Category: Sepsis

Components of Critical Thinking

Assumptions

The patient has sudden deterioration, hyperthermia, chills, tachycardia, oliguria and symptoms of general intoxication, aggravating the main uropathology. There are signs of uncontrolled release of endogenous mediators with the subsequent development of inflammation, organ system damage, or pyemic foci that are separated from the primary focus of infectious inflammation. Most likely, this is a generalized nonspecific infectious and inflammatory process caused by the penetration of uroinfectious pathogens and their toxins into the bloodstream.

Data Inconsistencies

A person with a generalized nonspecific infectious and inflammatory process is often accompanied by vomiting, but this patient does not have this symptom.

Data Clusters

• Neurological System. The patient does not react to external signals; meningeal signs are negative, and cranial nerves are without focal pathology. The patient opens her eyes with loud handling or braking, and pain stimulation. Surface and deep sensitivity is preserved. However, the patient cannot swallow and is not conscious.
• Respiratory System. Breath sounds equal with crackle throughout. This occurs when it is difficult to pass air through the bronchi due to their swelling, filling with sputum, dust, irritating substances or a foreign body entering the lungs through the nasal cavity.
• Cardiac System. The patient has sinus arrhythmia and irregular sinus rhythm. This arrhythmia is caused by fluctuations in the automatic activity of the sinus-atrial node. Most likely, it is associated with changes in parasympathetic regulation, and physiological fluctuations in the frequency of the sinus rhythm are associated with breathing.
• Gastrointestinal System. The abdomen of the patient is soft, flat and non-tender, with diminished bowel sounds. Weakened intestinal motility associated with age-related changes led to the accumulation of gases and the appearance of bowel rumbling. This symptom has no diagnostic significance since it is the norm for a patient 84 years old.
• Genitourinary System. Foley to gravity drains cloudy yellow urine. A dark yellow, almost brown color may indicate an increased bilirubin content. This occurs with the massive destruction of red blood cells after infections and inflammation.
• Skin and Musculoskeletal. The patient has an undated Tegaderm on her coccyx. Her right side is weaker than her left, but she does grip to command with her left hand. The patient has a decrease in strength and increased fatigue of the muscles of the upper extremities.
• Psychosocial. The patient looks at the nurses when they call her name, but they cannot understand her when she tries to talk. She has a deterioration in some areas of cognitive functions, such as articulation. Most likely, this is the result of a weakening of the laryngeal muscles.

Missing Data

Data that is missing that would be beneficial to make stronger conclusions about the patient’s condition includes computed tomography of the urinary organs, the results of excretory urography and ultrasound examination.

Conclusions

Based on the survey data, most of the patient’s systems are within the normal range of acceptable changes. However, the state of the genitourinary system is of concern, the symptoms of pathologies in which are critical and life-threatening. They indicate acute or chronic diseases of the urinary organs.

Most Significant Pathophysiological Process

Etiology

The main risk factors and causes for the development of urosepsis are urinary tract obstruction at any level, congenital uropathies, neurogenic bladder as well as endoscopic interventions on the urinary tract (Prescott & Angus, 2018). Elderly patients, to the group to which this patient belongs, are at the greatest risk of developing urosepsis.

Pathology

The pathogenesis of septic lesions, in this case, is determined by a complex and close interaction of three factors: the pathogenicity of the microorganism, the state of the primary focus of infection and the immunoreactivity of the organism. The development of organ-system damage in the patient is primarily associated with the uncontrolled spread of endogenous proinflammatory mediators from the primary focus of infectious inflammation (Gyawali et al., 2019).

Clinical Manifestations

There is a life-threatening organ dysfunction which is caused by a violation of the regulation of the response to urinary tract infection (Levy et al., 2018).

Diagnostic Tests

This disease is diagnosed using a general urine and blood test, as well as sonography, contrast radiography and CT urography (Levy et al., 2018). As alternative or additional diagnostic methods, MSCT of the kidneys, MSCT cystourethrography, and MRI urography can be recommended (Gyawali et al., 2019). To determine the pathogen, urine is seeded for microflora and a three-time bacteriological seeding of blood is performed.

The rationale for Abnormal Data

Ultrasound of the retroperitoneal space allows to detect of morphological changes in the accumulation of pus (Cecconi et al., 2018). However, the patient’s stomach is soft; this may indicate the initial stage of the disease.

