You are working nights on an inpatient geriatric unit. An 82-year-old woman, is admitted from an extended care facility with urosepsis, Alzheimer's disease, and a history of hypertension and CVA. Her right side is flaccid. She does not communicate, moans when in pain, and hits, kicks, and claws with her left arm and leg when disturbed. Her initial assessment shows emaciation and multiple pressue ulcers. She has an indwelling Foley catheter and one peripheral IV of D5 NS at 75mL/hr. Her initial VS are 86/50, 108, 24, 104.5° F. Her initial WBC is 34.2mm³. (Learning Objectives 6 and 7)

 

 

1)What type of shock would this client be at risk for? Explain what risk factors that she has that made you think this.(2 points)

2)What potential findings would suggest that the patient's septic shock is worsening from the point of admission? (2 points)

3)The physician ordered two IV antibiotics, gentamicin (Garamycin) 4mg/kg every 24 hours and ticarcillin (Ticar) 3g IV every 6 hours, Her morning labs show serum creatinine is 3.2 mg/dl. Her admission serum creatinine was 2.0. Which medication would you be able to administer safely and which one would you question? Calculate how many mL to administer for both meds. Client weighs 132 lb. Gentamicin 4mg/kg IV and pharmacy sends you 40mg/1mL vial. Ticarcillin 3 g IV pharmacy sends you a 1g/2.5 mL vial.(4 points)

4)Your client has a PEG tube and tube feedings at 100mL/hr. During your assessment you note that her gastric residual is 175mL. What should you do? Explain the importance for nutritional support for this patient and why this is the preferred method for your client? (2 points)

1. Type of shock that the client in the given case is at risk for:

• Septic Shock.

Risk factors that the client has for developing septic shock are:

• Urosepsis: The bacteria causing urinary tract infection could have gained access into systemic circulation and contributed for the development of septic shock
• Co-moribidities: Right side flaccid paralysis, Alzheimer's disease, Cerebrovascular Accident (CVA) affects the mobility and cognitive perception about the voiding and self-care increases the risk of urinary tract infection
• Indwelling catheter: Presence of indwelling catheter along with immobility in the given client increases the urinary stasis which increases the risk of urinary tract infection. This could have lead to the development of urinary tract infection which caused the septic shock due to the spread of bacteria to the systemic circulation.
• Immobility: The assessment of the client in the given case has shown multiple pressure ulcers which indicate that the client is bed-ridden for prolonged period with ineffective positioning or mobility. Immobility along with indwelling catheter could have aided for the development of urinary tract infection  
• Age: As the age progresses, the compromised immune responses, atrophy of uro-genital epithelium, altered pH, decreased protective hormone responses increase the risk for bacterial invasion and infection 
• Gender: Women are more prone to urinary tract infection due to the various anatomical factors which favors the growth of microorganisms in the urinary tract.  
• Poor nutrition/ chronic illness: The initial assessment reveals that the client is emaciated which in turn indicates poor nutrition or chronic illness that could have resulted in the urinary tract infection. 

Step-by-step explanation

2. Potential findings would suggest that the patient's septic shock is worsening:

• Elevated serum creatinine: Increased serum creatinine from 2.0 mg/dL (admission labs) to 3.2 mg/dL (current labs) indicates decreased renal function, increased anerobic metabolism in the body in response to inadequate tissue perfusion. This indicates that the patient's condition is worsening and progressing towards multiple organ dysfunction. 
• Falling blood pressure (86/50 mmHg): The falling blood pressure (hypotension) is an evidence of systemic response, decreased cardiac output and reducing circulatory volume. 
• Elevated heart rate (108 bpm): Elevated heart rate is a sign of sympathetic response to reduced cardiac output and decreased tissue perfusion. 
• Increased respiratory rate (24 bpm): Increased respiratory rate is a sign of body's counter measures to compensate for hypoxia and inadequate tissue perfusion in septic shock.   
• Fever (104.5° F): Elevated body temperature is a sign of bacteremia (presence of bacteria in the blood) which in turn activated the systemic immune response. Release of inflammatory cytokines in response to bacteria in the blood results in fever as seen in the given case. 
• Elevated WBC count (34.2mm³): Elevated white blood cells (WBC) is also a sign of systemic infection and development of septic shock. 

All the above signs indicate that the bacteria gained access into the systemic circulation and resulted in septic shock. If left untreated this could lead to multiple organ dysfunction and death. 

