Toxic Shock Syndrome Nursing Diagnosis and Nursing Care Plan

Nursing Books

Toxic Shock Syndrome Nursing Care Plans Diagnosis and Interventions

Toxic Shock Syndrome NCLEX Review and Nursing Care Plans

Toxic shock syndrome is a rare condition that can result from a bacterial infection. It can be life-threatening and has an acute onset.

Toxic shock syndrome is a complication from an infection by group A streptococcus or methicillin-sensitive and methicillin-resistant staphylococcus aureus bacteria.

When an infection from these types of bacteria occur, exotoxins are released in the body which may then cause toxic shock syndrome.

Toxic shock syndrome can affect anyone, although historically, women using highly absorbable tampons where more susceptible.

This breakout in cases resulted to the discontinuation of these products in the market.

Signs and Symptoms of Toxic Shock Syndrome

The signs and symptoms of toxic shock syndrome can be non-specific and the condition can progress rapidly. In general, the following manifestations can be noted in a patient with toxic shock syndrome:

  • Sudden hyperthermia
  • Low blood pressure
  • Vomiting and diarrhea
  • Presence of a rash resembling a sunburn mostly on the palms and soles
  • Confusion
  • Muscle aches
  • Redness of the eyes, mouth, and throat
  • Seizures
  • Headaches

Causes of Toxic Shock Syndrome

Toxic shock syndrome is most commonly caused by exotoxins released by bacteria such as staphylococcus aureus and group A streptococcus bacteria.

The following are the risk factors associated with this condition:

  • Presence of cuts and open wounds
  • History of recent surgery
  • The use of contraceptive sponges, diaphragms, superabsorbent tampons and menstrual cups
  • Having a viral infection such as flu and chickenpox

Complications of Toxic Shock Syndrome

Toxic shock syndrome has a rapid progression. The complications are often serious and may lead to death.

  1. Shock – the exotoxins produced by the bacterial mediators of toxic shock syndrome acts on the body’s immune response. It can cause T cells in the body to proliferate causing symptoms of shock.
  2. Renal failure – The exotoxins produced by the infection can travel to the circulatory system and can therefore affect different organ systems in the body. The kidneys are mostly affected first. Tissue destruction may occur as a result of the body’s immune response.
  3. Death – due to the progressive characteristic of toxic shock syndrome, the body may not be given enough time to fight off and compensate for the damage. Death from toxic shock syndrome typically occurs within 2 days. In the US, about 3 in 100,000 cases die from toxic shock syndrome.

Diagnosis of Toxic Shock Syndrome

Early diagnosis is important to prevent serious complications including death. Since the clinical manifestations of toxic shock syndrome are often non-specific, a high index of suspicion is necessary to start early treatment.

There is no single diagnostic test to diagnose toxic shock syndrome.

The tests that are typically completed are mostly to provide supportive management and to identify the affected organs in the body.

  • Medical history – history may include obtaining an open wound or a cut anywhere in the body. It may also include history of a recent surgery or maybe the use of contraceptives involving the insertion of a material inside the vagina.
  • Physical Assessment – physical examination will support the information gathered during the history taking. It may also include the identification of new information that the patient may not be aware of. Risk factors and the presence of any other signs and symptoms may also be identified during the assessment.
  • Blood tests – a series of blood tests may be helpful to identify the presence of organ damage. A complete blood count and other blood markers may suggest the presence of an infection.
  • Culture and sensitivity – cultures of tissue or fluid samples may signify the presence of any of the bacterial mediators. Swabs may be taken for this procedure which may come from the throat, cervix, and/or vagina.
  •  Imaging studies will not diagnose toxic shock syndrome although they may be helpful to assess the extent of damage to the patient’s body.

Treatment of Toxic Shock Syndrome

Aggressive forms of management are often required to treat toxic shock syndrome given its serious complications.

