Wednesday, May 6, 2020

Susceptibility Patterns and Genomics of Bacteria †MyAssignmenthelp

Question: Discuss about the Susceptibility Patterns and Genomics of Bacteria. Answer: Introduction To deliver the care for chronic illnesses, multiple factors have to be taken into consideration. It is important for the nurse to consider the patients and the clinical needs. Assessment of patient is an important part of the nursing as it can be life saving. It helps improve the clinical performance, by identifying the priorities of care (Viera, 2016). Primary and secondary assessments are important for the observation, and interpretation of data. It significantly influences the patients diagnosis and the prioritisation of care. Prioritisation of care will help improve the care delivery (Brown, Edwards, Seaton Buckley, 2017). The essay deals with case study of Catherine Bexley, a 77 year old woman, presented to ED with right lower lobe pneumonia. The patient also has the history of heart disease, hypertension, and hypercholesterolemia. In response to the case study the essay discusses the primary assessment using the DRSABCDE approach followed by the focused assessment for respirat ory distress. The essay then discusses the pathophysiology of the shock experienced by the patient and explains the clinical manifestations. Lastly, the essay presents the appropriated nursing interventions, based on evidence to improve Catherines health outcomes. DRSABCDE approach will be used for primary assessment. It stands for Danger, Response, Send for help, Airway, Breathing, Circulation, Disability, Exposure. According to Smith Bowden (2017) it is the systematic approach to immediate assessment and treatment. On assessment of Danger, initially the patient appeared to need HDU however, found safe to ward after oxygen and antibiotics. The DRS assessment showed that patient is conscious and responsive. She was further assessed using PPE. Immediate help required in the ED is that of physician. The patient may be at risk of shock and death due to low oxygen supply. The neurological assessment showed that the patient is complaining of pain and is confused. The airway assessment showed that the Catherine is using her upper accessory muscles. She has decreased air entry to her Right lobe to midzone. There were no noisy respirations found and no sign of cyanosis. On breathing assessment, shortness of breath was found and the patient is having increased effort evident from speaking of short sentences. He patient has pain 5/10 in her Right lower chest with deep. Immediate intervention is needed to prevent to prevent decreased GCS (15/15 in patient), life threatening conditions (Velasco Howard, 2017). The circulatory assessment revealed low BP 90/65mmHg instead of normal 120/80, HR 120 bpm instead of 96 regular, The radial pulse was very weak, with skin flushed and sweaty. The capillary refill is 3 seconds. Her ECG is NAD. Immediate intervention is required as hypovolaemia, pump failure, and vasodilatation (sepsis) causes this breathing problem. Adequate perfusion is needed (Perman, Goyal Gaieski, 2012). Further patient was assessed for disability to rule out possibility of stroke. Catherine was confused to day and place. Further, assessment includes examination of patient head to toe and front and back, showed no sign of haemorrhage but the patient was bleeding as she has removed her IV line. The patient has sign of fever and is ensured to be warm. According to Zhang, Chen Ni (2015) fever, chills, confusion, difficult breathing and significant drop in blood pressure are indicators of septic shock. Thereby, focused assessment is necessary. The relevant focused assessment required in this case is related to respiratory. The red flags for focusing on respiratory assessment are chest pain and shortness of breath. Therefore, the secondary assessment is justified (Nemer Villar, 2015). The oxygen flow rate and delivery device is assessed. It is necessary as the patient demonstrated hypoxia, tachypnoea, tachycardia, hypotension, hyperglycemia condition. The delivery device must be assed as the low flow systems do not provide the adequate ventilatory requirement. The high flow system is used only when approved but meets or exceeds their Peak Inspiratory Flow Rate. Mechanical ventilation is associated with function of lungs (Perman, Goyal Gaieski, 2012). In this case the patient may ensured of high flow system. The patient is assessed for auscultation of breath and type of breath that is cough or deep. Cough is common in pneumonia, a noscomial infection. It is necessary to identify the wheezes, crackles, adequate inspiration and expiration time. Wheeze indicates the narrowed airway and respiratory distress. Sound indicates pulmonary congestion and impaired gas exchange indicates abnormal breathing. Narrowed airway, pulmonary ventilation, perfusion, is common in septic shock (sellars et al., 2016). Further, injuries to the chest wall are observed and assessed for pain, deformities, and