sepsis, septic shock, mods

Program for Nursing Curriculum Integration (PNCI®) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome© 2009 METI, Sarasota, FL

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome

PNCI

OverviewSynopsis

The learner is providing care to an elderly gentleman who is a long-term resident of an extended care facility. He was recently treated for a urinary tract infection. He now presents to the Emergency Department (ED) with an altered level of consciousness and hypotension. However, his history of mid-stage Alzheimer’s disease complicates the clinical picture. The patient’s initial presentation meets the systemic inflammatory response syndrome (SIRS) criteria. His clinical status improves after initial fluid management allowing stable transfer to the Intensive Care Unit (ICU). Once in the ICU, the patient’s condition dramatically deteriorates as he manifests septic shock and eventually multi-system organ dysfunction despite aggressive intervention including intubation, mechanical ventilation, IV fluid therapy and vasopressor support. His status eventually progresses to cardiac arrest despite intervention.

This Simulated Clinical Experience™ (SCE™) consists of four states that are transitioned manually at the facilitator’s discretion. With manual transitions, instructors should advance to the applicable state when appropriate interventions are performed. This SCE is intended for the learner in Semester IV.

During State 1 Admit to Emergency Department, the patient demonstrates a HR in the 120s, BP in the 90s/60s, RR in the mid to upper 20s and SpO2 in the mid 90s on room air. Temperature is 35.4°C. He weighs 81.8 kg. Breath sounds are clear bilaterally. The patient’s cardiac rhythm reveals sinus tachycardia. Upon auscultation of heart sounds, S1 and S2 are heard. He is groaning and moans in response to painful stimuli. Only random spontaneous movement is noted. Pupils are equal and reactive to light. His skin is cool and flushed. A 20-gauge IV to saline lock is present in the right forearm. Bowel sounds are normoactive. After the learner inserts the urinary catheter, his urine output averages approximately 10 mL/hr of dark, brown cloudy urine. The learner is expected to perform a complete assessment, place on cardiac and pulse oximetry monitoring, ensure the correct administration of IV fluids and medications, monitor respiratory status, administer oxygen, evaluate effectiveness of interventions, collaborate with the healthcare provider (HCP) regarding the placement of a pulmonary artery (PA) catheter and determines if advance directives are in place.

Between State 1 and State 2, a PA catheter is inserted. Verbal orders are given for a STAT portable chest x-ray to verify the line placement. After verbal orders are given, the learner is expected to clarify the verbal orders by repeating them back to the HCP.

Edgardo YoastAge: 72

Weight: 81.8 kg

Base: Stan D. Ardman


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In State 2 Slight Improvement with Fluids, the patient’s condition initially improves with a HR in the 90s, BP in the 100s/60s, RR in the mid 20s and SpO2 in the upper 90s on 6 LPM oxygen by nasal cannula. Temperature is 36.0°C. Readings from the PA catheter include a central venous pressure (CVP) between 5 and 10, pulmonary artery pressure (PAP) in the upper teens to low 20s/5 to 10 and systemic vascular resistance (SVR) of 1000. Breath sounds are clear bilaterally. His cardiac rhythm reveals sinus tachycardia with no ectopy. He is groaning and moans in response to painful stimuli. Only random spontaneous movement is noted. His skin is cool and flushed. Urine output is dark gold and cloudy at a rate of 25 mL/hr. When the learner calls for lab results, the simulation lab personnel should roleplay the laboratory technician and give a short report of laboratory values – CBC: WBC 27.0, Hgb 11.3, Hct 32%, platelets 104,000; Chemistry: Na 145, K 5.0, BUN 20, Creatinine 1.1, Cl 110, Mg 2.2, CO2 18, glucose 76; Lactate level 6; ABG: pH 3.71, PaCO2 78, HCO3 19; Urine: Blood positive, WBC positive, gram stain shows gram negative rods; ScvO2 71%. When the learner calls for chest x-ray results, simulation lab personnel should roleplay the radiology technician and give the following report – Portable chest x-ray: Unremarkable, pulmonary artery catheter in proper position; no pneumothorax. The learner is expected to reassess the patient, monitor infusion pumps, obtain and interpret lab and x-ray results, inquire about the status and findings of the patient’s advance directives, notify healthcare of significant findings and communicate appropriately with patient. After ICU admission orders are received, the learner should call report to the ICU admitting nurse and prepare the patient for transport.

