Case Study: Sepsis
Vanessa Gonzales
UIN# 00845433
Submitted in partial fulfillment of the requirements in the course
N451 Clinical Management of Adult Health Nursing III
Old Dominion University
NORFOLK, VIRGINIA
Fall, 2013
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The focus of this case study will be of a 64 year old Caucasian male diagnosed with
severe sepsis leading into septic shock. The 64-year-old male patient will be referred to as SS
throughout the course of the case study. The purposes of this case study is to identify and
describe the medical diagnosis of SS and determine the nursing interventions, outcomes, and
evaluations that are based on evidence based practice involved in his recovery process.
Medical Diagnosis
The reason for SS hospitalization in the intensive care unit has a partial health history that
takes place at one hospital and the remaining health history that takes part at the hospital he is
currently receiving treatment from. All of the following information regarding SS health history
was noted from his chart.
Toward the end of August SS presented to the emergency department of a different
hospital complaining of severe abdominal pain. His CT scan revealed fluid in the abdomen and
he was scheduled to have abdominal surgery. Once the surgery was under way, the surgeons
were forced to do a vertical midline incision to effectively evacuate 3 liters of murky fluid built
up in the abdomen, which was attributed to a perforated gastric ulcer. As a result of the fluid
built up in the peritoneal cavity, a Jackson-Pratt (JP) drain was placed to continue to drain the
fluid after the surgery was over. However the fluid that was already in the peritoneal cavity prior
to the beginning of the surgery caused peritonitis, which then manifested into sepsis. Following
the procedure, the patient went into Acute Respiratory Failure indirectly related to sepsis. The
patient was then intubated and transferred to the intensive care unit (ICU) of the same hospital.
In the ICU his vertical midline incision had an incident of dehiscence, to which was repaired
with three retention sutures. The ICU gave SS antibiotic therapy, fluid resuscitation, and weaned
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him off of the ventilator. He was then discharged to a rehabilitation facility on oral antibiotics
and with a Foley catheter.
On September 7 SS was admitted to the emergency department of the hospital he is
currently receiving treatment from. He was admitted directly from the rehabilitation facility due
to reported diarrhea, confusion, low urine output, and ripping out his Foley catheter. In the
emergency department SS had a blood pressure of 92/63, a heart rate of 131, a respiratory rate of
24, and a temperature of 40 degree Celsius. A culture was taken of his diarrhea and came back
negative for Clostridium difficile. He was diagnosed with severe sepsis, which encompassed
Acute Kidney Failure due to the low urine output over the course of several days before the
diarrhea started. He also had elevated BUN and creatinine level.
SS was then transferred to the medical intensive care unit (MICU). The MICU placed SS
on contact precautions for a positive culture of Methicillin-resistant Staphylococcus aureus
(MRSA) in the nares and was made aware of his past medical history of anxiety, chronic
obstructive pulmonary disease (COPD), emphysema, and hypertension. SS is a full code
undergoing antibiotic therapy, fluid hydration, and establishing adequate nutritional intake. SS is
currently on 5 L of oxygen via nasal cannula, has a nonproductive cough, and is scheduled to
work with physical therapy everyday because he is unable to ambulate independently. The
medications SS is receiving include Protonix, Cipro, Flagyl, Albuterol, Paxil, and Dilaudid
which is as needed.
In order to determine the nursing diagnoses, interventions, and evaluation of goals, it is
important to understand the pathophysiology of the medical diagnosis of Sepsis. Sepsis is a
systemic infection that results in a systemic inflammatory response that can be fatal to the patient
(McCance & Huether 2010). For this patient in particular, the sepsis resulted from peritonitis, an
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infection in the peritoneal cavity, or abdominal cavity. The peritonitis occurred from the gastric
ulcer that perforated and leaked into the abdomen that is otherwise a sterile environment
(McCance & Huether 2010). This local infection in the abdomen developed into a larger,
systemic infection, meaning it affects the entire body (McCance & Huether 2010). As with any
infection, the body attempts to compensate and rid itself of the infection. The septic body
attempts to compensate by initiating an inflammatory response that affects the entire body as a
system (Urden, Stacy, & Lough 2010). Unfortunately, the body’s attempt to eradicate the
infection can be fatal.
The inflammatory response that sepsis is responsible for results in vasculature
vasodilation, increased capillary permeability, maldistribution of blood flow, and cardiac
malfunction (McCance & Huether 2010). The vasodilation results in a dramatic drop in blood
pressure, increased capillary permeability allows the cells within the body to respond to
inflammation, the maldistribution of blood flow does not allow for all body organs to be perfused
adequately, and cardiac malfunction occurs in an attempt to correct the body’s response
(McCance & Huether 2010). Sepsis, the systemic inflammatory response, and the body’s attempt
to compensate can result in septic shock; this leads to multiple organ dysfunction syndrome
(MODS) and decreased blood pressure, despite the attempts to raise the blood pressure through
fluid resuscitation (McCance & Huether 2010). (McCance & Huether 2010).