movement of chest wall. The rationale is to rule out any clot formation due to inflammatory process. Increased capillary permeability and Vasodilatation also hampers the bodys adequate perfusion indicating sepsis. The chest pain was found to be 5/10 and may be due to clot. Fever and increased heart rate may be due to systematic inflammatory response syndrome trigged by activated immune system (Zhang, Chen Ni, 2015). It is also evident from the high respiration rate evident from the primary assessment. According to Silversides et al. (2015), presence of sepsis leads to systematic inflammatory response syndrome. Heart rate, temperature and respiratory rate are important criteria to confirm infection in respiratory tract. Two of the above criteria is fulfilled and is confirmation for sepsis. It rules out any other major insult to the body such as myocardial infarction. Septic shock is further confirmed by the hypoxemia, hypotension, and oliguria, as they are signs of organ dysfunction (Van Vught et al., 2016). Pathophysiology of septic shock Sepsis is defined as a life threatening organ dysfunction which occurs as a result of infection. The infection may be caused from a variety of conditions such as post operative treatment procedures or due to incomplete cure from a variety of medical conditions. Under sepsis conditions the blood pressure falls below the abnormal level and sufficient oxygen are not transferred to the vital organs of the body leading to ac condition of multiple organ failure (Avni, Lador, Lev, Leibovici, Paul Grossman, 2015). The septic shock leads to tissue perforations where the capillaries start to leak resulting in organ failure. It is defined by persistent hypotension requiring vasopressin to maintain a mean arterial pressure of 65 mm hg or higher and a serum lactate level greater than 2 mmol/L. The signs and symptoms of sepsis vary within the patients such as fevers, chills, rigors, confusion, anxiety, difficult breathing, nausea, vomiting etc. As mentioned by Damiani et al. (2015), the sepsis is further triggered by a variety of clinical conditions such as the presence of chest and pulmonary infections. One of the major features of septic shock is the occurrence of peripheral vasodilatation where the normal mechanisms to vasoconstrict fail in the smooth muscles. Septic shock is further triggered by conditions such as pneumonia. It affects the blood coagulation system resulting in tissue leakage. As mentioned by Liu et al. (2014), sepsis has been mostly recently related to being immune-stimulated. Under sepsis schok cellular changes becomes activated in a deteriorating fashion leading to lymphocyte apoptosis. The systematic inflammatory response syndrome is characterised by a number of clinical conditions and symptoms such as body temperature garter than 38 degree centigrade, heart beat greater than 90 per minute, respiratory rate greater than 20 per minutes along with blood white cells count greater than 12,000 /mm3 (Singer et al., 2016). Additionally the medical professio nal worldwide have further developed another acronym for dealing with the medical condition of the patient suffering from septic shock which is known as PIRO, where P stands for pre-disposition indicating pre-existing co-morbid conditions, I refers to infection, R represents the response to the infectious challenge and O stands for organ dysfunction or organ failure. The septic infection results in disseminated intravascular coagulation (DIC) (Duan et al., 2016). This disturbs the blood coagulation homeostasis resulting in blood to clot when it should not, resulting in clogging of vessels, which further restricts the blood flow in the patient. The dysfunctional vasculature results in local bleeding. Additionally, the tissue perforations results in the contents between the cells to mix, resulting in organ failure by disrupting the normal homeostasis of the body (Semler, Andrews Bernard, 2018). The sepsis shock results in the production of high amount of interleukins which result in the development of hyper inflammatory responses. The tissue in jury also enhances the levels of endotoxin which further triggers the release of cellular cytokines. The release of cellular cytokines further induces widespread secondary infection. The excessive activation of TNF ad endokines would result in suppression of activity of neutrophils, which fail to engulf the phagocytic cells (Andrews et al., 2017). The disturbed homoeostasis also affects the normal mechanism of apoptosis by delayed removal of the neutrophils and hastened removal of the lymphocytes, which further enhances the rate of the infection resulting tissue lyses. The respiratory syndrome has been associated with decreased chemotactic responses, which could be related to disrupted homeostasis of the cell. One of the most serious concerns of the septic shock is the occurrence of multi-organ failure which could enhance the chances of mortality in the patient. The pro-inflammatory and the anti-inflammatory responses