In State 3 Deteriorates Upon Admit to ICU, the patient’s condition worsens with a HR in the 120s, BP in the 60s/40s, RR in the upper 20s and SpO2 in the upper 50s to low 60s on oxygen at 6 LPM via nasal cannula. Temperature is 35.0°C. Readings from the PA catheter include a CVP of 1 to 5, PAP in the teens/less than 10, cardiac output of 6.0, SVR of 400 and central venous oxygen saturation (ScvO2) of 40%. Crackles are present in both lung fields. His cardiac rhythm reveals sinus tachycardia. His skin is cool and diaphoretic. He is dyspneic and using accessory muscles to breathe. He exhibits no response to painful stimuli. Urine output remains dark gold and cloudy at a rate of 10 mL/hr. Despite their best efforts, the learners are unable to contact the patient’s daughter or verify his living will. The learner is expected to order the ABG and obtain results. When the learner calls for the ABG results, the simulation lab personnel should roleplay the laboratory technician and give the following report – ABG: pH 7.16, PaCO2 53, PaO2 69, HCO3 18. The learner is expected to reassess the patient, interpret findings, place the head of bed flat, monitor infusion pumps, recognize the need for and prepare intubation and mechanical ventilation and notify the HCP of significant findings. After verbal orders are given, the learner is expected to clarify the verbal orders by repeating them back to the HCP. The learner is also expected to assist with intubation and the insertion of arterial line, continually reassess the patient, recognize the need for ABG and a chest x-ray, correctly calculate and initiate norepinephrine infusion, perform nasogastric intubation, verify placement of nasogastric tube and communicate appropriately with the patient. When the learner calls for the chest x-ray result, the simulation lab personnel should roleplay the radiology technician and give the following report – Portable chest x-ray: Endotracheal tube in proper position, lungs with patchy infiltrates bilaterally.


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In State 4 Code Blue, MODS, Death the patient’s condition deteriorates with a HR of 0, BP in the teens/teens and RR per bag-valve-mask device ventilation. His cardiac rhythm initially reveals sinus tachycardia with frequent premature ventricular contractions (PVCs) before rapidly progressing to ventricular tachycardia and subsequently asystole regardless of intervention. There is no urine output and no response to painful stimuli. The daughter has been contacted and is in route to the hospital. When the learner recognizes cardiac arrest, simulation lab personnel should assume the role of the code blue leader and give orders based on advanced cardiac life support (ACLS) protocols. The learner is expected to begin basic life support (BLS) measures, ventilate with the bag-valve-mask device, initiate ACLS measures per protocol, collaborate effectively with healthcare team, communicate effectively with daughter upon her arrival and provide emotional support.

This SCE prepares the learner for the following items of the NCLEX-RN test format:NCLEX-RN Test Plan:

Safe and Effective Care Environment X Management of Care X Safety and Infection Control

Health Promotion and Maintenance X (Aging process)

Psychosocial Integrity X (Therapeutic communication, Family dynamics, End-of-life care)

Physiological Integrity X Basic Care and Comfort X Pharmacological and Parental Therapies X Reduction of Risk Potential X Physiological Adaptations

Author

Jami Nininger and Dawn Hughes, Mount Carmel College of Nursing - Columbus, OH and Thomas J. Doyle, METI - Sarasota, FL Reviewed by Jami Nininger, The Ohio State University College of Nursing - Columbus, OH, 2008 and Christie Pawley, METI - Sarasota, FL, 2009


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BackgroundPatient History

Past Medical History: Alzheimer’s Disease, mild hypertension

Allergies: No known drug allergies

Medications: Atenolol, metformin

Code Status: Has a living will, but no copy is on file at the hospital

Social/Family History: Has one adult daughter who rarely visits him in the nursing home

Handoff Report

The learner is expected to notify the healthcare provider of abnormal assessment findings where appropriate and necessary

The report should follow the SBAR format and include:

Situation:The patient is a 72-year-old male who is brought to the ED today from an area nursing home due to increasing unresponsiveness over the past 24 hours. Admission orders have been written.