Indications that a patient has sepsis can be, but are not limited to an elevated white blood
cell count, a high heart rate, referred to as tachycardia, fever, and rapid breathing, known as
tachypnea (McCance & Huether 2010). SS exhibited an elevated white blood cell count of 22.4
as well as tachycardia, tachypnea, and hypotension, which was documented during his first
admission to the emergency department prior to his surgery. After the surgery, SS went into
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acute respiratory failure, a sign of MODS, but involved only one organ: the lungs. His recent
admission to the current hospital, the patient presented with confusion, low urine output, and was
still hypotensive. Those clinical manifestations suggest possible acute kidney failure, which
would be the second organ needed to officially determine MODS. However, the patient’s lab
values to determine kidney function, BUN and Creatinine, were at optimal levels. This shifts the
focus to the prevention of MODS, rather than the treatment of MODS.
Nursing Diagnosis
While there are multitudes of nursing diagnoses that can be applied to a patient with
sepsis, this case study will only focus on five. Of the five nursing diagnoses stated, two will be
identified as nursing priorities for the patient and his specific needs. The nursing diagnoses that
should be taken into consideration for SS are as follows: Ineffective Tissue Perfusion,
Imbalanced Nutrition, Decreased Cardiac Output, Impaired Skin Integrity and Anxiety. The
priority nursing diagnoses for this patient are Ineffective Tissue Perfusion and Imbalanced
Nutrition.
Decreased cardiac output is a precursor to ineffective tissue perfusion and therefore
generally trumps ineffective tissue perfusion. However, a nurse focuses on individualized,
patient centered care and for SS, decreased cardiac output was no longer an issue. When the
patient’s heart is attempting to compensate for the systemic infection and inflammation, the heart
rate becomes tachycardic. As stated in the pathophysiology of Sepsis, when the heart attempts to
compensate along with the vasculature vasodilation, this causes a decrease in blood pressure
(McCance & Huether 2010). The compensation mechanism of the cardiac muscle is to contract
harder and raise the patient’s heart rate. The faster in which the heart contracts, the less effective
the contractions become and the heart does not adequately supply the body with oxygenated
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blood from the lungs. Due to this natural body response, the heart’s demand for blood increases,
while the supply of blood decreases.
This decrease in blood pressure leads to a decrease in tissue perfusion that is ineffective.
It is important to maintain adequate tissue perfusion and oxygenation by increasing the patient’s
blood pressure to prevent the patient from going into acute kidney failure/MODS. By the time SS
came into my care, his heart rate was controlled in the lower to mid 90s thus tachycardia was a
non-issue. Therefore, the primary priority nursing diagnosis is ineffective tissue perfusion.
The second nursing priority specific to SS is imbalanced nutrition. While the quality of
the patient’s skin appears to be of more or equal importance to the patient’s nutrition, nutrition is
the precursor to wound healing (McCance & Huether 2010). SS has a vertical midline incision
that dehisced, meaning that when the wound tore through the surgical sutures (McCance &
Huether 2010). The wound was reinforced by removing the surgical sutures, leaving the top and
bottom of the wound open to air to promote the drainage of possible infectious secretions, and
the remaining middle area of the wound is secured by three retention sutures. The retention
sutures will be able to be removed once the patient has achieved adequate nutrition. Proper
nutrition facilitates faster wound healing, which in turn will eliminate another possible source of
infection, thus protecting the patient and moving him toward recovery.
Now that the nursing diagnoses for SS have been established, a nursing theorist must be
identified. The theorist that is most applicable to the selected nursing diagnoses is Betty Neuman.
Neuman’s theory is a systems model that looks at an individual as a whole and the factors that
construct that individual (Ross & Bourbonnais 1985). The factors the Neuman refers to are
described as basic survival factors that protect the core of the individual (Ross & Bourbonnais
1985). Surrounding the core of the individual, there are three boundaries, which Neuman
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represents as lines (Ross & Bourbonnais 1985). Each line is necessary to protect the core and
maintain the health of the individual (Ross & Bourbonnais 1985). The three lines or boundaries
identified by Neuman are lines of resistance, lines of defense, and lines of flexibility (Ross &
Bourbonnais 1985). The lines of resistance include the body’s natural responses to maintain
stability and equilibrium, which is known as homeostasis (Ross & Bourbonnais 1985). The line
of defense is what constitutes the individual’s ability to adapt in intelligence, problem solving,
coping abilities, and attitude (Ross & Bourbonnais 1985). The flexible line is the most
susceptible to change because it relates to what the individual learns and does, such categories
include: exercising, socializing, and healthy eating (Ross & Bourbonnais 1985).