lead to mitochondrial or endothelial dysfunction (Semler, Andrews Bernard, 2018). The series of septic shock also affects the normal neurotransmission in the patient. This results in loss of sense regarding time and surroundings and result in the development of utter confusion in the patient. This situation has also been referred to as encephalopathy with sepsis. In this respect, administration of glucorticoids has been seen to relive the condition of sepsis within the patient (Gawlytta et al., 2017). However, the results are debatable as no assured benefits have been obtained for the follow up of the method. Pathophysiology of experienced clinical manifestations The clinical condition of the patient could be studied over here in order to understand the deep rooted pathophysiology of the patient. The patient here depicted a number of clinical conditions as an associated symptom of septic shock. Some of these have been studied in details in order to understand the current health scenario pertaining the patient. Catherines past medical conditions shows that she had a history of cardiac ischemia. Therefore, the disturbed homeostasis owing to sepsis could have hampered the rate of neurotransmission resulting in delayed responses across the sinoatricualr (SA) node of the heart (Toan et al., 2018). The patient recorded a respiratory rate of 36 breaths/ mins. The septic shocks lead to tissue and blood vessels blockage resulting in disrupted flow of oxygen. The patient was admitted to the hospital with decreased air entry to right lower lobe. Additionally, the sepsis shock could further aggravate the condition of the patient leading to airway block. One of the most common clinical symptoms expressed in sepsis is the lock jaw syndrome which could have fatal consequences. As mentioned by Montull et al. (2016), most of the times the lock jaw happens owing to secondary infections caused by pathogens , which gain entry into the body of the patient through catherer port channels. The doctor further examined her symptoms based upon nursing scales and standards such as PEARL which refers to Pupil equal, accommodating and reactive to light. The pupil dilations were noted around 3 mm which signifies a state of anxiety or confusion in the patients. The IDC drainage bag of the patient has 30 ml of urine output which further confirms the presence of oligourea. Additionally, the medical emergency team has suggested the administration of 500 mg of azithromycin to the patient in a 2 L of normal saline solution. The purpose for the admini stration of Azithromycin was to regulate the spread of the sepsis shock infection in the patient. As mentioned by Singer et al. (2016), the use of azithromycin has been associated with more ICU free days for sepsis with or without pneumonia. The sepsis shock and resultant tissue perforations resulted in blood coagulations s directly cutting off the oxygen supply in the patient. Therefore, the patient had been feeing breathlessness. On increasing the oxygen supply the state of panting in the patient could be reduced. Therefore, the patient was put upon increased oxygen supply in order to reduce the chances of a septic shock. As commented by Andrews et al. (2017), the restricted blood flow cuts off the required amount of glucose to the brain resulting in neural shock. Therefore, administration of glucose in standard normal solutions may prevent the chances of a severe septic shock. Therefore, the glucose control acts as substantial protection of the endothelial cells. Therefore, at any point care should be taken to avoid the administration of steroids to the patient. It has seen to produce lethal consequences in the patient resulting in high mortality rates most of the times. Nursing interventions Based on the assessment and the evaluation the prioritisation of care involves oxygen supply followed by fluid resuscitation, blood culture tests and lastly antibiotic therapy. The patient may be provided with significant respiratory support. It includes monitoring and providing adequate oxygen supply. High flow system is used only when approved but meets or exceeds their Peak Inspiratory Flow Rate. In this case the patient may be ensured of high flow system. Mechanical ventilation is associated with function of lungs. The goal would be to maintain SpO2 greater than 94% (Gaudry et al., 2018). It will help reduce the shortness of breath and maximise the oxygen level for cellular uptake. When resting the patients head on bed will be elevated and the position to be change frequently. It will help lower the diaphragm. It will promote aeration of lungs by chest expansion. It will promote the mobilization and expectoration of secretions. It will ensured by nurse that the patient is conscio us and the airway is clear by regular monitoring. Active intolerance is common in this condition due to decreased gas exchange. Therefore, the care will be clustered to conserve the patients energy. It is needed for essential task like ambulation, eating, deep