Background: He has been a resident of an area nursing home for the past 10 years because his family is no longer able to care for him due to his development of Alzheimer’s disease. His medical and surgical history is fairly insignificant but is positive for mild hypertension for which he receives no medications. His blood pressure normally runs 140 to 160/90 to 95 mmHg. His normal mental status includes responsiveness to his name and following the routine of the extended care facility appropriately. He is normally able to feed and toilet himself, but on occasion, he is incontinent of both urine and stool. The nurse at the nursing home reports the patient had just completed a course of antibiotics for a urinary tract infection.

He has exhibited increasing unresponsiveness over the past 24 hours. He now only responds to painful stimuli by groaning even though his eyes open spontaneously. He does not follow commands. Additionally, his blood pressure has dropped to the low 100s/60s.


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Assessment: Vital signs: HR 126, BP 102/66, RR 26 and slightly labored, SpO2 has been 96% on room air, Temp 35.7oCCardiovascular: Sinus Tachycardia on telemetry monitoringRespiratory: Clear in both lobesGI: Active bowel soundsGU: Has not voided Extremities: Random spontaneous movement that is increasingly weak in all four extremities (2+)Skin: Cool and flushedNeurological: Pupils equal, round and reactive to light, moans to painful stimuli altered level of consciousness off his baselineIVs: 20-gauge IV to saline lock in right forearm, patent and non-reddenedLabs: Ordered upon admissionFall Risk: High-risk Pain: Moaning

Recommendations: Implement admission orders and monitor for instability.

Orders

Initial Healthcare Provider’s Orders:IV 0.9% NS 500 mL IV bolus wide open, may repeat x2 if breath sounds are without rales and systolic blood pressure is below 90CBC, electrolytes, BUN and creatinine, urinalysis, urine culture and sensitivity with gram stain, sputum cultureand sensitivity with gram stain, ABG, blood cultures x2, lactate level, coagulation profile STATOxygen at 6 LPM per nasal cannula, may titrate to maintain SpO2 greater than 94%Chest x-ray STATInsert urinary catheterCefotaxime 1 g IVPB every 6 hours — first dose STATAcetaminophen 625 mg rectal suppository for Temp greater than 38°CContinuous ECG and SpO2 monitoringNPOBedrestVancomycin 1 g IV every 12 hours — first dose STAT

State 1 Orders:STAT portable chest x-ray to verify line placement


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State 2 Orders:ICU Orders:IV 0.9% NS at 20 mL/kg until CVP greater than 8 mmHg; Consult healthcare provider for further orders once CVP greater than 8 mmHgContinuous CVP monitoringVital signs per ICU routineOxygen at 6 LPM per nasal cannula to maintain SpO2 greater than 94%Heparin 3000 units in 500 mL 0.9% NS at 3 mL per hourMonitor ScvO2 every two hours; Get ABG and notify healthcare provider if less than 70%Consult surgical house officer or Acute Care NP for arterial catheter placementNotify healthcare provider for MAP less than 70 mm HgVancomycin 1 gm IV every 12 hoursUrinary catheter to gravity drainageHourly Intake and OutputNotify healthcare provider if urine output less than 0.5 mL/kg/hourCefotaxime 1g IVPB every 6 hoursAcetaminophen 650 mg rectal suppository every 4 hours for Temp greater than 38°CRoutine arterial catheter care and monitoring once line insertedCBC, electrolytes, BUN and creatinine with ABG every AMSerum Lactate level every 8 hoursNPOFull Code Blue until next of kin contacted to confirm Patient Self-Determination Act (PSDA) documentationPT, INR, Type and ScreenBedrest