3.

i. Medication that can be safely administered = Ticarcillin (Ticar)

Rationale: Ticarcillin is a carboxypenicillin derivative which does not have any renal toxicity and effective against Pseudomonas. This can be safely administered to the patient as ordered and does not require dose adjustment. 

ii. Medication to be questioned = Gentamicin (Garamycin)

Rationale: Gentamicin is an aminoglycoside antibiotic which is nephrotoxic. Serum creatinine levels and blood urea nitrogen are to be monitored while administering this drug to prevent nephrotoxicity. As the client in the given case is having an elevated serum creatinine of 3.2 mg/dL, dosage adjustment of gentamicin is required. [approximately 30% of the original ordered dose should be administered to prevent the nephrotoxicity]. 

iii. Number of mL of Gentamicin to be administered = 6 mL.

Solution:

Physician order for gentamicin = 4mg/kg every 24 hours

Available supply = 40 mg/1 mL

Body weight of the client = 132 lbs

By using dimensional analysis method: In this method, the equation is set up in a manner that only required units are obtained while remaining units are cancelled off using appropriate conversion factors [i.e lbs to kg in this given case]

No. of mL to be administered per dose = 

 = 40mg1mL? x kg4mg? x 2.205lbs1kg?x 132 lbs [since, 1kg = 2.205 lbs]

= (88.2528?) mL [remaining units are cancelled off]

= 5.986 mL (or)

= 6 mL 

Therefore, the nurse needs to administer 6 mL of gentamicin from the given vial

iv. Number of mL of Ticarcillin to be administered = 7.5 mL.

Solution:

The physician ordered two IV antibiotics, gentamicin (Garamycin) 4mg/kg every 24 hours and ticarcillin (Ticar) 3g IV every 6 hours, Her morning labs show serum creatinine is 3.2 mg/dl. Her admission serum creatinine was 2.0. Which medication would you be able to administer safely and which one would you question? Calculate how many mL to administer for both meds. Client weighs 132 lb. Gentamicin 4mg/kg IV and pharmacy sends you 40mg/1mL vial. Ticarcillin 3 g IV pharmacy sends you a 1g/2.5 mL via

Physician order = Ticarcillin 3g every 6 hours

Available supply = 1g/2.5 mL

By using dimensional analysis method:

No. of mL of Ticarcillin to be administered per dose = 

= 1g2.5mL?x 3 g

= 7.5 mL.

Therefore, the nurse has to administer 7.5 mL of Ticarcillin intravenously.  

4. Your client has a PEG tube and tube feedings at 100mL/hr. During your assessment you note that her gastric residual is 175mL. What should you do? Explain the importance for nutritional support for this patient and why this is the preferred method for your client

Gastric residual volume of 175 mL indicates:

• Too frequent or rapid frequency of tube feeding (or)
• Emptying time of stomach is decreased (delayed gastric emptying due to decreased peristalsis)

Nursing actions: 

• The nurse should hold the feeding for 2 hours. After 2 hours, the nurse should check the gastric residual volume again. 
• If the value is greater than 120 mL, it indicates that the above problems are still persistent and the physician should be notified regarding the same. 
• If the residual volume is less than 120 mL, the feeding can be administered. 

Importance of nutritional support in this client:

• Due to the ongoing condition: From the vital signs and elevated serum creatinine it is evident that the condition of the client is worsening and the client is on the verge of developing multiple organ failure due to septic shock. It is important to maintain nutritional support which helps in maintaining the integrity of physiological systems to withstand the extensive treatment for shock
• Reduce anerobic metabolism: Due to decreased perfusion body depends on anerobic metabolism in patients who develop shock. Providing adequate nutritional support along with oxygen therapy helps in meeting the body's energy demands and prevents further worsening of the condition. 
• Emanciated state of the client: The initial assessment revealed that the client is emanciated and providing nutritional support helps in promoting the general status of the client. 
• Support treatment: The medications, antibiotics used for the management of shock requires adequate nutritional support to provide therapeutic benefits

Tube feeding is preferred method in this client because:

• Co-moribidities: The client in the given case has Alzheimers disease (could result in difficulty in swallowing) which along with right sided flaccid paralysis could affect feeding. In such cases providing tube feeding is the preferred method as it overcomes the difficulty for swallowing associated with these co-morbidities
• On going condition: Septic shock and systemic responses could affect the mental status of the client and affect the airway reflexes. Providing tube feeding prevents the risk of aspiration