breathing and coughing (Silversides et al., 2015). The patient may then be provided width N/S infusion. A massive fluid resuscitation is required in patient with sepsis. As per instructions from the medical emergency team 2L of Normal Saline 0.9% STAT will be started. A large amount of fluid may be required to maintain the tissue perfusions as the oxygen intake is already low (Silversides et al., 2015). It will help support the circulating volume and overcome hypovolemia and reduce fever diaphoresis (Rastegar, 2015). Adequate precautions will be taken to prevent fluid over resuscitation. According to Semler, Andrews Bernard (2018), sepsis is a combination of arterial dilation, venodilation, intravascular volume depletion, therefore, care will be clustered to address each problem. Prior to commencing antibiotics the blood test may be conducted, as antibiotics may alter the blood test results. For Catherine, appropriate labs shall be obtained that includes antibiotic troughs, ABGs and sputum cultures. For Catherine two sets of blood culture will be taken from separate sites. It will used to check for coagulations, blood glucose level and FBE. The next assessment will comprise of lactate (venous blood gas). The rationale is to assess CRP, LFTs and ELIC. The cultures will be taken without delaying the antibiotic administration. Senior clinician will be informed immediately if unable to access IV or obtain blood cultures. Ensure the blood cultures will be properly examined for identification of appropriate pathogen. Identification of organism is crucial to effective septic shock treatment. The timings of the collection of the lab reports are essential as related to administration of antibiotics and ensure accuracy (Urden et al, 2017). These interventions will be immediately followed by the administration of the antibiotics as the responsibility of nurse. The patient will be assessed for penicillin allergy and use of antibiotics previously that may have caused any side effects. The same will discussed with concerned physician. In case of renal impairment the dosage may be reviewed. Antibiotic therapy will also be discussed with ID service. Currently as per the Medical emergency team advice, Azithromycin- 500 mg will be administered on the right time and in right dosage to ensure efficacy. The use of azithromycin has been associated with more ICU free days for the patient affected with severe sepsis with or without pneumonia. Broad spectrum antibiotics will be used such as methicillin, but the dosage will be balanced against the renal function clearance. If MRSA is detected then vancomycin may be preferred for its efficacy (Hagen et al., 2017). Followed by the above interventions the patient and the family members will be educated on energy conservations, symptoms requiring emergency care, food and nutrition and effective airway clearance as well as coughing and breathing. It is necessary create awareness among patient on these aspects of recovery. It will ensure adherence the treatment protocol and compliance to medication (Viera, 2016). To evaluate the effectiveness of the treatment, and determine the next steps, it is imperative to draw the labs promptly. It is very sensitive in sepsis treatment. Therefore, the lab studies for the neutrophils and band counts will be monitored. Bodys response to the infection is indicated by the elevation of band cells. The room temperature may be decreased as the patient has high fever. Catherine may be provided with the antipyretics and the cooling blankets to save her from chills and shivering. The nursing interventions may further involve continuous monitoring of temperature. The patient may be assisted with tepid sponge bath. According to Zhang, Chen Ni (2015) septic patient has fluctuating temperature. It is essential to maintain the body temperature as an increase in the temperature increases metabolic oxygen demands. The patients cardiac output may be monitored as indicated. The patient will be monitored of the urinary output as the decrease in urine output indicates hypovo lemeia associated with vasodilation (Viera, 2016). Further evaluation may comprise assessment of hemodynamic status, nutritional status and fluid intake and output. The patient may evaluate the patient for hemodynamic stability. It must be evaluated if the patient can verbalise the feelings and understanding of disease process. Based on the findings appropriate discharge and home care guidelines will be provided (Urden et al., 2017). Conclusion In conclusion the essay helped understand the importance of assessment and need of early findings prevent shock. The case study analysis of Catherine has developed insights into the pathophysiology of septic shock and the cause of clinical manifestations. It helped develop the care plan based on prioritisation. It was evident from case study analysis that considering the clients personal and clinical needs is essential in prioritisation of care. 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