Assessment

HISTORY. Patients appear critically ill and may have already been intubated and on mechanical ventilation for adult respiratory distress syndrome (ARDS). Because of the severity of the patient's condition, you may not be able to interview him or her for a complete history. You may obtain a great deal of information from the family and from other healthcare providers when the patient is transferred to your care. Because patients with septic shock are among the most critical of all patients treated in a hospital, they are admitted to a critical care unit for management.

Patients often have a history of either an infection or a critical event, such as a traumatic injury, perforated bowel, or acute hemorrhage. Some patients may also have a long-standing IV catheter or a Foley catheter. Determine the cause for the patient's admission to the hospital and any history of a chronic disease such as cancer, diabetes mellitus, or pneumonia. Note any brief periods of decreased tissue perfusion such as hemorrhage, severe hypotension, or cardiac arrest that may demand emergency management before the development of septic shock. Take a thorough medication history, with particular attention to recent antibiotic administration or total parenteral nutrition. Ask if the patient has been exposed to any treatment—such as organ transplantation, radiation therapy, or chemotherapy—that would lead to immunosuppression.

PHYSICAL EXAMINATION. Three stages have been identified, but all patients do not progress with the same pattern of symptoms. In early septic shock (early hyperdynamic, compensated stage), some patients are tachycardic, with warm and flushed extremities and a normal blood pressure. As shock progresses, the diastolic blood pressure drops, the pulse pressure widens, and the peripheral pulses are bounding. The patient's temperature may be within normal limits, elevated, or below normal, and the patient may be confused or agitated. Often, the patient has a rapid respiratory rate, and peripheral edema may develop. In the second stage (late hyper-dynamic, uncompensated stage), widespread organ dysfunction begins to occur. Blood pressure falls, and the patient becomes hypotensive. Increased peripheral edema becomes apparent. Respirations become more rapid and labored; you can hear rales when you auscultate the lungs; and the patient's sputum may become copious, pink, and frothy. In late septic shock, the blood pressure falls below 90 mm Hg for adults, the patient's extremities become cold, and signs of multiple organ failure (decreased urinary output, abdominal distension, absence of bowel sounds, bleeding from invasive lines, petechiae, cardiac dysrhythmias, hypoxemia, and hypercapnia) develop.

PSYCHOSOCIAL. As the syndrome progresses, patients may develop symptoms that change their behavior and appearance and situations that increase their anxiety and that of their family members. Ultimately, the family may be faced with the death of a loved one. Continuously assess the coping mechanisms and anxiety levels in both patients and families.

840 Septic Shock

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Cultures and

Negative for pathologi

Positive for

Identifies infecting organism in

sensitivities

cal bacterial flora or

pathological

blood, urine, sputum, or wounds;

Diabetes 2

Diabetes 2

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