NSN804

Contemporary Issues in Intensive Care Nursing

Assessment 1-Essay: Critical Discussion

Introduction

Septic shock functions as an urgent life-threatening illness in intensive care units, where it frequently complicates pneumonia because of the patients' severe infections. This essay analyses the adult situation of an 81-year-old male who fell into septic shock after suffering acute respiratory distress during the COVID-19 pandemic (Hibbert et al., 2021). The ADPIE assessment approach: Assessment, Diagnosis, Planning, Implementation, and Evaluation enables examination of the patients case by reviewing clinical signs, pathophysiological elements, and supportive medical approaches in treatment. The paper examines emergency septic shock detection combined with relevant patient care practices from the nursing scope for effective septic shock treatment. This essay examines existing literature and clinical guidelines to boost critical care nursing decision-making abilities and secure optimal, culturally appropriate treatment of patients with severe septic shock.

1. Case Study

An elderly male aged 81 visited the emergency department because he developed fever, dry cough and acute shortness of breath together with left-sided pain, which was described as pleuritic. The patient suffered from hypertension, while a doctor suspected he had interstitial lung disease as part of his medical background (Hibbert et al., 2021). His condition before illness displayed normal chest breathing capabilities and independent daily activities. Upon evaluation at the emergency department, his heart rate was elevated and his breathing was fast, while his blood oxygen saturation was recorded 91% with room air, improved to 96% while using 4L oxygen through a nasal cannula (Hibbert et al., 2021). Due to physical assessment, there were clear lung crackles along with supraclavicular muscle movement, yet no swollen legs or sensitive chest wall area was detected.

Laboratory tests displayed bilateral peripheral opacities on the chest X-ray together with elevated inflammatory markers (CRP and ferritin) and lymphopenia and neutrophilia, and lactic acidosis (lactate 3.5 mmol/L). These results indicated systemic inflammatory response and early sepsis. At that time, my patient was awaiting results from a SARS-Cov-2 PCR test (Hibbert et al., 2021). The patient displayed no accurate recognition of early indicators that suggested clinical deterioration. Healthcare professionals delayed arterial blood gases tests, together with echocardiograms and lactate level monitoring, which possibly resulted in delayed aggressive sepsis treatment initiation.

Medical staff diagnosed the condition as pneumonia acquired in the community that developed into septic shock from either viral pneumonia with possible SARS-Cov-2 infection or bacterial infection on top of this. Impaired gas exchange with ineffective tissue perfusion combined with the systemic inflammation risk, leading to multi-organ dysfunction, formed the nursing diagnoses.

The first stage of care planning began by rapidly restoring blood circulation through fluid therapy and vasopressor administration of norepinephrine to maintain a minimum mean arterial pressure of 65 mmHg (Hibbert et al., 2021). The treatment included immediate administration of broad-spectrum antibiotics (ceftriaxone and azithromycin) to the patient after his condition was diagnosed within the first hour as per established sepsis management guidelines.

Underlying Pathophysiology

Patients with septic shock develop a serious illness characterised by low blood pressure that continues despite fluid replenishment as well as substandard tissue blood flow and elevated blood lactic acid levels, which cause multiple organ damage. The human immune system develops chaotic responses that control disease. when it faces an infection, it cannot properly handle. Prior to adult age, immune senescence along with limited physiological reserves and interstitial lung disease (ILD) makes elderly patients highly vulnerable to severe systemic inflammation, which can lead to organ failure.

The patient exhibits highly elevated Inflammatory markers (CRP at 184 mg/L) along with ferritin at 1760 ?g/L and D-dimer exceeding 10,000 ng/mL, and these levels demonstrate severe cytokine-mediated hyperinflammation. Scientific research indicates that the elevated laboratory values found in COVID-19 patients suggest massive endothelial activation, together with hypercoagulable situations, which ultimately lead to tissue damage (Hibbert et al., 2021). The clinical sign of septic shock includes lactic acidosis measured at 3.5 mmol/L due to oxygen delivery breakdown to tissues that forces cells into anaerobic metabolism.

Lymphopenia at 850/?L combined with neutrophilia at 10,100/?L indicates a faulty equilibrium between natural and adaptive immunity because reduced lymphocytes hinder viral elimination as elevated neutrophils accelerate tissue damage. Widespread cellular damage becomes evident through elevated CK, together with elevated LDH (Hibbert et al., 2021). Early disseminated intravascular coagulation (DIC) constitutes a recognised severe complication of sepsis when the PT/INR results show mild prolongation.