  1. Aggressive intravenous fluid hydration. Shock is part of the pathophysiology of toxic shock syndrome. It may involve depletion of intravascular fluids which causes symptoms like low blood pressure and elevated heart rate.
  2. Treatment of soft tissue infections. Bacterial infections are typically caught from a cut or an open wound. Treating soft tissue infections reduces the possibility of further growth of the bacteria or new infections. 
  3. Removal of any possible source of bacterial infection. Other sources of infections may include the use of high absorbing tampons, menstrual cups, and contraceptive diaphragm.
  4. Urgent surgical consultation for possible need of wound debridement or any other surgical treatment. Wounds may sometime appear superficial, but on examination, they may be affecting deeper tissues. Surgical involvement may sometimes be necessary to hasten the healing of wounds anywhere in the body.
  5. Administration of broad-spectrum antibiotics for unidentified organisms. If the bacterial mediator is unknown, a broad-spectrum antibiotic is used. A full course of treatment is necessary which is about 7-14 days.
  6. Vasopressors. Vasopressors are sometimes used to promote vasoconstriction and help the body compensate with the signs and symptoms of the condition.
  7. IVIg administration. This helps neutralize the activities of exotoxins and is often done to help manage toxic shock syndrome.

Nursing Diagnosis for Toxic Shock Syndrome

Nursing Care Plan for Toxic Shock Syndrome 1

Nursing Diagnosis: Hyperthermia related to the disease process of toxic shock syndrome as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Nursing Interventions for Toxic Shock SyndromeRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
Remove excessive clothing, blankets and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s hyperthermia. If the bacterial mediator is unknown, a broad-spectrum antibiotic is used. A full course of treatment is necessary which is about 7-14 days.
Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan for Toxic Shock Syndrome 2

 Nursing Diagnosis: Risk for Septic Shock

Desired Outcome: The patient with establish normal vital signs, balanced input and output, and usual mentation.

Nursing Interventions for Toxic Shock SyndromeRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
Start strict input and output monitoring. Measure the urine output hourly.Decreased urinary output is a sign of diminished renal perfusion, indicating damage to the kidneys due to sepsis.
Assess for changes of level of consciousness/ mentation.Decreasing level of consciousness indicate diminished cerebral perfusion and/or hypoxemia.
Administer intravenous fluid therapy.  To facilitate effective tissue perfusion and maintain circulatory blood volume.  
Administer IVIg as prescribed.This helps neutralize the activities of exotoxins and is often done to help manage toxic shock syndrome.  
Administer vasopressors and inotropic agents as prescribed.To maintain blood pressure level and help improve organ perfusion.
Place the patient on bed rest. Assist him/her with important activities of daily living or ADLs.To decrease myocardial workload and oxygen consumption.

Nursing Care Plan for Toxic Shock Syndrome 3

Nursing Diagnosis: Risk for Trauma/Injury related to loss of sensory coordination and muscular control secondary to seizure

Desired Outcome: The patient will be able to prevent trauma or injury by means of maintaining his/her treatment regimen in order to control or eliminate seizure activity.

Nursing Interventions for Toxic Shock SyndromeRationale
Explore the usual seizure pattern of the patient and enable to patient and caregiver to identify the warning signs of an impending seizure.To empower the patient and his/her caregiver to recognize a seizure activity, and help protect the patient from any injury or trauma. To reduce the feeling of helplessness on both the patient and the caregiver.  
Place the bed in the lowest position. Put pads on the bed rails and the floor.To prevent or minimize injury in a patient during a seizure.
Advise the caregiver to stay with the patient during and after the seizure.To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.
Administer anti-seizure drugs as prescribed.To prevent the occurrence of seizures.  
During seizure, turn the patient’s head to the side, and suction the airway if needed. Use a plastic bite block only when the jaw is relaxed.To maintain a patent airway Avoid inserting the plastic bite block when the teeth are clenched to prevent any dental damage. Do not use wooden tongue depressors as they can break or splinter, causing oral damage.  

Other possible nursing diagnoses:

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Facebookredditpinterest

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.