Nursing Plan of Care

Clinical Practice Guidelines

Clinical practice guidelines prescribe the treatment of urosepsis with active infusion and anti-shock therapy and tricyclic glycopeptides, which will fight the focus of infection (Paoli et al., 2018). As auxiliary measures, the authors recommend raising immunity through immunoglobulins and immunomodulators, and blood purification by introduction of plasma substances.

Evaluation of Medical Therapy

Although with late diagnosis and ineffective therapy, urosepsis is characterized by a high probability of death, medical therapy can significantly reduce mortality. The effectiveness of treatment increases significantly when combining empirical and targeted antibiotic therapy.

Rationale for Medical Orders

The main tasks in urogenic septic conditions are elimination of the pathogen, correction of multiple organ disorders, and restoration of homeostasis. Taking into account the severity of the patient’s condition, medical orders are recommended (Cecconi et al., 2018). Etiotropic treatment of urosepsis involves effective rehabilitation of the infectious focus and adequate antibacterial therapy.

Medications

Identification of Questionable Orders

Given the elderly age of the woman, it is necessary to verify with the health care provider which antibiotics can be used for 84-year-old patients (Cecconi et al., 2018).

Legal and Ethical Issues

Legal issues that have been identified in the case relate to the need to start treatment urgently. However, it is not possible to obtain consent from the patient, and her relatives are not in the hospital. On the one hand, it is impossible to start treatment without getting consent, but on the other hand, waiting can lead to a deterioration of the patient’s condition (Cecconi et al., 2018). Ethical issues that have been identified in the case relate to the prescription of expensive drugs to the patient, the purchase of which she may not be able to afford.

The stakeholders are doctors, nurses and patients. Doctors and a nurse should make a decision regarding the start of treatment and prescribing the necessary medications, and the patient should try to assist them and follow the instructions as far as possible.

The nurse should address the issues by making a phone call to the patient’s relatives and discussing controversial issues with them.

References

Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. The Lancet, 392(10141), 75-87.

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., & Levy, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(4), 1181-1247.

Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7(7), 1-13.

Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Medicine, 44(5), 925-928.

Paoli, C. J., Reynolds, M. A., Sinha, M., Gitlin, M., & Crouser, E. (2018). Epidemiology and costs of sepsis in the United States: An analysis based on timing of diagnosis and severity level. Critical Care Medicine, 46(12), 1889-1897.

Prescott, H. C., & Angus, D. C. (2018). Enhancing recovery from sepsis. The Journal of the American Medical Association, 391(2), 62-75.

Introduction

Neonatal sepsis is an infection of the blood that affects infants who are below ninety days of age. There exist two categories of neonatal sepsis, namely: early-onset as well as late-onset sepsis (Belleza, 2021). Early-onset occurs within the first week of birth, while late-onset affects infants who are between one week and three months old. Additionally, in early-onset sepsis, the newborn baby either transmits this infection before or while the mother gives birth. Factors increasing the occurrence of early-onset sepsis include preterm delivery, placenta, and amniotic fluid infection, and in case water breaks more than eighteen hours before birth (Belleza, 2021). Moreover, an extension of hospital stay and the presence of the catheter in the blood vessels contribute to late-onset sepsis in infants. The major bacteria causing sepsis in newborn babies is Group B streptococcus. Other bacteria that cause neonatal sepsis include Escherichia coli, certain streptococcus strains, and Listeria. However, these cases are not rampant in current years due to the introduction of screening technology for pregnant women. This essay critically reflects the care given to a preterm baby on optiflow with sepsis in the neonatal unit during my shift.

Description

The name of the preterm baby was Simon, born at twenty-seven plus two weeks of pregnancy. Simon was delivered through a cesarean section and weighed 779g. After delivery, Simon could not breathe normally, and therefore, he was incubated after forty-five minutes of birth for ventilation breaths. Simon was transferred to the neonatal unit, where he was ventilated for three days. Afterward, a continuous positive airway pressure (CPAP) machine provided him with steady air pressure to assist him in breathing. The last alternative was optiflow which is more comfortable than dry or standard oxygen. Optiflow, also known as Nasal high flow oxygen, provides high-flowing, humidified, and warmed oxygen to patients (Belleza, 2021). Simon was twenty-six days old during the reflection period and was on an eight-liter optiflow. Additionally, the oxygen requirement was between twenty-five and thirty percent.