The septic cardiomyopathy and direct viral myocarditis can cause myocardial strain that shows itself through elevated levels of Troponin T (62 ng/L) and NT-proBNP. The observation of bilateral alveolar infiltrates through imaging tests verifies respiratory involvement and breathing difficulties. The different test results demonstrate how inflammation interacts with coagulation problems while leading to organ dysfunction. This patient fulfils the criteria for SARS-Cov-2-induced septic shock because their condition exhibits key signs of endothelial failure and immunological cascade, combined with damage to multiple organs. However, The timely detection and active intervention of the disease need to be implemented to stop its further development.

Therapeutic Intervention One: Early Goal-Directed Therapy (EGDT)

Early Goal-Directed Therapy stands as an essential treatment framework that medical professionals use to improve tissue perfusion, combined with maintaining stable blood circulation during the first critical hours of septic shock diagnosis. The treatment requires standardised therapeutic actions that deliver fluid through resuscitation procedures while administering vasopressors and maintaining constant analysis of vital signs for precise resuscitation targets (Rivers et al., 2001, p.3). The Surviving Sepsis Campaign (2021) approves this approach, which proves effective at reducing mortality when started right after diagnosis. The start of EGDT requires patients to receive 30 ml/kg of isotonic crystalloids during the first three hours when medical providers detect shock symptoms. Kindred tissue fluid replacement eases circulation volume while enhancing cardiac preload function, which in turn increases output. Elderly patients, including the 81-year-old male, need careful fluid resuscitation management because their increased vulnerability to fluid overload mainly occurs when they have interstitial lung disease or COVID-19-related alveolar injuries (Hibbert et al., 2021). Hospitalised elderly patients possessing pulmonary disorders manifest severe complications when provided with excessive fluid because it leads to pulmonary edema, worsening oxygen distribution and respiratory failure. The importance of delivering fluids in a timely fashion exists together with the essential need for medical professionals to use their clinical expertise alongside continuous observation.

Physicians need to initiate vasopressor medications when hypotensive pressure persists after sufficient fluid administration to maintain a mean arterial pressure (MAP) at 65 mmHg. According to protocol, the first-line choice of vasopressor should be norepinephrine because it effectively restores vascular tone without elevating heart rate. The patient's situation would benefit from early norepinephrine use because it would aid in combating systemic vasodilation while enhancing organ blood flow and decreasing multi-organ failure risk. The effects of vasopressors on the patient need ongoing evaluation through measurements of arterial pressure and clinical assessments of end-organ perfusion combined with laboratory serum lactate measurements.

Monitoring functions as the core element in the implementation of EGDT. The therapeutic goals for EGDT focus on maintaining MAP above 65 mmHg at the same time as maintaining CVP within 8 to 12 mmHg while achieving urine outputs higher than 0.5 ml/kg/hour and serum lactate normalisation (Hibbert et al., 2021). The indicators serve as tools to assess treatment results, which direct additional treatment strategies. Urine output, in particular, offers a reliable and accessible measure of renal perfusion and fluid status.

Nurses hold critical positions for executing and maintaining the activities of EGDT throughout its duration. Nurses fulfil their essential role by performing precise fluid and vasopressor delivery while tracking vital signs and spotting warning signs of progression and sharing all team-related updates (Kang et al., 2024). Nurses must conduct ongoing evaluation of respiration, oxygen levels, fluid management and neuro-psychiatric status to make appropriate clinical choices. Through advocacy, nursing staff protect patient dignity while providing comfort to patients during demanding treatment events. When caring for patients with impaired lungs, nurses must consider Adventure Resuscitation against the potential harm of fluid accumulation because excellent clinical decision-making remains vital for reaching the best possible results under EGDT.

Therapeutic Intervention Two: Empirical Antimicrobial Therapy

Late initiation of antimicrobial drugs remains a critical treatment element for sepsis and septic shock since it handles the primary infectious source in a timely way. Medical care providers give broad-spectrum antibiotics promptly to patients displaying suspected sepsis when their assessments show signs of community-acquired pneumonia. The one-hour antibiotics initiation time recommended by the Surviving Sepsis Campaign (2021) serves as a basis for this intervention to reduce mortality. The early start of medicines reduces infections from progressing further while stopping the spread of microorganism transmission and decreasing the body's excessive inflammatory activity, which causes sepsis. Immediate empirical antimicrobial treatment was started for this patient who exhibited symptoms of acute respiratory distress and abnormal inflammatory indicators.

