Critical Thinking in Diagnosing Sepsis

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Table of Contents

Components of Critical Thinking
Most Significant Pathophysiological Process
Nursing Plan of Care
Clinical Practice Guidelines
Legal and Ethical Issues
References

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

Nursing /Collaborative Diagnoses	Measurable Outcome Statement	Priority Interventions with Rationale
The patient has inadequate tissue and organ perfusion, homeostasis disorders and toxemia. These diagnoses are caused by excessive accumulation of endotoxins in the body. The weak immunity of an elderly patient is not able to perceive the pathological changes occurring in the body and activate the mechanisms that prevent these changes.	Restoration of tissue perfusion and normalization of cell metabolism are indicators of successful treatment. A biochemical blood test should demonstrate an established carbohydrate, protein, and fat metabolism as well as the utilization of normal energy sources – glucose and fatty acids.	It is necessary to conduct active infusion and antishock therapy (Gyawali et al., 2019). Thus, the active substances will enter the circulatory system as quickly as possible and the normalization of the patient’s body functions will occur in the shortest possible time.
The patient has a decrease in nonspecific reactivity. Her body has a reduced ability to resist the action of foreign agents by stereotypical mechanisms. Nonspecific resistance is closely related to cellular and humoral mechanisms of the immune response and is necessary for the development of full-fledged immunity, which is also reduced in the patient who is unable to resist infection.	An indicator of a positive outcome will be an immunogram – a blood test, during which the components of the immune system are examined. It will contain a healthy number of cells and their percentage ratio, functional activity as well as the concentration of immunoglobulins and the overall indicators of the blood test.	To strengthen the patient’s immunity, it is necessary to prescribe replacement therapy with specific immunoglobulins and use immunomodulators (Paoli et al., 2018).
It is obvious that the patient has a primary infectious focus, from which pathogens and their toxins penetrate into the blood and lymph, causing the development of bacteremia. This causes activation of the immune system, which reacts by releasing endogenous substances that cause damage to the endothelium of the vascular wall of the urinary organs.	Determination of the elimination of the infectious focus will be carried out using the immunofluorescence method. It is based on the use of specific antibodies marked with fluorescent markers. If there is no evidence of the pathogen and associated antibodies during microscopy, the infectious focus is eliminated.	Since the patient is infected with gram-positive microorganisms, therapy should be supplemented with tricyclic glycopeptides (Levy et al., 2018). They disrupt the synthesis of the bacterial cell wall and have a bactericidal effect.
The patient’s condition is life-threatening due to a sharp decrease in the volume of circulating blood. This was due to the development of hypotension, and the filling of the chambers of the heart negatively affects the size of the shock volume.	Along with clinical signs of normal blood circulation, there are laboratory indicators that allow to assess the volume of circulating blood. The number of red blood cells should be below 3×1012 / l, and the hematocrit should be above 0.35 (Levy et al., 2018).	The introduction of plasma substitutes will be used for therapeutic purposes to replace blood, replenish its volume and correct its composition as a result of intravenous administration (Evans et al., 2021). This will prevent complications associated with large-volume paracentesis, such as reduced effective plasma volume and liver dysfunction.
The patient has significant arterial hypotension. Her condition is characterized by a decrease in blood pressure below 100/60 mm Hg (Prescott & Angus, 2018). These indicators are lower than 20% of normal values (Levy et al., 2018). The syndrome in the patient has persistent indicators of critical levels of systolic and diastolic pressure.	Norm indicators and diagnostic criteria in the analysis of blood pressure are based on the subjective state of the patient, and not just specific numerical indicators. The possibility of subjective and objective signs of hypotension at blood pressure values exceeding these indicators should also be regarded as outcome statement.	It is necessary to introduce crystalloid and colloidal solutions to the patient (Evans et al., 2021). They easily penetrate into the interstitial space, regulate water-electrolyte metabolism and the acid-base state of the blood. Such drugs can improve the rheological properties of circulating blood, activate renal blood flow and have a moderate diuretic effect.