Neuman’s model encompasses all five nursing diagnoses selected for SS. Decreased
cardiac output, ineffective tissue perfusion, and impaired skin integrity all fall under the lines of
resistance because each of the diagnoses relate to how the body protects itself to maintain
homeostasis. The patient’s anxiety related to his disease process, health, and pre-existing
condition relate to the patient’s coping abilities, which falls under the line of defense. Lastly,
imbalanced nutrition falls under the flexible line because prior to falling ill the patient reported
unhealthy eating and during his hospitalization he became even more malnourished. Since the
flexible line is more susceptible to change, the nurse will provide patient teaching regarding
healthy eating habits and depending on the patient individually choosing to follow a healthier
eating plan, will determine if the flexible line will change.
Outcomes for Priority Nursing Diagnoses
As stated previously, the top two nursing priorities for SS are ineffective tissue perfusion
and imbalanced nutrition. Once the nurse identifies the priority nursing diagnoses, the nurse will
then identify the desired outcomes for each nursing diagnosis. The nursing outcome will negate
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the nursing diagnoses, thus indicating a positive outcome. The outcome for both nursing
diagnoses will be measurable, realistic, and require a nursing intervention.
The overall outcome for the patient with ineffective tissue perfusion will be: effective
tissue perfusion (Gulanick & Myers 2011). In order to achieve the overall outcome of effective
tissue perfusion, the patient must meet several measurement criteria to ensure effective tissue
perfusion over time. Effective tissue perfusion outcomes will be measured during each nursing
assessment by: strong palpable pulses, warm, dry extremities, a blood pressure within a
therapeutic range, remaining alert and oriented, adequate capillary refill of less than two seconds,
and urinary output of at least 30 milliliters an hour (Gulanick & Myers 2011). The outcomes that
can be measured throughout the nurse’s shift will be: maintaining a mean arterial pressure
(MAP) between 70 to 90 mmHg, the continuity of adequate fluid hydration by infusing fluids as
ordered, and strictly monitoring the patient’s intake and output (Urden, Stacy, & Lough 2010).
The outcomes that can be measured throughout a 24-hour period are daily laboratory draws and
readings to monitor the patient (Gulanick & Myers 2011).
The desired overall outcome of effective tissue perfusion is not attainable within the
timeframe of each nursing assessment, the seven hour nursing shift, or within the 24-hour period
because effective tissue perfusion occurs over time. However, the outcome criteria suggested for
the overall outcome of effective tissue perfusion has been attained within the specified
timeframes. This is because each of the outcome criteria, when appropriately followed by the
nurse, contributes to the accomplishment of effective tissue perfusion over time. During each
nursing assessment SS had: strong palpable pulses of 2+, each assessment showed that he had
warm, dry extremities, which indicated adequate blood flow, a blood pressure within the
therapeutic range with MAPs ranging between 68 to 85 mmHg, he remained alert and oriented
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throughout assessment, which indicates effective cerebral perfusion, and adequate capillary refill
of less than 2 seconds, which indicates adequate peripheral blood flow (Gulanick & Myers
2011). During the seven hour shift, the nurse: monitored for any trends in blood pressure and
MAP, an no alarming trends were noted, the continuity of adequate fluid hydration with 0.9
normal saline running at 125 cc/hr as ordered, which plays a role in maintenance of the patient’s
blood pressure, and the intake of 1,040 cc and urine output for the seven hour shift total was 725
cc which is equivalent to 103 cc/hr, which is well above the minimum of 30 cc/hr, indicating
adequate kidney perfusion and excretion (Gulanick & Myers 2011). During the 24-hour period of
the patient’s daily laboratory readings SS was found to have abnormal levels within each of the
following area: white blood cells 19.1, red blood cells 2.76, hemoglobin 8.3, and hematocrit
24.8; these values require a nursing intervention and suggest an infection that is still present, and
either a possible decrease in kidney functionality related to erythropoietin excretion or
malnutrition (Urden, Stacy, & Lough 2010). The nurse will also provide teaching regarding the
importance of physical therapy related to effective tissue perfusion one time to the patient, but
the teaching session itself is considered a nursing intervention. The learning outcome for this
patient will be nurse-led teaching and be measured by the patient practicing exercising on his
own throughout each day.