All safety checks were conducted after handover, and after assessment, it was discovered that Simon had desaturation and frequent bradycardia, which required oxygen stimulation. I also noticed that Simon had a rapid rate of breathing, irritability, and tachypnea. I immediately informed the doctor in charge and the nurse on duty. A partial septic screen (blood cultures, CRP, FBC) was conducted, and began on antibiotics. An x-ray of the chest was done, and respiratory distress was revealed. Lastly, 3.0 lactate was detected through blood gas, and an assessment of pain was administered. Simon looked lethargic, in distress, and unwell. Seeing his condition, I felt sympathy and concern for him. Nurses and other healthcare practitioners need to have the ability to determine and provide care to such infants to increase long-term outcomes.

Nursing Assessment

One of the major responsibilities of nurses is an assessment which should be practiced with utmost diligence and preciseness. A physical assessment was done on Simon to determine any changes in his behavior or condition. The nurse on duty also inspected Simon for any visible distress symptoms, including lethargy, poor tone, and stimuli response. The nurse also watched from baseline the trends in his vital signs such as pulse, pressure, and temperature. In addition, the nurse assessed the pain Simon was going through, measuring some indicators of behavior.

These behavior indicators included: facial expressions, considering contextual indicators like the gestational period at birth and his sleep rate. Some physiological indicators included the level of oxygen in the blood and checking his heartbeat rate. Furthermore, input and output monitoring, also known as body fluid management, was done on Simon. This process is vital as it permits the normal functioning of metabolic activities in the body of the patient. The fluid input was assessed by determining the rate at which Simon became hungry and thirsty, while output was measured by checking stools and urine from their body of Simon.

Hand Hygiene and Aseptic Technique

Adhering to the cleanliness of hands, using individual protective equipment, and an aseptic technique by nurses are crucial in preventing more infections and spreading harmful bacteria and organisms to other patients and workers in a health institution. Depending on the type and effects of the bacteria or organism, practices of controlling these infections might require isolation. In this incident, the nurse wore gloves and rubbed her hands with alcohol when attending to Simon. The purpose of alcohol was to assist in minimizing the occurrence of late-onset sepsis, especially since Simon was a preterm baby.

The nurse insisted that using hand hygiene protocols such as washing hands, hand rubbing, and wearing gloves is important as it significantly minimized the length of stay (LOS) occurrence in preterm babies. This hygiene technique is also important in producing a sustained refinement in the rate of infection. The aseptic technique involves using procedures and practices to curb pathogens and microbes contamination. The septic technique used on baby Simon was the use of sterile masks and gloves. The nurse used an autoclave to sterilize her gloves and mask and also made sure of disposing of all the used equipment.

Maintaining a Neutral Thermal Environment

Instability of temperature is a very common condition in sepsis patients, especially preterm infants. The disadvantage of an unstable temperature is that it minimizes the strength and energy essential to the growth and ability of the body to fight certain infections (Belleza, 2021). This temperature instability was the reason why Simon was moved to an incubator where the nurse regularly monitored his temperature. Humidified oxygen in the incubator also helped prevent Simon from nasal obstruction usually caused by incorrectly positioned prongs and excess nasal secretions. When newborn babies experience unstable body temperature, it can lead to hypothermia, which is associated with higher mortality and morbidity rate. Therefore, body temperature regulation should be considered a basic detail of infant care. There are various reasons why newborn babies are prone to thermoregulation at birth. These reasons include a relatively high rate of metabolism, a large surface area to volume ratio, and a large head compared to the body, which accounts for almost twenty-five percent loss of heat.

Maintaining Fluids and Electrolytes

The nurse made sure that Simon had a balanced intake of fluids and nutrients. Additionally, Simon was given nothing by mouth as a result of an increase in necrotizing enterocolitis, paralytic ileus, and aspiration risks. Management of nutrition, electrolyte, and fluid is essential in preterm infants since most babies in NICU (Neonatal Intensive Care Unit) need IFVs (Intravenous Fluids). These infants also have fluid shifts between extracellular, vascular, and intracellular compartments. The only fluid Simon fed on was breast milk from his mother. Breast milk is highly rich in nutrients required by the baby for his development and growth. Although various commercial milk formulas are designed for use in place of breast milk, most of these formulas contain cow milk. In the NICU, Simon was fed intravenously, that is, using a feeding tube. Here, Simon received three types of nutrition: breast milk, infant formula for preterm babies, and TPN (Total Parenteral Nutrition). Moreover, intravenous access was required after a few minutes of birth, mostly because Simon was a premature baby. The purpose of intravenous access was to administer fluids, nutrients, and medications in the course of postnatal maintenance.

