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Assessing a patient

You are making rounds in the intensive care and the nurse reports the patient has spiked a fever, oxygen saturations are below 85%, tachycardia, and variant hypotension. The patient is intubated and has been treated for COVID pneumonia for 10 days. What are some specific aspects of assessment and diagnostic workup on which you would want to focus? Provide three differential diagnoses at this point and what treatment parameters you need to start while ruling out complications. What are the risk factors necessary to take into considerations as you develop treatment parameters for this patient? Think about sepsis from multiple sources of a prolonged ICU stay. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources.

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Sample Answer

Assessment and Diagnostic Workup

The patient’s worsening condition, including the onset of fever, oxygen desaturation, tachycardia, and variant hypotension, raises concerns about potential complications or new infections. A thorough assessment and diagnostic workup are crucial to identify the underlying cause and initiate appropriate treatment promptly.

Specific Aspects of Assessment:

  1. Respiratory Status: Assess the patient’s respiratory effort, breathwork, and oxygenation status. Monitor oxygen saturation levels closely and administer supplemental oxygen as needed to maintain adequate oxygenation.

  2. Cardiovascular Status: Monitor heart rate, blood pressure, and signs of peripheral perfusion. Assess for potential arrhythmias, cardiac tamponade, or myocarditis.

Full Answer Section

  1. Neurological Status: Evaluate the patient’s level of consciousness, pupillary reflexes, and motor function. Rule out potential neurological complications like meningitis, encephalitis, or cerebrovascular events.

  2. Infection Control: Assess for signs of infection at potential sources, including the respiratory tract, urinary tract, intravascular catheters, and surgical incisions. Obtain appropriate cultures to identify the causative organism.

  3. Laboratory Investigations: Conduct a comprehensive laboratory evaluation, including complete blood count (CBC), electrolytes, liver function tests, kidney function tests, coagulation panel, and inflammatory markers (CRP, procalcitonin). Consider blood cultures and respiratory pathogen testing.

Differential Diagnoses:

  1. Worsening COVID-19 Pneumonia: The patient’s recent history of COVID-19 pneumonia and the onset of respiratory distress raise concerns about worsening pneumonia or a secondary bacterial infection.

  2. Ventilator-Associated Pneumonia (VAP): Prolonged intubation and mechanical ventilation increase the risk of VAP, which can lead to respiratory failure and sepsis.

  3. Sepsis from Other Sources: Prolonged ICU stay and invasive procedures increase the risk of sepsis from other sources, such as urinary tract infections (UTIs), intravascular catheter infections (CVCIs), or surgical site infections (SSIs).

Treatment Parameters:

  1. Broad-Spectrum Antibiotics: Pending the identification of the causative organism, initiate empiric broad-spectrum antibiotics to cover potential bacterial pathogens.

  2. Supportive Care: Maintain adequate oxygenation, hemodynamic stability, and nutritional support. Monitor for and manage potential complications like arrhythmias, electrolyte imbalances, and renal dysfunction.

Risk Factors for Sepsis:

  1. Prolonged ICU Stay: Prolonged ICU stay increases the risk of exposure to pathogens and nosocomial infections, leading to sepsis.

  2. Intubation and Mechanical Ventilation: Intubation and mechanical ventilation introduce potential entry points for pathogens, increasing the risk of VAP and sepsis.

  3. Invasive Procedures: Invasive procedures like central venous catheter placement and surgical interventions increase the risk of introducing pathogens and developing sepsis.

  4. Immunosuppression: Underlying medical conditions or medications that suppress the immune system increase susceptibility to infections and sepsis.

Scholarly Resources:

  1. Sepsis in the Intensive Care Unit: A Review of the Epidemiology, Pathophysiology, and Management.

  2. Worsening Respiratory Failure in COVID-19 Patients: A Clinical Review.

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