3. Tramadol

Tramadol is similar to opioid analgesics such as Morphine. It works in the brain to change how your
body feels and responds to pain. This was given to the patient because of his complaints of pain from his
infected stump wound. A skin infection may have symptoms like pain, redness and swelling (WebMD, 2018).
Moreover, tramadol has a lower potential for addiction than other opioids but it does not mean that it is
non-addictive.

Drug Description and Purpose Nursing Interventions

PNSS 1L X 16○ Normal Saline is a 1. Frequently assess the patient's

sterile, no pyrogenic
Date and Time Ordered: solution for fluid and
electrolyte
September 25, 2018
replenishment; contains
no antimicrobial agents
3:30pm (RxList, 2018).
response to I.V. therapy, monitoring
for signs and symptoms of
hypervolemia.
2. Monitor intake and output.
3. Elevate the head of bed at 35 to 45
degrees, unless contraindicated. If
edema is present, elevate the patient's
legs. Note if the edema is pitting or
non-pitting and grade pitting edema.

4. Educate patients and their families

about signs and symptoms of volume
overload and dehydration, and
instruct patients to notify their nurse
if they have trouble breathing or
notice any swelling.

Table 4. Plain Normal Saline Solution

Plain normal saline solution (PNSS) was used as the patient’s intravenous solution to aid in hydration
and it is specifically used for blood transfusion since patient Phantom was on packed red blood cell

A C A S E S T U D Y O N S E P T I C S H O C K | 40
transfusion. It also does not contain glucose compared to other isotonic solution such as dextrose 5% in
water because he does not need any nutritional support.

A C A S E S T U D Y O N S E P T I C S H O C K | 41
 Drug Description and Purpose Nursing Interventions

1 unit of PRBC x 4-6○ Packed red blood cells are 1. Monitor for any signs of
typically given in situations anaphylactic reactions.
Date and Time Ordered: where the patient has either
lost a large amount of blood 2. Monitor vital signs.
September 26, 2018
or has anemia that is causing
6:00 am notable symptoms.Repeated
transfusions may be
required in people receiving
cancer chemotherapy
(Wikipedia, 2018).

Table 5. Packed Red Blood Cells

Packed red blood cells were given due to the low blood levels. It helps in augmenting the levels
of the hematocrit and haemoglobin as reflected on the lab results.

Drug Description and Purpose Nursing Interventions

N-acetylcysteine 600 mg N-acetylcysteine has an 1. Assess type, frequency, characteristics, of

2 tabs BID in ½ glass H2O antioxidant and anti- patient’s cough. Particularly note sputum.
inflammatory properties, it
Date and Time Ordered: also possesses vasodilatory 2. Monitor patient for tachycardia.

October 1, 2018 properties and improve blood 3. Instruct patient to notify prescriber
flow (J, 2018). immediately about nausea, rash, or
11:00 am vomiting.

4. Encourage patient to consume two to

three litters of water unless
contraindicated.

Table 6. N-acetylcysteine

N-acetyl cysteine is used by the body to build antioxidants. Antioxidants are vitamins, minerals, and
other nutrients that protect and repair cells from damage.The patient was prescribed N-acetylcysteine to
serve as a prophylaxis to prevent pulling or thickening of secretions while in the hospital.

A C A S E S T U D Y O N S E P T I C S H O C K | 42
 Drug Description and Purpose Nursing Interventions

Morphine 2g IV for Morphine is a pain medication 1. Assess level of consciousness,

breakthrough pain which acts directly on the
central nervous system (CNS)
Date and Time Ordered: to decrease the feeling of pain.
October 1, 2018 It can be taken for both acute
pain and chronic pain
11:00 am (Wikipedia, 2018).
blood pressure, pulse, and
respirations before and
periodically during administration.
2. If respiratory rate is less than
10/min, assess level of sedation.

3. May cause drowsiness or

dizziness. Caution patient to call
for assistance when ambulating
and to avoid doing other activities
requiring alertness until response
to medication is known.

4. Advise patient to change

positions slowly to minimize
orthostatic hypotension.

5. Encourage patients who are

immobilized or on prolonged bed
rest to turn, cough, and breathe
deeply every 2hr to prevent
atelectasis.

Table 7. Morphine

Morphine is a powerful pain reliever used for both acute and chronic pain. Higher circulating
morphine levels in patients with sepsis/septic shock have been shown to promote disease progression by
impairing gut barrier integrity and mortality rates by increasing degree of immunosuppression (Scherer,
2018). The patient was given Morphine because of his complains of severe pain and he claims that
tramadol has no effect on him.