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

Name of Medication	Class of Medication	Indications for Use	Action of the Medication	Nursing Implications
Aztreonam has a bactericidal effect, which is associated with a violation of the formation of the bacterial cell wall.	Aztreonam is the only antibiotic from the class of monobactams, or monocyclic β-lactams, which is used in clinical practice (Paoli et al., 2018). Monobactam antibiotics are similar in structure to penicillins and cephalosporins, since they have a beta-lactam ring in their structure. They are characterized by a wide spectrum of action and effectiveness against some anaerobes.	Aztreonam has a bactericidal effect, which is associated with a violation of the formation of the bacterial cell wall. It has a narrow spectrum of antibacterial activity and is used to treat infections, including urological ones caused by aerobic gram-negative flora. Of clinical significance is the activity of aztreonam against many microorganisms of the Enterobacteriaceae family, including nosocomial strains resistant to aminoglycosides, ureidopenicillins and cephalosporins.	The peculiarity of the antimicrobial spectrum of action of Aztreonam is due to the fact that it is resistant to many beta-lactamases produced by aerobic gram-negative flora, and at the same time is destroyed by beta-lactamases of staphylococci and bacteroids.	Aztreonam is only used parenterally, and is distributed in many tissues of the body. During hemodialysis, the concentration of Aztreonam in the blood decreases by 25-60%, which must be taken into account in the case of this patient (Levy et al., 2018).
Ertapenem is currently the only effective original carbapenem on the American market, which is protected by patent law and which does not have generics.	Ertapenem belongs to the class of carbapenems. At this point in time, carbapenems remain drugs with the widest possible spectrum of activity, while maintaining maximum safety of use, as with all beta-lactams. This is due to the fact that they have a common class effect and affect the cell wall of microorganisms, disrupting its formation.	The basis of the spectrum of action of Ertapenem is its pronounced gram-negative activity (Prescott & Angus, 2018). It is able to penetrate the wall of gram-negative bacteria faster than any beta-lactams.	Starting therapy with carbapenems is necessary in this case, since the patient is in a serious condition. However, it is necessary to replace antibacterial therapy after receiving the results of a microbiological study, if carbapenem therapy has given its result. Clinical monitoring of the effectiveness of antibacterial therapy in the case of Ertapenem should be carried out after 48 hours.	This drug is notable for having a long half-life, which allows it to be driven 1 time a day, which is very important. Like all beta-lactam antibacterial drugs belong to time-dependent medicines, Ertapenem is extremely important to be administered strictly by the hour. Otherwise, the bactericidal concentration falls below the minimum and the selection of resistant strains begins.
Amikacin is one of the most commonly used drugs in clinical practice. It has a more powerful bactericidal action than beta-lactams, which develops more quickly.	Amikacin belongs to the class of aminoglycosides, which are divided into three generations based on their microbiological activity and ability to overcome acquired drug resistance (Paoli et al., 2018). Amikacin is the only one of the classes belongs to the third, new generation. The main clinical significance of aminoglycosides is in the treatment of nosocomial infections caused by aerobic gram-negative bacteria.	Amikacin has a high variability of pharmacokinetics, due to which the drug penetrates strongly into sputum, bile and cerebrospinal fluid. Further, with nephrotoxicity, it reduces the activity of hypoxia and acidosis in the patient. Using the property of pronounced synergy between aminoglycosides and beta-lactams, Amikacin stops the focus of infectious inflammation.	All aminoglycosides, including Amikacin, should be used exclusively against gram-negative flora. This is due to the fact that they have a post antibiotic effect against gram-negative pathogens. The antibacterial effect of the drug is associated with a violation of protein synthesis on ribosomes.	Amikacin is best administered intramuscularly, since after this injection, the maximum concentration is reached in 30-60 minutes (Evans et al., 2021). And when taken orally or rectally, less than 1% of the drugs are absorbed (Evans et al., 2021). Amikacin is well absorbed, so it should be used very carefully, in very limited areas and in very small quantities due to the risk of side effects.
Ciprofloxacin is used against Pseudomonas Aeruginosa strains, as they have extremely high sensitivity to Cipro. This drug is vital in the treatment of urological infections.	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. Etiotropic treatment of urosepsis involves effective rehabilitation of the infectious focus and adequate antibacterial therapy. Ciprofloxacin refers to fluoroquinolones.	Ciprofloxacin has a high activity against pathogens of urogenic infections. It is used against streptococci (including penicillin-resistant strains) and septic mycoplasmas (the very pathogens for which Ampicillin does not work). The main indications for it are infections of the genitourinary system.	The drug is used at a dose of 500 mg once a day for elderly patients (Gyawali et al., 2019). However, Ciprofloxacin is a dose-dependent drug and it is the right dose that will achieve the desired effect in treatment, so it is necessary to gradually increase the dosage for the patient. The activity of Ciprofloxacin is ensured by inhibiting two vital enzymes of the microbial cell – DNA gyrase and topoisomerase IV. This leads to disruption of DNA synthesis and the replication process of the LHC cells.	This drug has a large number of potential adverse reactions. Therefore, it is necessary to monitor the elderly patient for allergic reactions, photosensitization, headache, dizziness and sleep disorders. If any of their symptoms appear, Lomefloxacin and Parfloxacin should be administered, and the attending physician should be notified (Prescott & Angus, 2018).
Ampicillin is almost identical to amoxicillin in the antimicrobial spectrum.	Ampicillin belongs to the class of penicillins. Common properties for this group are the presence of a beta-lactam ring in the structure and a bactericidal effect by acting on the cell wall of microorganisms. It also has a low toxicity characteristic of penicillins.	Unlike penicillin, it differs by a more extended spectrum of action due to individual representatives of the Enterobacteriaceae family and anaerobes. It is a broad-spectrum antibiotic and is destroyed by beta-lactamases of both gram-positive and gram-negative bacteria.	The drug is a three-component which contains penicillins that destroy penicillinases and cephalosporins that destroy cephalosporins of I-II generations. It also includes extended-spectrum beta lactamases that combine the properties of three generations of penicillins (Paoli et al., 2018). Amoxicillin is used when ingested. Its main advantage is the increased sensitivity of pathogen to this drug. If it is used by parenteral administration, no more than 30% of the administered dose reaches the vascular bed (Paoli et al., 2018). This is due to the fact that the drug is quickly and effectively destroyed by bacterial protection enzymes.	The drug has a time-dependent effect, and should be prescribed strictly by the hour, at regular intervals. The drug has a very short half-life, and therefore requires its 4-6 single administration per day (Evans et al., 2021). However, the drug has a high price, so the nurse should clarify whether the elderly patient’s family is able to pay for the use of this drug.

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.

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