Septic Shock

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106 Terms

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Define sepsis

Is a life-threatening organ dysfunction caused by a dysregulated host response to infection

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Define Septic Shock

Is a subset of sepsis with persistent hypotension and tissue hypo perfusion despite adequate fluid resuscitation.

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How is septic shock identified?

MAP <65 mmHg despite fluids

Serum lactate > 2mmol/L

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What are the main events for the pathophysiology for septic shock

  1. Infection enters the blood stream —> bacteria releases endotoxins

  2. Immune response is triggered:

  • cytokines released cause vasodilation

  • increase in capillary permeability which increases leakage of fluid from vessels

  1. The results in Hypotension (due to vasodilation, hypoperfusion( due to less oxygen in tissues) and Organ dysfunction (due to lack of oxygen and inflammation)

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What would the vital signs look like

Increased HR

Increased RR

Decreased BP

Normal or elevated Temp

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What is the treatment for septic shock

IV fluids and vasopressors

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What is septic shock?

Septic shock is a severe, life-threatening condition caused by overwhelming infection leading to circulatory collapse, hypotension, and organ dysfunction, despite adequate fluid resuscitation.

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Define oritetanga in the context of nursing

Oritetanga refers to equity—ensuring fair and equitable access to healthcare services, especially for Māori, by addressing barriers and promoting shared power in care.

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What does CAUTI stand for?

Catheter-Associated Urinary Tract Infection.

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What are the early signs of sepsis

Fever or hypothermia, tachycardia, tachypnoea, altered mental status, hypotension, and elevated inflammatory markers (e.g., CRP, WBC)

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List three vital signs commonly altered in septic shock

Blood pressure (decreased), heart rate (increased), respiratory rate (increased).

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What does hypoperfusion mean?

Inadequate blood flow to organs and tissues, leading to oxygen and nutrient deprivation.

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Why is aseptic technique important in catheter care?

It prevents the introduction of pathogens and reduces the risk of CAUTIs

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How do beta-blockers alter the presentation of septic shock in elderly patients like Max?

Beta-blockers can blunt the expected tachycardic response, masking sepsis severity and delaying recognition

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Why must fluid resuscitation be carefully managed in a patient with CHF?

Excessive fluids can precipitate pulmonary oedema and worsen heart failure; balance is needed between perfusion and overload

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Explain how Max’s altered mental status links to septic shock pathophysiology

Sepsis leads to inflammatory cytokine release and poor cerebral perfusion, resulting in confusion or delirium, especially in the elderly.

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How does Max’s age affect his immune response and symptom presentation?

Immunosenescence in the elderly leads to atypical presentations like confusion instead of fever, delayed immune response, and increased risk of deterioration.

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Why might Max be alienated from healthcare despite living in a nursing home?

He may experience institutionalisation, reduced agency in care decisions, infrequent family contact, and communication challenges due to cognitive decline

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Describe how cultural safety applies to caring for Max

It involves respecting his cultural values, ensuring he feels safe, heard, and supported, and addressing any unconscious bias in care.

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What are the ethical considerations around consent in patients with altered cognition?

Assessing capacity is crucial; if absent, the EPOA or legal guardians must be consulted, and decisions should respect autonomy and best interests

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How do you assess fluid balance in a patient like Max?

Monitor input/output, daily weights, observe for oedema or dehydration, and assess urine concentration and vital signs.

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What is the rationale for using broad-spectrum antibiotics early in sepsis?

To quickly target likely pathogens before cultures confirm the source, reducing mortality and controlling infection progression

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Discuss how Max’s comorbidities interact with the pathophysiology of septic shock

CHF compromises cardiac reserve, making fluid resuscitation risky; diabetes impairs immune response; age-related decline slows recovery and exacerbates delirium risk

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Analyse the socio-political barriers Max may face in accessing equitable care.

Ageism, underfunding of aged residential care, disconnection from whānau, and institutionalisation can all limit access to holistic, respectful healthcare.

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How would you advocate for Max if he lacked capacity and had no EPOA in place?

Involve a social worker or mental health team to assess capacity; initiate a Welfare Guardian application if needed; advocate for Max's prior wishes and dignity.