State 3 Orders:Intubate patientVentilator settings: Vt 500 mL, RR 16, RR 24, mode AC, PEEP 5, FiO2 100%Insert nasogastric tube and place to low wall suctionPortable chest x-ray STAT for endotracheal tube placementRepeat ABG in 30 minutesStart norepinephrine 4 mg in 250 mL D5W at 3 mcg/minute and titrate to keep MAP greater than 70 mmHgRepeat chemistry panel STAT


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PreparationLearning Objectives

Uses patient history and assessment data in the early identification and management •of patients at risk for or with sepsis, septic shock and multisystem organ dysfunction (ANALYSIS).Formulates, prioritizes and individualizes a plan of care based on assessment findings •(SYNTHESIS).Anticipates diagnostic orders and therapies including medications for the •management of patients with sepsis, septic shock and multi-system organ dysfunction (COMPREHENSION).Discusses the possible sequela and consequences of unrecognized and untreated sepsis •(COMPREHENSION).Evaluates and documents the patient’s response to therapies and identifies follow-up •intervention based on patient assessment data (EVALUATION).Discusses the legal, ethical and moral implications of care delivery in the acute care setting •and discusses the concept of medical futility (COMPREHENSION).Identifies the emotional implications of patient death on healthcare personnel involved in •the care delivery of a patient (SYNTHESIS).

Learner Performance Measures

State 1 Admit to Emergency Department:Performs a physical assessment on a 72-year-old male•Documents all findings appropriately•Places on cardiac and pulse oximeter monitors•Identifies cardiac rhythm accurately•Obtains ordered IV fluids•Initiates ordered IV fluid therapy in a timely manner, using the Six Rights and an aseptic •techniqueMonitors the IV infusion for correct operation and•adequate infusion rate•Assesses the IV site for signs of infiltration•Applies oxygen per nasal cannula•Requests lab values•Initiates indwelling urinary catheter using a sterile•technique•Administers cefotaxime and vancomycin according to•the Six Rights•Documents medication administration accurately in•the MAR•Reassesses breath sounds frequently during fluid•resuscitation•Evaluates the effectiveness of the fluid therapy by monitoring the response of the blood •pressureCollaborates with the healthcare provider regarding the patient’s vital signs and evaluated •non-response to IV fluid therapy


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Collaborates with the healthcare provider regarding the placement of a central venous •catheter or central venous catheter with ScvO2 capabilityCommunicates appropriately with patient and offers reassurance•Determines if the patient has advanced directives in place or on file with hospital•

State 2 Slight Improvement with Fluids:Reassesses the patient’s condition and status•Interprets the assessment findings and documents appropriately•Monitors the infusion pump and the patient frequently to ensure the correct operation, flow •rate and early detection of infiltrationObtains and interprets lab and x-ray results•Notifies the healthcare provider of abnormal findings•Frequently reassesses breath sounds•Calls report to ICU RN; providing relevant information•Inquires about the status and findings of the patient’s advanced directives•Communicates appropriately with the patient and offers reassurance•Prepares the patient for transfer to ICU•

State 3 Deteriorates Upon Admit to ICUReassesses the patient, interprets findings and documents appropriately•Places the head of bed flat in response to hypotension•Monitors the infusion pump and patient frequently to ensure the correct operation, flow •rate and early detection of infiltrationRecognizes the need for intubation and mechanical ventilation•Calls for assistance•Collects equipment, supports patient’s airway and prepares for intubation•Notifies healthcare provider of change in patient status•Communicates patient data to healthcare provider in a clear and concise manner providing •relevant information