A C A S E S T U D Y O N S E P T I C S H O C K | 43
 Drug Description and Purpose Nursing Interventions

Amikacin 300mg IV q12 Amikacin is used for a short-
term treatment of serious
Date and Time Ordered: susceptible infections
October 4, 2018 (Haymarket Media, Inc. ,
2018).
7:51 am
1. Assess for infection (vitalsigns,
wound appearance, sputum, urine,
stool, WBC) at beginning of and
throughout therapy.
2. First dose may be given before
receiving results. Obtain specimens
for culture and sensitivity before
initiating therapy.

3. Discontinue aminoglycosides if
tinnitus or subjective hearing loss
occurs.

4. Monitor intake and output and

daily weight to assess hydration status
and renal function.

Table 8. Amikacin

Piperacillintazobactam was completed and was shifted to Amikacin. The patient has infected
stump wound, gram stain test was requested. The test resulted that there are many gram negative bacilli
in singles and in pairs. Amikacin was prescribed to further reduce or eradicate the bacteria in the patient’s
body.Amikacin is usually used in short-term treatment of serious infections due to susceptible strains of
Gram-negative bacteria.

A C A S E S T U D Y O N S E P T I C S H O C K | 44
 Drug Description and Purpose Nursing Interventions

Multivitamins+minerals 1 tab This medication is used to treat or 1. Advise patient to take

OD prevent vitamin deficiency due to
poor diet, certain illnesses, or
Date and Time Ordered: during pregnancy. An important
October 4, 2018 building blocks of the body that
help keep good health (Wikipedia,
7:51 am 2018).
medicine as prescribed.
2. Caution patient to make
position changes slowly to
minimize orthostatic
hypotension.
3. Instruct patient to avoid
concurrent use of alcohol or
OTC medicine without
consulting the physician.
4. Advise patient to consult
physician if irregular heartbeat,
dyspnea, swelling of hands and
feet and hypotension occurs.
5. Inform patient that angina
attacks may occur 30 min. after
administration due reflex
tachycardia.
6. Encourage patient to comply
with additional intervention for
hypertension like proper diet,
regular exercise, and lifestyle
changes and stress
management.

Table 9. Multivitamins

Multivitamins was given to the patient because of the patients less intake of food and loss of
appetite due to his condition. This is given to aid in the body’s nutrient needs. The patient has low RBC
count which is 3.71 which also mean that he has low iron. Multivitamins + iron was given to provide
vitamins and iron that is not present in the diet.

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 DISCHARGE PLAN

Discharge planning is a process that aims to improve the coordination of services after discharge
from hospital by considering the patient's needs in the community. It sought to bridge the gap between
hospital and the place to which the patient is discharged, reduce length of stay in hospital, and minimize
unplanned readmission to hospital.

Activity and Rest Advised to do light exercises that can be done at home, including
some that can do while sitting like stretching arms and foot,
changing position every 2 hours while resting in bed, and walking
with the use of assistive device like crutches. Encouraged to avoid
muscle inactivity client should always do their daily activities.

Encouraged to take a nap during the day if you feel tired this can
help to recharge their system and your body.

Medication and treatment Instructed take all medicines at the right time and with the right
dose.

Amikacin, Multivatmins, celecoxib, ferrous sulphate.

Diet and Nutrition Educated on diet restrictions which includes avoiding

raw/uncooked foods such as meats, seafood, eggs, and vegetables
or unpeeled fruits such fresh salad like Caesar salad.

Instructed that he must eat well-cooked food such as stewed meat,

fried fish, and food rich in fiber like stir- fried vegetables,
pineapples, and banana and to increase oral fluid intake as
tolerated.

Hygiene Instructed to change wound dressing as needed and to maintain

wound clean and dry.

Encourage to maintain cleanliness around house like proper

waste segregation and emphasize the importance of personal
hygiene such as hand washing, bathing, and changing clothes
regularly.

Follow-up Follow up as advised by your healthcare provider. Keep all follow-

up appointments.