26
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Create a short care plan including 3 SMART goals for Max

  • Maintain SBP >90 mmHg within 4 hours to ensure perfusion.

  • Normalize temperature to <38°C within 12 hours with antibiotics and fluids.

  • Achieve urine output >0.5 ml/kg/hr in 6 hours as indicator of renal function

27
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Explain how a nurse would apply te Tiriti o Waitangi principles to Max’s care.

  • Partnership: Involve Max and whānau/EPOA in care decisions.

  • Protection: Uphold Max’s rights, safety, and privacy.

  • Participation: Encourage Max’s active engagement in care if possible.

  • Equity: Address systemic barriers in his aged care setting

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In what ways can healthcare systems reduce alienation of elderly patients in residential care?

Increase person-centred care, strengthen whānau engagement, train staff in communication and dementia care, and reduce over-medicalisation

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If Max deteriorated further and became non-verbal, how would you ensure he receives culturally appropriate care?

Use non-verbal cues, involve cultural advisors, ensure familiar objects/rituals are present, and maintain communication with whānau or EPOA

30
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Discuss the rationale and risks behind withholding or continuing medications such as ACE inhibitors in septic shock

ACE inhibitors can worsen hypotension in shock; they are often temporarily held to preserve renal perfusion and prevent further blood pressure drop

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How does sepsis lead to altered mental status in the elderly?

Inflammatory cytokines cross the blood-brain barrier, disrupting neurotransmitter balance. Combined with hypoperfusion and metabolic changes (e.g., hypoglycaemia or acidosis), this can cause delirium or confusion—more pronounced in older adults due to reduced cerebral reserve

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Describe the pathophysiology of septic shock

Septic shock begins with an overwhelming infection that triggers a systemic inflammatory response (SIRS). Cytokines cause widespread vasodilation, increased capillary permeability, and microvascular clotting. This leads to hypoperfusion, tissue hypoxia, organ dysfunction, and eventually hypotension unresponsive to fluids

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Explain why Max’s kidney function may be impaired in septic shock

Hypoperfusion leads to reduced renal blood flow, impairing glomerular filtration. This can progress to acute kidney injury (AKI), indicated by decreased urine output and rising creatinine levels

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What is the link between chronic heart failure (CHF) and poor sepsis outcomes?

CHF limits cardiac output, making it harder to meet tissue oxygen demands during sepsis. Fluid resuscitation may precipitate pulmonary oedema, and CHF patients often have altered inflammatory responses.

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Why does hypotension persist in septic shock even after fluid resuscitation?

Persistent vasodilation and capillary leak from inflammatory mediators prevent adequate vascular tone and fluid retention in the intravascular space, requiring vasopressors to maintain blood pressure.

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How would you assess whether Max is responding to sepsis treatment?

Improved blood pressure, rising urine output, clearer mental status, normalising lactate levels, stabilising temperature, and reduced CRP/WBC indicate clinical improvement

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Why are older adults more vulnerable to sepsis and septic shock?

They have reduced physiological reserves (immunosenescence, cardiovascular instability), are more likely to have comorbidities, and often exhibit atypical or delayed symptoms

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What would prompt you to escalate Max’s care urgently?

Signs of worsening hypotension, decreasing GCS, anuria, rising lactate, increasing oxygen demand, or failure to respond to initial fluids and antibiotics

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Why might a MAP (mean arterial pressure) <65 mmHg be critical in Max’s case?

It indicates insufficient perfusion to vital organs; maintaining MAP >65 mmHg is essential to prevent organ failure, especially in the elderly with pre-existing organ compromise.

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What is the rationale for early administration of IV antibiotics in Max’s condition?

Early antibiotics reduce bacterial load and inflammatory response, improving survival. Delays increase mortality risk in septic shock.

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How would you monitor for fluid overload during sepsis treatment in a CHF patient like Max?

Watch for crackles on auscultation, raised JVP, peripheral oedema, sudden weight gain, decreasing SpO₂, and changes in respiratory rate or effort.

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What lab values would be critical to monitor in Max during septic shock?

CRP, WBC, creatinine, urea, electrolytes, lactate, blood cultures, arterial blood gases (ABGs), and urine output

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How does sepsis impact oxygen delivery at the cellular level?