Interventions After State 3 Orders Received:Prepares for intubation•Assists with intubation•Reassesses patient status and documents•Collaborates with healthcare provider regarding changes in patient status•Recognizes the need to repeat ABG and portable chest x-ray•Notifies lab and radiology of ordered tests•Correctly calculates rate and starts norephinephrine infusion according to Six Rights.•Performs nasogastric intubation, verifies placement and places to suction appropriately•Inquires about status of family contact•Communicates appropriately with patient and offers reassurance•Inquires about results of x-ray in a timely manner•

State 4 Code Blue, MODS, Death:Begins BLS to identify type of arrest•Ventilates with bag-valve-mask device attached to flowing oxygen source•Begins compressions and evaluated effectiveness•Applies defibrillation pads in appropriate locations once available•Charges defibrillator to 200 joules•Clears area to ensure no one is touching the patient or bed•Ensures the safety of the team•


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Continues CPR•Administers ordered emergency medications in accordance with the Six Rights (in •accordance to ACLS protocol)Collaborates with the healthcare team to facilitate care delivery (environmental •management)Ensures documentation is occurring•Communicates effectively with daughter on her arrival•Considers emotional support for daughter (hospital chaplain)•

Preparation Questions

Differentiate the following terms:•Systemic Inflammatory Response Syndrome (SIRS)oSepsisoSevere sepsisoSeptic shockoMultiple organ dysfunction syndrome (MODS)o

Identify the nursing priorities in the care of the patient with sepsis and septic shock.•What class of bacteria is responsible for more than one half of the cases of septic shock? •What are some common causes of this?Explain why myocardial depression is almost always present in a patient with septic shock •despite an initial rise in cardiac output.Discuss the cascade of host inflammatory responses that produce the major detrimental •effects seen in sepsis due to gram-negative bacteria.What is early-goal-directed therapy in the management of sepsis?•Identify the treatment guidelines currently recommended for the management of sepsis •and septic shock.Discuss how the drug dobutamine affects cardiac output. Identify the nursing implications •with the administration of this drug.Discuss how norepinephrine works and its indications for use. Identify the nursing •implications with the administration of this drug.Discuss how drotrecogin alfa works and its indications for use. Identify the nursing •implications with the administration of this drug.Describe the concept of ScvO• 2 monitoring. Identify the significance of abnormally high and low ScvO2 readings.Describe the nursing responsibilities in assisting with central line insertion.•Discuss the importance/rationale for central line placement in a patient with sepsis.•Describe the physiologic alterations of each organ system identified below that may be •associated with aging and potentially impact a patients ability survive sepsis or septic shock.

CardiacoRenaloImmuneoHematologico

If a patient has no advanced directives and no immediate family to make a decision •regarding his care, what options are available to the healthcare team? Discuss if you feel this patient should or should not be a full Code Blue. Defend your position.


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Equipment and Supplies

IV SuppliesDistilled water 1000 mL (label 0.9% Normal Saline) (4)Distilled water 500 mL (label 0.9% Normal Saline) (3)IV pump (3)Pulmonary artery catheterIV tubing for pump (3)Macrobore IV tubingPressure infuser

Medication SuppliesDistilled water 10 mL syringe (label Epinephrine 1 mg/mL) (label Amiodarone 50 mg/mL) (label Lidocaine 10 mg/mL) (3)Distilled water 250 mL (label Norepinephrine 4 mg/250 mL) (label Drotrecogin alpha 2 mg/mL) (2)Distilled water 50 mL (label Cefotaxime 1g)Distilled water 250 mL (label Vancomycin 1 gram)Distilled water 500 mL (label Heparin 3000 units)

Oxygen, Airway and Ventilation SuppliesOxygen flowmeterOxygen sourceNasal cannulaResuscitation bagNon-rebreather maskIntubation trayEndotracheal tube 7.0

Suction Equipment and SuppliesClosed system suction for ventilatorTonsil tip suction deviceSuction tubing (2)Suction canisters (2)Sputum trap

Dressing SuppliesCentral line dressing kitCloth tape (endotracheal tube)Silk tape (nasogastric tube)