Provision of Adequate Ventilation and Oxygenation

Hypoxemia is regularly associated with sepsis and refers to the insufficient oxygen level in the blood. Therefore, uninterrupted pulse oximetry was required, and subsidiary oxygen was necessary to keep oxygen saturation easy to reach. Simon had a severe sepsis condition, and therefore, he required mechanical ventilation or Continuous Positive Airway Pressure (CPAP). The choice of a clinician on ventilator modes to a serious degree is restricted to the available equipment in the NICU. Although many current ventilators can provide necessary synchronized ventilation modes, many hybrid combinations or modes are unique to each device and manufacturer.

For example, several ventilators can combine Pressure Support Ventilation (PSV) as well as Synchronised Intermittent Mandatory Ventilation (SIMV). In contrast, others only use PSV as an isolated mode with a rate of backup similar to AC (Assist/Control). Even though PSV eliminates the hold of inspiration, thus better synchronization and effective time of inspiration, it was not appropriate for use in the case of Simon. PSV was not ideal because he was a premature infant therefore, the constant in his breathing time was very short: could be below 0.25 seconds. This inspirational duration is not adequate for gas combination and could lead to overly fast rates of respiration.

Maintaining Perfusion

Septic and hypovolemic shock are both types of sepsis complications. Therefore it is essential to monitor blood pressure as well as use inotropes or volume expanders for blood pressure maintenance. An inotrope is a type of drug used to increase the contraction force of the heart while pumping. Since his heart was pumping a very low amount of blood, leading to low blood pressure, an inotrope was required to maintain his blood pressure (Carbone et al., 2020). This assessment was primarily based on clinical signs, and significant advances in technology have provided a thorough comprehension of perfusion. These technologies have also permitted pathophysiology therapy instead of targeting and monitoring blood pressure. This approach was guided by the knowledge that disorders caused by perfusion have diverse causes, and thus using one management viewpoint might cause more harm.

Monitoring Laboratory Results

Laboratory results include CBC (Complete Blood Count), electrolytes, aerial blood gases, and blood cultures. A CBC evaluates the entire health of a patient and detects a variety of disorders such as leukemia, anemia, and infection. Moreover, a CBC test is used to measure distinct features and components of blood such as platelets, white blood cells, hematocrit, and red blood cells, which transport oxygen. The nurse carried out a CBC test on Simon to determine the amount of hemoglobin in his blood and also evaluate any disorders. Overall, these results are essential in determining the rate at which the conditions of infants progress. Another example of a sepsis complication is hypoglycemia which also requires monitoring of blood glucose. Treatment of hypoglycemia includes providing the baby with a rapid-acting glucose source. Generally, glucose in the body of an infant acts as a source of energy for both the body and brain.

Parental Support

Both caregivers and parents of sepsis infants need emotional support throughout the illness period of their child. They should have the appropriate knowledge of the pathophysiology of neonatal sepsis, such as treatments, risk factors, need for isolation, and regular hand hygiene. Nurses and doctors encourage these parents to participate in bonding and care with their infants. When parents are discharged from the hospital, they should be aware of the symptoms and signs of sepsis. These signs include fast breathing, pale or clammy skin, fast heart rate, low temperature or fever, and breath shortness (Belleza, 2021). It is also important to note that these symptoms do not always illustrate sepsis: most of the time, it is not the case. However, if more than one of the signs mentioned above and symptoms occur simultaneously, or the child falls sick often, parents are advised to seek medical attention.

In conclusion, how neonatal sepsis manifests are not specific. A great suspicion index with or without laboratory infection evidence is the only effective method of diagnosing the illness early. Additionally, immediate antibiotic therapy institutions as well as nurturing care will help save a large percentage of neonatal sepsis cases. Various parameters found in the laboratory can also help screen neonates having neonatal sepsis. However, none of these parameters are specific enough to be used alone. The diagnostic technique focuses on reviewing and history of symptoms and signs that are none specific. On the other hand, antibiotic treatment is termed the mainstay treatment of neonatal sepsis, with care and support equally essential.

References List

Belleza, M., 2021. Sepsis and Septic Shock. Nurseslabs. Web.

Carbone, F., Montecucco, F. and Sahebkar, A. (2020) Current and emerging treatments for neonatal sepsis. Expert opinion on pharmacotherapy, 21(5), pp.549-556.