Mitochondrial dysfunction and impaired oxygen extraction occur despite adequate oxygen supply, due to systemic inflammation and acidosis.

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How would you ensure informed consent when Max may lack full cognitive capacity?

Assess capacity first. If impaired, consult EPOA or legal representative. Ensure documentation of all discussions and that decisions reflect Max’s best interests and previous values.

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What steps would you take to ensure culturally safe and equitable care for Max

Avoid assumptions, consult with whānau/EPOA, incorporate Max’s preferences, use culturally appropriate communication, and follow the principles of Te Tiriti o Waitangi.

46
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What does "hypoperfusion" mean in septic shock?

Hypoperfusion refers to inadequate blood flow to organs and tissues, leading to oxygen and nutrient deprivation, cell death, and organ failure.

47
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Define MAP and its clinical significance.

Mean Arterial Pressure (MAP) is the average pressure in a patient’s arteries during one cardiac cycle. It’s vital in sepsis because a MAP <65 mmHg indicates poor organ perfusion

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What is the role of vasopressors in septic shock?

Vasopressors like norepinephrine help restore vascular tone and raise BP when fluid resuscitation alone is insufficient

49
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Why might Max underreport symptoms or discomfort?

Due to generational norms around stoicism, communication difficulties, or cognitive changes. Elderly men often downplay symptoms to avoid burdening others.

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What considerations apply when administering oxygen to Max?

Start with nasal prongs and titrate to SpO₂ targets (>92%). Monitor for confusion or CO₂ retention if history suggests chronic respiratory disease.

51
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How does immobility contribute to complications in Max’s case?

It increases risk of pressure injuries, VTE, pneumonia, and deconditioning—especially relevant in frail, elderly patients in long-term care.

52
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How would you integrate health literacy into Max’s care plan?How would you integrate health literacy into Max’s care plan?

Use plain language, visual aids, involve his EPOA/family, and confirm understanding with teach-back—tailored to cognitive capacity

53
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What ethical dilemmas could arise if Max refuses care but has borderline capacity?

Nurses must balance autonomy with beneficence. If Max is borderline cognitively impaired, legal consultation or EPOA involvement may be necessary to avoid coercion or neglect

54
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How does age-related physiological change affect Max’s response to sepsis?

Reduced cardiac reserve, altered immune response, and diminished renal function make him more prone to rapid deterioration and atypical presentations.

55
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How do you apply the principle of ōritetanga in Max’s care?

By ensuring equity—recognising ageism and healthcare disparities in residential care, actively advocating for Max’s right to timely, respectful, and quality care regardless of his setting.

56
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How would you assess Max’s fluid status without invasive tools?

Check skin turgor, mucous membranes, capillary refill, BP trends, pulse strength, respiratory effort, and urine output

57
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Why is polypharmacy a concern for Max in septic shock?

Older adults often have multiple medications. Sepsis can alter renal/hepatic function, increasing risk of drug accumulation, side effects, and interactions, especially with antibiotics, antihypertensives, or psychotropics

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What strategies reduce polypharmacy harm in elderly patients?

Medication reconciliation, deprescribing when appropriate, involving a pharmacist, and monitoring for adverse effects closely.

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What professionals should be involved in Max’s care and why?

Nurses, physicians, pharmacists, physiotherapists, dietitians, and social workers to address infection, mobility, nutrition, psychosocial needs, and safe transition planning

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What are common reversible causes of delirium in sepsis?

Infection, hypoxia, dehydration, electrolyte imbalances, medication side effects (especially opioids or sedatives), and pain.

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How would whakawhanaungatanga shape your relationship with Max and his whānau?

By building trust through respectful conversation, acknowledging mana, and taking time to connect personally—not just clinically

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What does "protection" under Te Tiriti o Waitangi mean in Max’s context?

Ensuring Max’s dignity, rights, language, and culture are safeguarded in all care decisions—even more vital in vulnerable settings like aged residential care.

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How might institutionalisation in aged residential care contribute to health inequities for Max?

Older residents may face depersonalised care, limited autonomy, reduced visibility in healthcare planning, and difficulty accessing culturally appropriate services — all of which can delay recognition of deterioration like sepsis.

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Why might sepsis be underdiagnosed in older patients like Max?

