samplecareplan.docx

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Care Plan

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Care Plan #2

Background and Etiology

The patient is a 65-75-year-old African American female who was admitted to the adult intensive care unit (AICU) due to elevated lactic acid level, metabolic acidosis, anasarca, and pleural effusion which was drained via chest tube by interventional radiology (IR). She also complained of worsening abdominal pain since her admission and has had increasing shortness of breath, dyspnea, increased work of breathing, and bilateral lower extremity edema. She was diagnosed with severe sepsis due to malnutrition, deconditioning, and recurrent bacteremia with worsening respiratory failure. Her past medical history is significant for adenocarcinoma of the pancreas treated with neoadjuvant chemotherapy and radiation (April 2019), a jejunal ulcer at the biliary anastomosis, vancomycin-resistant enterococci (VRE) bacteremia and Pseudomonas at the abdominal laparotomy site, multi-loculated liver abscesses growing Klebsiella and VRE, right ureteropelvic junction (UPJ) obstruction causing hydronephrosis, hypertension (HTN), hypothyroidism, osteoarthritis, diverticulosis, transient ischemic attack (TIA), Hepatitis C (2014), Vitamin D deficiency, and right foot fracture (2016). Her past surgical history is significant for a Whipple procedure (6/25/19), exploratory laparotomy (6/28/19), IR-guided drain placement for hepatic abscesses and right double-J ureteral stent (9/19), port placement (2018), and total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH/BSO) (1990s). The patient does not smoke, does not drink alcohol, or use illicit drugs. The patient has two adult sons from a previous marriage and has been with her significant other for 40 years.

The patient has difficulty moving in the bed but is able to move all of her extremities and follow commands. She has an 18-gauge IV in her left arm, double-lumen central line in the right subclavian vein, two hepatic drains attached to a collection bag for her liver abscesses, a nephrostomy tube draining into a urine collection bag, and a chest tube that had drained 450mL of serosanguinous fluid. She is unable to ambulate or use the restroom. She has no known drug allergies. She has full code status.

According to the Sepsis Alliance (2019), sepsis “is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death”. It is a medical emergency which requires immediate treatment (Cedars Sinai, 2019). It occurs when the chemicals released by the immune system to fight infection overwhelm the body, causing “widespread inflammation” that impedes blood flow and causes a decrease in nutrients and oxygen to organs which leads to organ damage and failure (National Institute of General Medical Sciences (NIGMS), 2019). Sepsis can be caused by a bacterial or fungal infection in the bloodstream, infection of the kidney, bladder, or other part of the urinary system, and abnormal function of the liver (Mayo Clinic, 2019). Some complications of sepsis can include kidney failure, permanent lung damage from acute respiratory distress syndrome (ARDS), and damage to heart valves which can lead to heart failure (Cedars Sinai, 2019).

Morbidity and Mortality

Sepsis is described as a collection of symptoms in response to an infection, characterized by critical patient response with organ dysfunction related to that infection (Lewis, Bucher, Heitkemper, & Harding, 2017, p. 1592). According to the Centers for Disease Control (CDC) (2019) and Cedars Sinai (2019), these symptoms can include tachycardia, shortness of breath, increased respiratory rate (RR), leukocytosis, extreme pain or discomfort, and shivering or feeling very cold. This patient presented with all of these symptoms when she was admitted to the AICU. These symptoms can be caused by bacteremia due to vancomycin-resistant enterococcus (VRE) bacteria, cancer, kidney infections, abnormal liver function, and invasive devices (Sepsis Alliance, 2019), and this patient presented with all of these conditions.

According to NIGMS (2019), each year, around 1.7 million adults in the United States develop sepsis and almost 270,000 die as a result. Sepsis cases per year have increased, due to several factors: people who have chronic diseases are living longer – sepsis is more common and dangerous in older adults and those with chronic diseases; some infections can no longer be cured with antibiotics – antibiotic resistance can lead to sepsis; and people who undergo procedures with medications that can suppress or destroy the immune system have a higher risk of developing sepsis.

Pathophysiology

Bacteremia is the presence of bacteria in the bloodstream due to an infection when the immune system fails or becomes overwhelmed. The bacteria can evade the immune response, increase in number, and become a localized infection that eventually migrates to other parts of the body. If this occurs, the infection may progress to septicemia. Medical procedures that pass through the skin interfere with the skin’s natural defense barriers and increase the potential for bacteria to proliferate and cause sepsis (Smith & Nehring, 2019). This patient was diagnosed with VRE in her surgical abdominal wound. According to Johnstone et al. (2018), patient risk factors for VRE bacteremia include those with cancer, those who are admitted to the intensive care unit (ICU), and those receiving treatment at large hospitals and teaching centers. They also found that 40% of patients with VRE bacteremia died within 30 days of VRE bacteremia diagnosis and that being admitted to the ICU was the most important predictor of death.

According to the CDC (2019), having cancer and undergoing treatment such as chemotherapy can cause the body to be unable to fight off infections as it normally would. Chemotherapy kills both bad and good cells within the body. In addition to killing the fast-growing cancer cells, chemo also kills the infection-fighting white blood cells (WBC). This leaves the patient immunocompromised and more prone to acquiring an infection that can lead to sepsis. Patient risk factors for cancer include age, immunosuppression, chronic inflammation, alcohol use, and obesity (National Cancer Institute, 2015). According to the Sepsis Alliance (2019), people with cancer are more at risk for sepsis due to frequent hospital stays (which increases the risk for a hospital-acquired infection), surgeries or procedures that puncture the skin allowing for the increased possibility of infection, a depressed immune system due to treatment for cancer, and weakness due to malnutrition, illness, or age-related frailty.

Hepatic abscess is defined as “an encapsulated collection of suppurative material within the liver parenchyma which may be infected by bacterial, fungal, and/or parasitic micro-organisms” (Mavilia, Molina, & Wu, 2016). According to Jun (2018), hepatic abscesses are pockets of pus that form due to a bacterial infection primarily caused by strains of Klebsiella pneumoniae and that most of these infections are community-acquired. Patient risk factors that contribute to the development of hepatic abscess include diabetes mellitus, general immune-compromised state, age, gender (Mavilia, et al. 2016), and history of antibiotics use (Jun, 2018).

An invasive device is any medical device that is introduced into the body through a break in the skin or opening in the body. Whenever one of these devices is used, there is an increased potential for infection, including healthcare-acquired infections, that can lead to sepsis. Although the device itself does not cause infection, it can provide a route for bacteria and/or fungi to enter the body. Types of invasive devices include urinary catheters, IV lines (peripheral venous catheters), nephrostomy tubes, central lines, and chest tubes (Sepsis Alliance, 2019). According to the United States Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) (2015) and the CDC (2019), patient risk factors for requiring invasive devices include urinary tract infections requiring catheterization, receiving IV fluids, medications, or blood through peripheral venous catheters (the most commonly used catheter), respiratory failure requiring endotracheal tubes for mechanical ventilation, and cancer or cardiac treatments that require central venous catheters (central lines) that can remain in place for weeks or months.

References

Cancer. (2019). Retrieved November 21, 2019, from .

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019).  Nurses pocket guide: diagnoses,

prioritized interventions, and rationales(14th ed.). Philadelphia: F.A. Davis Company

Epidemiology of invasive devices and complications. (2015, October). Retrieved November 22,

2019, from .

Frequently asked questions about catheters. (2019, May 9). Retrieved November 22, 2019, from

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Huether, S. & McCance, K. (2017). Understanding pathophysiology (6th ed.) (p. 909). St.

Louis, MO: Elsevier.