MABEL STACK, AGE 78, is admitted to your unit at about 9:00 A.M. She states she had been taking levofloxacin for pneumonia for 3 days but was having worsening symptoms of dyspnea and cough. Also, she has developed watery diarrhea, weakness, and dizziness.
History and assessment hints
Mrs. Stack’s history is significant for coronary artery disease, hypertension, and heart failure. Her current medications include enalapril, atenolol, aspirin, and furosemide; she has taken all of her doses today.
Physical findings include rhonchi and wheezes, dry mucous membranes, and poor skin turgor. Since admission, her total urine output has been minimal and concentrated.
Laboratory results include: white blood cell count 14,000 cells/mm3, hematocrit 40%, blood urea nitrogen (BUN) 45 mg/dl, and a normal creatinine level. Culture results are pending. Mrs. Stack is started on I.V. ceftriziaxone and azithromycin.
Deteriorating vital signs
Later that day, you note Mrs. Stack’s temperature is 100.5° F (38.1° C); blood pressure, 106/52 mm Hg; heart rate, 98 beats/minute; respiratory rate, 36 breaths/minute; and oxygen saturation (SaO2), 86% on room air. She is lethargic and pale. As you examine her, she becomes stuporous.
After quickly notifying the charge nurse of the patient’s condition, you recheck Mrs. Stack’s vital signs. Her blood pressure is now 92/50 mm Hg and her SaO2 has dropped to 78%. Meanwhile, the charge nurse has called the rapid response team (RRT) and Mrs. Stack’s primary care physician and brings you the patient’s chart.
On the scene
When the RRT arrives, you rapidly summarize the situation. The team concludes that Mrs. Stack’s hypotension stems partly from diarrhea-induced dehydration. As ordered, you infuse 1 L of saline solution I.V., paying careful attention to the patient’s fluid status and breath sounds.
Once the infusion is completed, Mrs. Stack’s blood pressure increases to 110/80 mm Hg and her mental status improves. The respiratory therapist gives 100% oxygen by mask. You remain with Mrs. Stack as the RRT assists you with these interventions.
You document the event, including assessment findings, interventions, and the patient’s response. The RRT requests a follow-up chest X-ray and echocardiogram to assess left ventricular function. Once culture results are available, Mrs. Stack’s antibiotic therapy will be fine-tuned.
Mrs. Stack has stabilized and will continue to be monitored on your unit. Your fast actions and the quick interventions of the RRT have averted a crisis. The RRT will follow up within 4 hours.
Education and follow-up
Reviewing the case with the RRT provided clues and warnings that the patient was deteriorating. Given her history of hypertension, her initial blood pressure reflected relative hypotension. Poor skin turgor, dry mucous membranes, scanty urine, and diarrhea indicated dehydration, as did her elevated BUN and normal creatinine levels. Taking a diuretic that morning exacerbated her dehydration.
You provide education to Mrs. Stack and her family about fluid intake, medications, and the need to contact the healthcare provider at once if symptoms don’t improve during treatment of an infection.
Although initial emergency treatment is similar, it’s important to differentiate dehydration from septic shock—a more serious condition. Both may follow a documented infection and cause hypotension, but septic shock requires further aggressive treatment. Fortunately, Mrs. Stack improved rapidly after the fluid infusion, and she was able to avoid end-organ damage secondary to hypoperfusion.
For a list of selected references, visit www.AmericanNurseToday.com.
Jeanne Powers, MS, RN, CCRN-CMC, is a Clinical Nurse Specialist in the Medical Intensive Care Unit (MICU) and an Early Nursing Intervention Team (ENIT) committee member at Rochester General Hospital in Rochester, N.Y.Mary Lu Daly,MS, RN, CCRN, CCNS, is a Clinical Nurse Specialist in the MICU and ENIT program coordinator at the same facility. (Special thanks to Mindee Hite, PharmD, for her contributions.)