Genitourinary SuppliesUrinary catheter insertion tray with gravity drainage bag with urimeterDistilled water 1000 mL with 2 mL yellow food coloring for urine source


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Gastrointestinal Supplies14 Fr nasogastric tube50 mL piston syringe

Miscellaneous Crash cart and defibrillatorVentilatorsPressure tubing and transducer systemSpray bottle filled with distilled waterYellow and red food coloringBottle of ammoniaRose-colored blushStethoscope BP cuff adapted for use with simulatorNon-sterile gloves (1 box)Sharps container Patient identification band Patient chart with appropriate forms and order sheets Audio and visual recording devices

Monitors RequiredECGArterial lineNIBPSpO2

CVPTemperature


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NotesFacilitator Notes

This SCE was created with the patient Edgardo Yoast, and only this patient can be used. The physiological values documented indicate appropriate and timely interventions. Differences will be encountered when care is not appropriate or timely.

If using the Muse platform, don’t hit “Run” until you are ready to start the scenario. If using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the simulated clinical experience.

Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize physical findings the learner is seeking but not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to learner questions if present on your simulator.

Where appropriate, do not provide information unless specifically asked by learner. In addition, ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.

If the patient becomes unconscious in the SCE, remember the patient stops speaking.

It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinical experience. For this patient, dress the simulator in casual clothing and place the simulator in supine position. Apply rose-colored blush to the simulator skin to simulate flushed appearance.

For simulators without the diaphoresis feature, spray the face and other appropriate body areas with water.

When the learner initiates cardiac monitoring, the tracing and heart trate appear on a real ECG monitor for those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchPro or Waveform display ECG tracing.

Prime the Genitourinary system per simulator feature. Remove the catheter as the learner is to insert the urinary cathether in State 1. Add one drop of yellow food coloring to 1000 mL of distilled water. Urine color should be dark and cloudy. Add yellow and red food coloring to distilled water to achieve desired color of urine and add to drainage bag and tubing. Also add a small amount of chalk dust and ammonia to urine mix in drainage bag to complete the effect. Note that this mixture should not be used to prime the simulator’s genitourinary system.

Simulation center personnel should play the following roles:Healthcare provider•Code Blue Leader•Laboratory technician•EMS personnel bringing patient to ED•Radiology technician•Daughter•


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Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners to utilize. The chart should include the specific patient identification information.

Begin simulation with the EMS personnel/Paramedic providing verbal handoff to the admitting unit using SBAR.

Have the learners roleplay inter-professional communication by reporting the patient’s response to interventions. If the data presented is disorganized or missing vital components, have the healthcare provider become inappropriate in response. Emphasize the importance of data organization and completeness when communicating.

Roleplay intra-professional communication by having the learner hand off to the admitting or transferring unit or have the learner hand off to the next shift.

Role-play therapeutic communication with patient to encourage expression of feelings about being a victim of violence.

When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or Treatment Scenario and choose the appropriate flow rate. If using the HPS, no software command is necessary when real oxygen is applied.

When learners provide pharmaceutical interventions, the facilitator should open the Medication Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug recognition feature of the HPS, no software command is necessary when a drug is administered using that system.

When learners provide IV fluid interventions, the facilitator should open the Intervention Option or Treatment Scenario and choose the appropriate fluid and volume to be administered.

Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view a videotape of the scenario afterward for instructional and debriefing purposes.

Debriefing Points

The facilitator should begin by introducing the process of debriefing:Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe-•discussion environment Personal Reactions: Allow students to recognize and release emotions, explore student •reactions Discussion of Events: Analyze what happened during the SCE, using video playback if •available Summary: Review what went well and what did not, identify areas for improvement and •evaluate the experience


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Questions to be asked during debriefing:What was the experience like for you? •What happened and why? •What did you do and was it effective? •Discuss your interventions (technical and non-technical). Were they performed appropriately •and in a timely manner? How did you decide on your priorities for care and what would you change? •How did patient safety concerns influence your care? What did you overlook? •In what ways did you personalize your care for this patient and family members (recognition •of culture, concerns, anxiety)? Discuss your teamwork. How did you communicate and collaborate? What worked, what •didn’t work and what will you do differently next time? What are you going to take away from this experience?•

Teaching Q&A

State 1 Admit to Emergency Department:Does this patient meet the criteria for systemic inflammatory response syndrome (SIRS), sepsis or septic shock?