They may not present with classic signs like fever or tachycardia due to age-related immune response blunting. Instead, subtle signs like confusion, reduced appetite, or general decline are common.

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What causes sepsis?

A dysregulated immune response to infection that leads to widespread inflammation and organ dysfunction.

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What is the main cardiovascular change in septic shock?

Vasodilation and capillary leak, causing hypotension and poor tissue perfusion

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What is lactic acidosis in sepsis?

Accumulation of lactate due to hypoperfusion and anaerobic metabolism in tissues, indicating cellular distress

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What are the renal consequences of sepsis, especially in elderly patients like Max?

Sepsis may lead to acute kidney injury (AKI) due to hypoperfusion, inflammation, and nephrotoxic medications. Older adults are particularly vulnerable due to reduced baseline renal reserve

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How does septic shock impair oxygen delivery to tissues?

Widespread vasodilation and capillary leakage cause hypotension and fluid shifts, reducing perfusion and impairing oxygen transport to cells, triggering anaerobic metabolism

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How does systemic inflammatory response syndrome (SIRS) contribute to organ dysfunction?

SIRS triggers cytokine release, endothelial injury, and microvascular thrombosis, impairing organ perfusion and leading to dysfunction (e.g., renal, pulmonary)

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How does frailty impact the body’s pathophysiological response to infection?

Frail individuals have diminished physiological reserve, which impairs immune response and recovery; this often results in atypical presentation, prolonged inflammation, and higher risk of organ failure

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How does Max’s CHF exacerbate the pathophysiology of sepsis?

His heart’s reduced ability to increase cardiac output worsens hypotension and impairs organ perfusion. Fluid resuscitation may cause pulmonary oedema due to already-compromised cardiac function

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Why are elderly patients like Max more vulnerable to multi-organ dysfunction in sepsis?

Due to decreased physiological reserves, immunosenescence, and coexisting diseases, which reduce the body's ability to compensate for the metabolic demands of sepsis.

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Describe the full pathophysiological cascade from urinary infection to septic shock in Max’s case

A lower UTI progresses as bacteria spreads. In Max’s case, the pathogen triggers an exaggerated immune response. Cytokines and inflammatory mediators cause systemic vasodilation, increased capillary permeability, and endothelial injury. This leads to hypotension, poor perfusion, and mitochondrial dysfunction in tissues — compromising organs like the kidneys, lungs, and brain. In older adults, reduced cardiovascular and immune reserve accelerates deterioration, culminating in septic shock and multiple organ dysfunction syndrome (MODS) if not reversed rapidly

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How does systemic inflammation contribute to multi-organ failure in septic shock?

Pro-inflammatory mediators damage the endothelium, activate coagulation pathways (disseminated intravascular coagulation), and impair cellular oxygen use. This leads to cellular hypoxia, metabolic acidosis, and organ dysfunction (e.g., acute respiratory distress syndrome, AKI, altered mental status)

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Describe how sepsis affects three organ systems in Max and the physiological changes involved.

  • Cardiovascular: Vasodilation and capillary leakage cause hypotension. Max’s weak heart cannot compensate, worsening perfusion.

  • Renal: Hypoperfusion leads to acute kidney injury (AKI), reducing urine output and increasing serum creatinine.

  • Respiratory: Inflammatory mediators and fluid overload may cause pulmonary oedema and impair gas exchange — evident in Max's low O₂ saturations and crackles.

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What does raised lactic acid indicate?

  • Cellular hypoxia (cells are starved of oxygen).

  • Poor tissue perfusion from vasodilation, capillary leak, and hypotension.

  • A strong predictor of severity and mortality — >2 mmol/L is concerning, >4 is critical

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What are the early signs?

  • Warm, flushed skin (due to vasodilation).

  • Tachycardia.

  • Normal or low-normal BP.

  • Elevated respiratory rate.

  • Confusion or restlessness.

  • Elevated lactate.

  • Low urine output begins

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What are the late signs

  • Hypotension unresponsive to fluids (requires vasopressors).

  • Cold, mottled, clammy skin (vasoconstriction sets in).

  • Severe confusion or unresponsiveness (due to poor cerebral perfusion).

  • Anuria or severe oliguria.