A C A S E S T U D Y O N S E P T I C S H O C K | 46
 CONCLUSIONS AND RECOMMENDATIONS

CONCLUSION

Sepsis is a potential life-threatening due to untreated infection. This can cause multiple organ
dysfunctional and death. Immunosuppression can be caused by the underlying condition such as diabetes,
renal failure, and cancer, or because of previous health care intervention like chemotherapy. Therefore,
we conclude that chemotherapy leads to immunosuppression and without the proper intervention it can
lead to possible complication like septic shock. In the case of patient Phantom amputation and
chemotherapy is the treatment of choice for his cancer however this treatment increases the chances of
infection because of the untreated infection and continuous suppression of immune system the client
have acquired to septic shock. Several laboratory was done where in the result shows that the client has
low hemoglobin and hematocrit, elevated BUN and creatinine level, low potassium level and urine pH,
and has positive one puss cell this laboratory tests was done to determine that the client has infection in
his system and this is the basis of the health care providers for the appropriate treatment. Therefore we
conclude that laboratory result is needed before an appropriate intervention and treatment. Treatment
were given such as antibiotics such as amikacin and ampicillin to treat serious infection, analgesics such
as celecoxib and tramadol however they administered morphine for breakthrough because in the case of
phantom the pain he felt cannot be ease by tramadol and celecoxib therefore morphine is already needed.
Sepsis affects Sepsis can contribute in acute reduction of hemoglobin, including the reduced production
of red blood cells induced by inflammatory response as well as increased destruction of red cells due to
hemolysis and bleeding (Gassan Fuad Muady, 2016)

The actual problem that may be encountered by the nurses would be the following: first priority
of the NCP was acute pain because the patient experiences break through pain during our duty. Hence,
he was given morphine to ease the pain. Second, nursing diagnosis was hyperthermia due to infection of
the stump wound. A laboratory results of increase neutrophils and decrease lymphocytes was also noted.
As a manifestation of increased WBC the patient has had fever. Third, ineffective tissue perfusion was
also considered. The patient has a laboratory result of decrease hemoglobin and hematocrit this is caused
by a poor oxygen levels that binds to the RBC causing symptoms of cold and clammy extremities. Fourth,
impaired physical mobility was included. The patient had a right foot amputation last 2017. So as an
assessment we notice that the patient was not able to perform ADL and he’s in need of assistance in the
aspect of it. We therefore conclude that in coming up with a comprehensive nursing care plan it must be
inclined with the nursing process. We were able to sort the problem in terms of its priority and we
categorize it as actual, potential and risk. (Doenges, Moorhouse, & Murr, 2008)

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 RECOMMENDATION

The importance of increase awareness of the health care providers and the patient on underlying
cause of septic shock can more likely prevent the risk of having sepsis. Client has undergo several
treatment such as antibiotic therefore we recommend to the health care providers that appropriate
administration of antibiotics should be practice in the hospital and even in home care. We suggest
infection control or preventing further complication like prophylactic medication and regular wound care.
We recommend laboratory test such as culture and sensitivity and gram stain should be taken before
administering antibiotics. The client also undergo blood transfusion to correct the low hemoglobin and
hematocrit therefore, we recommend that giving PRBC should be continue as a practice in augmentation
of altered CBC. Also we recommend that pain management should be one of the priority of the health
care provide to promote the comfort of the client. We also recommend moderation and regulation of
giving morphine as analgesic because this drug can cause addiction. We recommend that the best
treatment for non-Hodgkin’s lymphoma is amputation however consistency of follow-up check-up and
infection control is highly should be initiated. We also recommend to develop nursing care plan
concerning the actual, potential and risk problems of the patient during his hospitalization and the nurse
must also be sure that the interventions are: Consistent with the established plan of care, implemented
in a safe and appropriate manner, evaluated for effectiveness, documented in a timely manner (Doenges,
Moorhouse, & Murr, 2008)

Home care and client awareness is also important to prevent spread of infection and untreated
infection therefore we recommend that the client should have awareness regarding sepsis and its cause.
We suggest that the client should more responsible on their health like having well balanced nutrition
such as high protein, high potassium food, and high fiber and having adequate fluid intake. We suggest
that proper hygiene should be regularly done like hand washing, bathing and changing clothes regularly.
We suggest adherence to medication and treatments to prevent the reoccurrence of the sepsis. We
suggest to have well balanced activities and exercises hence exercises does not really mean to be
extraneous but it can be light activities like stretching, and walking. We recommend to always consult the
health care provider if there are symptoms such as high grade fever, low blood pressure, fast heart rate,
rapid breathing, dizziness, and pain, or symptoms that affect their activities of daily living.

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 NURSING CARE PLAN

A. List of Problems as Prioritized

1. Acute Pain

2. Hyperthermia

3. Ineffective peripheral tissue perfusion

4. Impaired physical mobility

5. Risk for impaired gas exchange

6. Risk for ineffective cerebral tissue perfusion

B. Nursing Care plans (Refer to pages 51-56)

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