SIRS, possibly septic shock due to presentation with hypotension•

What is the rationale behind the large fluid resuscitation orders?To improve tissue perfusion in light of low blood pressure•

Why is it necessary to frequently assess breath sounds in this patient while administering large volumes of crystalloid solutions?

The elderly are more likely to have co-existing cardiac disease and have some decrease in •left ventricle (LV) performance with agingWill manifest fluid volume overload more quickly than those without a history or less than 65 •years of ageSepsis causes cardiac suppression that can lead to heart failure manifestations•

Why would cefotaxime and vancomycin be chosen as initial treatment for this patient?Broad spectrum coverage is indicated in the initial management of sepsis•Cefotaxime covers gram-negative organisms commonly associated with urosepsis•Vancomycin is appropriately added to increase the spectrum of organisms covered •because the patient is coming from an extended care facility (ECF) and the source may be nosocomial in nature

How are two sets of blood cultures obtained?Requires adequate cleansing of site and obtained from two separate peripheral accesses•

How will the sputum culture and sensitivity be obtained in this patient?Most likely through nasotracheal suctioning and the use of a sputum trap•Patient will not likely produce a spontaneous cough and cannot follow instructions for •obtainment


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Would a consent be required for the placement of a central line in this patient? Given the severity of illness and the patient’s inability to provide consent, it would be •medically prudent to proceed with central line placement as it is standard of care in the management of septic shock

What are the nursing responsibilities in assisting the healthcare provider with placement of a central line?

Help obtain supplies•Be certain that baseline assessment is established (especially vital signs, including SpO• 2 and lung sounds)Witness if non-emergent consent•Performance of timeout procedure for site placement•Trendelenburg positioning prior to insertion•Monitor patient status during and after insertion (assessing for potential complications)•Dress site as per policy•Notify radiology for portable chest x-ray•Verify radiologic placement of the catheter (healthcare provider verification)•SvO• 2 and CVP set up for monitoring per manufacturer/ institutional policyBegin venous infusion once radiographic confirmation of placement•

What are post-placement pulmonary artery catheter nursing considerations?Monitor for potential complications (bleeding, pneumothorax, dysrhythmias)•Monitor ongoing respiratory status of a patient lying flat•

What is ScvO2 monitoring?Monitoring the venous saturation of oxygen that represents the oxygen reserve of the body•

How might ScvO2 be of use in the patient with sepsis or septic shock?ScvO• 2 can provide information about tissue oxygenation Low ScvO• 2:

Decreased cardiac output (CO) oDecreased Hgb oDecreased SaO o 2Increased oxygen consumption (SIRS, Sepsis, Septic shock) o

High ScvO• 2Increased cardiac output oIncreased Hgb oIncreased SaO o 2Decreased oxygen consumption o

How is a MAP calculated?2x diastolic + systolic/3•

What is the significance of a MAP less than 65 mmHg?Inadequate tissue and organ perfusion•


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State 2 Slight Improvement with FluidsIf no advance directives are found, does that mean the patient is automatically a full-code? Why or why not?