Doctors often select ceftriaxone along with azithromycin as their first choice to treat bacterial or viral pneumonia in patients. The antibiotic combination of ceftriaxone with azithromycin fights both typical bacterial pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, and less common atypical bacterial pathogens like Mycoplasma pneumoniae and Chlamydia pneumoniae. The decision to consider antiviral therapies, including remdesivir or corticosteroids, must happen when COVID-19 emerges as a concern during the pandemic. The presence of COVID-19 disease can trigger bacterial secondary infections, which makes treatment complex because medical attention needs to address both viral and bacterial pathogens simultaneously (Richardson et al., 2020, p.3). The dual-pathogen analysis becomes essential for choosing the correct treatment methods.

When practising antimicrobial stewardship, we need a culture-based de-escalation strategy as an important measure. The results of pathogen cultivation using blood and respiratory samples and sputum identification guide medical professionals to initiate specific antibiotic treatment targeted toward the isolated organism. This antibiotic approach prevents both needless broad-spectrum antibiotic prescriptions and AMR development, which ensures the sustainability of antibiotic effectiveness for upcoming therapeutic needs (Tarrant et al., 2021, p.1). Culture results direct the de-escalation or change of broad-spectrum antibiotic therapy in this patient, which limits the development of resistance.

The evidence shows that patients gain better outcomes when receiving antibiotics early in the first hour after hospital admission. Evidence shows that delayed antibiotic treatment leads to higher organ dysfunctions and worsened septic shock progression with higher mortality rates. The survival prospects for patients depend heavily on the prompt delivery of antibiotics to their treatment process.

Staff nurses have the essential responsibility to deliver antimicrobial therapy without delay. Nursing staff must carry out prescribed antibiotic protocols to deliver proper medication amounts while tracking adverse effects and checking therapeutic progress and failure signs. The patient requires constant observation by nurses for any indications of allergic responses and reactions to infusions and gastrointestinal side effects (McDermott, 2023, p.6). Nursing staff have to monitor renal function test results since nephrotoxicity is a known risk for antibiotics such as ceftriaxone or aminoglycosides. Observation of therapy success by nurses includes monitoring how patients fare through changes in temperature, vital sign patterns and laboratory values, which show CRP and white blood cell count and lactate levels.

The spectic shock connected to initial antimicrobial treatment cannot be disregarded. The increasing problem of antimicrobial resistance emerges from both excessive use and improper application of broad-spectrum antibiotics. Some antibiotics like ceftriaxone display nephrotoxic properties, which lead to renal impairment, particularly within elderly patients as well as those who have existing renal conditions. The successful management of risks involves watching kidney performance closely as well as adjusting antibiotics according to test results for culture and sensitivity.

Evaluation

The implemented treatments worked effectively to stabilise the patient's condition. Hemodynamic stability returned thanks to fluid treatment and vasopressor medicine therapy, and treatment with broad antibiotic agents managed the infectious infection from its start. The patient's mean arterial pressure remained stable while lactate values reduced which indicates better tissue blood circulation. Functional respiratory disturbances persisted because of the patients chronic lung issues and potential dual viral infection, although their MAP improved. The medical team achieved positive results, yet some critical interventions for care delivery were absent (Naughton & Tuxen, 2020, p.2). More aggressive management strategies could have yielded better results because of delayed arterial blood gas testing as well as delayed ICU transfer. Healthcare professionals should implement strategies to speed up sepsis assessments and arrange immediate imaging, and implement proper escalation routes. Nursing staff should participate in regular education programs that teach them to identify sepsis warning signs, particularly among elderly patients. Nurses need to receive the tools needed to detect worsening clinical situations so that they can deliver swifter interventions that result in better patient recovery.

Conclusion

This critical essay provided an assessment of septic shock management in elderly ICU patients while applying the ADPIE model for care analysis. This healthcare situation demonstrated the diagnostic and management problems that healthcare providers encountered while treating sepsis during the COVID-19 pandemic. The healthcare professional examined both goal-directed fluid therapy and empirical antibiotic treatment supported by evidence-based nursing practice. Theories established early detection together with prompt diagnosis as fundamental practices to enhance patient outcomes. Critical care nurses require ongoing clinical education and vigilance, according to the discussion, while leading patient care through septic shock care implementation.