  • Multi-organ failure signs (e.g., AKI, liver dysfunction, ARDS)

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What is a critical lactate level in septic shock?

A lactate >2 mmol/L is concerning >4 mmol/L is critical and indicates severe shock.

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What is the defining feature of septic shock compared to sepsis?

Persistent hypotension requiring vasopressors despite fluid resuscitation, plus lactate >2 mmol/L

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Describe how lactic acid builds up in septic shock.

In sepsis, poor oxygen delivery due to hypotension and vasodilation leads cells to switch to anaerobic metabolism, producing lactate as a byproduct.

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What are early signs of septic shock to watch for in an elderly patient like Max?

Tachycardia, warm/flushed skin, increased respiratory rate, mild confusion, low urine output, and rising lactate

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What late signs of septic shock may appear if intervention is delayed?

Cold, clammy skin; hypotension unresponsive to fluids; anuria; severe confusion; multi-organ failure signs

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Why is Max’s advanced age a risk factor for atypical or muted sepsis symptoms?

Older adults often have blunted immune responses, meaning they may not develop a fever or elevated WBCs; instead, they may only present with confusion or lethargy

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Why is Max’s elevated lactate such a critical finding in the context of his clinical picture?

Because it signals inadequate perfusion at the cellular level. Combined with confusion, hypotension, and signs of poor renal output, it suggests Max is in late-stage septic shock and requires aggressive management (IV fluids, vasopressors, ICU support). His age and CHF history increase his risk of poor outcomes.

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How do you differentiate sepsis from septic shock using clinical signs and lab findings?

Sepsis involves signs of infection with organ dysfunction (e.g., confusion, low urine, raised lactate). Septic shock includes persistent hypotension despite adequate fluids and elevated lactate >2 mmol/L — often with signs of perfusion failure like cold extremities and low BP.

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What is a key cardiovascular comorbidity Max has?

Congestive heart failure (CHF)

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How does CHF impact fluid management in sepsis?

Increases risk of fluid overload and pulmonary oedema, so careful titration of IV fluids is necessary.

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How does CHF alter the presentation of septic shock in Max?

It may cause more rapid decompensation due to reduced cardiac reserve; pulmonary symptoms like crackles or hypoxia may worsen with fluid resuscitation.

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What complications can arise if Max receives too much IV fluid?

Pulmonary oedema, worsening hypoxia, and respiratory failure, especially with pre-existing CHF

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why was Max confused

likely confused due to cerebral hypoperfusion

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How does septic shock affect brain perfusion?

It causes vasodilation and hypotension, reducing blood flow to the brain.

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What is the rationale for using IV antibiotics promptly in Max’s care?

Sepsis is caused by a systemic infection. Prompt IV antibiotics target the underlying pathogen, reduce the inflammatory response, and improve survival. Delays in antibiotic administration are associated with increased mortality

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What does an elevated lactate level indicate in the context of Max’s condition

It reflects tissue hypoperfusion and anaerobic metabolism, suggesting cellular oxygen deficit. It is a key marker in diagnosing and assessing the severity of septic shock

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Why must a nurse monitor Max's fluid status closely during septic shock management?

Hypotension and fluid loss due to capillary leak require aggressive fluid resuscitation. However, overhydration risks pulmonary oedema—especially in older adults with compromised cardiac or renal function—so balance is critical.

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What ethical principles are important to consider in Max’s care if his capacity fluctuates

Respect for autonomy (involving him in decisions when able), non-maleficence (preventing harm), and beneficence (acting in his best interest). Ensuring the EPOA is involved and informed is essential when Max lacks capacity.

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What are key nursing responsibilities when managing a patient with septic shock like Max?

Continuous monitoring of vital signs, early escalation of care, administering antibiotics and fluids as prescribed, maintaining oxygenation, preventing secondary infections, and supporting the whānau through communication and culturally safe care

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How might Max’s beta-blocker (Metoprolol) affect the recognition of sepsis?

Metoprolol can blunt the heart’s response by limiting tachycardia, potentially masking early signs of sepsis.

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Why should Entresto be used with caution in septic shock?

Entresto lowers blood pressure, which may worsen hypotension during septic shock, complicating fluid resuscitation and vasopressor needs

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