Yes, there is no legal documentation on which to base a change in code status•No legal next of kin present to make the decision for change•

What would be the safest mode of transport to the ICU for this patient?On a cart/bed•Side rails up•Cardiac and SpO• 2 monitoringPortable oxygen on•Need RN and assistive personnel for transport•

Has the patient progressed to septic shock? Why or why not?Meets the criteria for SIRS and sepsis but not the definition for shock as it includes •hypotension that is unresponsive to fluid resuscitationCurrently the patient is responding to fluids•SIRS is defined as the presence of two or more of the following objective sings of systemic •inflammation:

Temp is greater than 38°C or less than 36°C oHR is greater than 90 beats per minute oRR is greater than 20 breaths per minute oWhite blood cell count is greater than 12,000 or less than 4,000 or greater than 10% oimmature forms

Sepsis is defined as SIRS in the presence of a presumed or confirmed infection•Septic shock is SIRS and cardiovascular failure manifested by hypotension unresponsive to •fluids, requiring inotropes and/or vasopressors

State 3 Deteriorates Upon Admit to ICUWhy do the breath sounds now indicate rales?

Cardiac suppression accompanying septic shock is causing manifestations of heart failure•

What is the rationale or intubation for this patient?Clinically manifesting respiratory distress•ABG confirms respiratory failure•Demonstrating hemodynamic instability•Securing airway and supporting respiratory system•

What is the rationale behind changing the position of the patient?Lying flat causes a temporary increase in venous return•Provides a means to support BP as other intervention is being prepared•

What is rationale for drotrecogin alfa infusion?Human activated Protein C exerts an antithrombotic effect•Inhibiting factors Va and VIIIa•Anti-inflammatory effect•Patients with sepsis rapidly produce endotoxins that cause inflammation•


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What are the nursing responsibilities in assisting with patient intubation?Monitoring vital signs and SaO• 2 throughout procedure and communicating changes to the healthcare teamAssessing breath sounds once intubated to ensure bilateral breath sounds•Secure airway•Assess depth (centimeter marking at the lip line) of the endotracheal tube and recording•Monitoring patient respiratory and hemodynamic status on initiation of ventilatory therapy•

How does norepinephrine work?Potent vasoconstrictor•

What is the purpose for using norepinephrine in septic shock?Profound vasodilation secondary to the release of inflammatory mediators is a hallmark •contributor to the profound hypotension seen in septic shockNorepinephrine vasoconstricts the dilated vascular bed to support blood pressure•

State 4 Code Blue, MODS, Death:What predisposed this patient to cardiac and respiratory arrest?

Age•Chronic illness•Severity of septic shock•Impaired tissue perfusion results in multi-system organ dysfunction including pulmonary •and cardiac dysfunction

Could this have been prevented?Early aggressive goal directed therapy is the best practice to promote survival and was •instituted for this patientPrevention and early detection needed also to occur at the extended care facility•

How aggressive should the healthcare team be?Legally, full intervention should be given as a living will could not be found and next of kin •could not be contacted prior to arrest

Is this patient a candidate for receiving activated Protein C (drotrecogin alfa)?Current guideline recommendations indicate adult patients with severe sepsis, low risk •of death (APACHE II less than 20) or one organ failure not receive activated Protein C as studies do not support benefit of decreased mortality in these patients.Only patients with and APACHE II score greater than or equal to 25, with a high risk •of mortality or multiple organ failure should receive this medication as long as no contraindications exist. This patient’s APACHE II score in State 3 is 18.

What is the rationale for drotrecogin alfa infusion?Inhibits macrophage production of tumor necrosis factor, blocks leukocyte adhesion and •limits thrombin induced inflammatory responses

Ethically, what would the quality of life be for the patient if he did survive? Who should make that decision?

Learners should discuss feelings regarding this situation•


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References

Bridges, E. & Dukes, M. (2005). Cardiovascular aspects of septic shock: Pathophysiology, monitoring and treatment. Critical Care Nurse 25, 14-41.

Dellinger, R., Levy, M.M., Carlet, J.M, Bion, J., Parker, M.M., Jaeschke, R., et al., (2008). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine 35, 296-327.

Dries, D. (2007). Cardiovascular support in septic shock. Air Medical Journal 26, 240-247.

Finfer, S. (2008). Corticosteroids in septic shock. The New England Journal of Medicine 2, 188-190.

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