Introduction

Despite developments in disease prevention and health restoration techniques, dangerous conditions requiring prompt interventions, such as sepsis, are still common. Sepsis is a disorder that involves high risks of lethal outcomes and may progress quickly. The condition stems from the immune system’s inadequate reactions to infection, is recognized by using simple screening tools, and can be managed with the help of fluid replacement, sepsis source control, and pharmaceutical treatments.

The Condition’s Pathophysiology

Concerning pathophysiological mechanisms, sepsis results from the immune system’s poorly controlled reaction to the microbial agents it identifies. The condition’s updated clinical definition positions it as a potentially lethal dysfunctional state stemming from “a dysregulated host response to infection” (Olander et al., 2019, p. 2). In certain cases, rather than recruiting white blood cells to particular sites/regions that are most affected by foreign agents, the body’s defense system starts activating them all over the organism, causing sepsis to occur. Overly intensive responses to infections result in damage to the body’s tissues, the immune system’s reduced efficacy, heartbeat irregularities, fever, breathing difficulties, and other symptoms (Olander et al., 2019; Smyth et al., 2019). Overall, the condition occurs due to the body’s inability to keep inflammatory reactions localized.

The Condition’s Recognition in the Field

Septic patients’ urgent need for immediate treatment necessitates strategies to improve sepsis recognition in emergency and prehospital contexts. The Robson five-symptom tool lists temperature abnormalities (<36°C or >38.3°C), high heart rates (>90 beats/min), noticeable mental status alterations, low serum glucose (>120 mg/dl), and bradypnea (>20 breaths/min) as diagnostic criteria (Widmeier & Wesley, 2015). In this tool, any two signs are enough to suspect sepsis. The Robson model has been demonstrated to outperform alternative frameworks, such as the three-component BAS 90/30/90 assessment scale, in accuracy, but prehospital settings commonly administer the two tools simultaneously (Widmeier & Wesley, 2015). Teaching sessions and screening methodologies that cover client categories other than severely septic patients, for instance, the SEPSIS score, are being developed to enable paramedics to diagnose the condition promptly (Smyth et al., 2019). In general, sepsis recognition education for paramedics and screening tool implementation are treated as promising measures for reducing delays in diagnosis.

Management Practices

Effective sepsis management approaches incorporate interventions for early disease detection and protocol-based measures. Common treatments include using fluid resuscitation (FR) techniques to achieve systolic BP exceeding 90 mmHg (Green et al., 2016; Widmeier & Wesley, 2015). The administration of vasopressor medications, for instance, dopamine or norepinephrine, is relevant if FR efforts fail to cause positive responses (Widmeier & Wesley, 2015). As per the National Institute for Healthcare Excellence NG51 guideline, all patients classified as having elevated risks of serious complications or even lethal outcomes resulting from sepsis should receive antibiotics (Smyth et al., 2019). Since the discussed condition tends to worsen quickly, providers should initiate antibiotic therapy within one hour if they diagnose a high-risk case (Smyth et al., 2019). Source control techniques aimed at preventing infectious agents’ further growth are also utilized (Smyth et al., 2019). Thus, sepsis management involves an array of interventions with proven effectiveness.

Conclusion

To sum up, the condition’s pathophysiology and relevant recognition and management practices require close attention to fight it effectively. In prehospital settings, sepsis should be identified as early as possible to initiate treatment without delay and maximize the chances of recovery. Accurate diagnostic tools and teaching practices to increase prehospital settings’ preparedness for identifying and managing sepsis cases shed light on crucial improvement areas in today’s healthcare systems.

References

Green, R. S., Travers, A. H., Cain, E., Campbell, S. G., Jensen, J. L., Petrie, D. A., Erdogan, M., Patrick, G., & Patrick, W. (2016). Paramedic recognition of sepsis in the prehospital setting: A prospective observational study.Emergency Medicine International, 2016, 1-5. Web.

Olander, A., Andersson, H., Sundler, A. J., Bremer, A., Ljungström, L., & Andersson Hagiwara, M. (2019). Prehospital characteristics among patients with sepsis: A comparison between patients with or without adverse outcome.BMC Emergency Medicine, 19(1), 1-8. Web.

Smyth, M. A., Gallacher, D., Kimani, P. K., Ragoo, M., Ward, M., & Perkins, G. D. (2019). Derivation and internal validation of the screening to enhance prehospital identification of sepsis (SEPSIS) score in adults on arrival at the emergency department. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 27(1), 1-13. Web.

Widmeier, K., & Wesley, K. (2015). Assessing and managing sepsis in the prehospital setting.Journal of Emergency Medical Services. Web.