As for the patient with imbalanced nutrition, the second overall outcome will be: the
patient will have adequate nutrition. In order to meet the second overall outcome, the patient
must meet several measurement criteria to accomplish adequate nutrition over time. The
patient’s nutritional status will be measured during each assessment by the following outcome
criteria: auscultating the presences of the patient’s bowel sounds and gastrointestinal mobility by
inquiring about the patient’s last bowel movement (Gulanick & Myers 2011). The nurse will
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measure the patient’s nutritional status throughout the shift by the following outcome criteria:
documenting the percentage of each meal eaten, such as breakfast, lunch, and dinner; the
documentation should also include any snacks ingested by the patient (Gulanick & Myers 2011).
The nurse will measure the patient’s nutritional status during the 24-hour timeframe by the
following outcome criteria: monitoring of the patient’s laboratory values and providing daily
teaching regarding healthy food choices and the role of adequate nutrition related to wound
healing (Gulanick & Myers 2011). The learning outcome for this patient will be nurse-led
teaching and be measured by the patient verbalizing the proper foods to eat within two days.
The desired outcome of adequate nutrition is not attainable within the timeframe of each
nursing assessment, throughout the nursing shift, or throughout a 24-hour period because
adequate nutrition is attained over time. However, the outcome criteria suggested for the
outcome of adequate nutrition has been attained within the specified timeframe. The
accomplishment of each outcome criteria over time will result in the accomplishment of
adequate nutrition. During each of the nurse’s assessments the nurse measured the following
outcome criteria: bowel sounds were present in all four abdominal quadrants and the patient
reported daily bowel movements, which suggests adequate gastrointestinal motility (Gulanick &
Myers 2011). The outcome criteria that were measured during the nurse’s seven hour shift: on
day one SS consumed 100% of breakfast consisting of toast and bacon, and ate 20% of lunch
which consisted of turkey and broccoli along with one tea and a vanilla ice cream, on day two
the patient consumed two Ensures for breakfast with 0% of food consumed, and 50% of lunch
which consisted of a grilled cheese sandwich, these pieces of information documented by the
nurse help to determine the sources of the patient’s nutrition and can serve to identify any
deficits (Gulanick & Myers 2011). The outcome criteria that were measured within a 24-hour
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timeframe by the nurse: monitoring the patient’s laboratory values which included abnormal, low
electrolyte levels: calcium 7.7 and potassium 3.4; and abnormal, low visceral protein levels of:
albumin 1.7, red blood cells 2.76, hemoglobin 8.3, hematocrit 24.8 and total lymphocyte count of
700; all of the preceding laboratory values will require a nursing intervention and suggests
malnutrition, the nurse also provided teaching on day one and will determine the effects of the
intervention on day two.
Interventions for Priority Nursing Diagnoses
Once the nurse determines the priority nursing diagnoses, establishes the desired
outcomes, and determines the means in which to achieve the outcome through the establishment
of outcome criteria, the nurse will then determine the nursing interventions necessary to achieve
or maintain the desired outcome criteria and overall outcome.
The patient with ineffective tissue perfusion will have adequate tissue perfusion. In
addition to meeting the outcome criteria during each assessment, vigilant monitoring of the
patient’s vital signs during each assessment can serve as an appropriate nursing intervention
(Gulanick & Myers 2011). The patient’s heart rate should remain within a therapeutic range of
60 to 100 beats per minute (Urden, Stacy, & Lough 2010). The patient’s blood pressure should
remain stable and remain at a mean arterial pressure (MAP) above 60 mmHg which is the
minimum MAP required to perfuse coronary arteries; however a higher MAP between 70 and 90
mmHg is necessary to perfuse the brain and the kidneys (Urden, Stacy, & Lough 2010). The
patient’s temperature will remain near a therapeutic range of 37 degrees Celsius (Urden, Stacy,
& Lough 2010). The nurse will use pulse oximetry to measure the patient’s oxygen saturation,
the patient’s oxygen saturation will remain above 90% due to his history of COPD (Gulanick &
Myers 2011).
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The nurse will also assess the patient hourly for all peripheral pulses and capillary refill
to ensure that the pulses are strong and palpable and that when the skin is blanched, the blood
return to the toes and fingers returns within a two second time frame (McCance & Huether
2010). The nurse will infuse fluids as ordered by the physician to help increase the blood
pressure of the patient (Gulanick & Myers 2011).
The 24-hour timeframe nursing interventions that can be done for SS include the
intervention for the patient’s laboratory values, physical therapy, and teaching. The patient’s
laboratory values that showed abnormal findings require a nursing intervention (Gulanick &
Myers 2011). For the patient’s high white blood cell count, the intervention of the nurse was the
continued administration of intravenous antibiotic therapy to eradicate the infection: Cipro,
Flagyl, and Clindamycin. Low laboratory values of red blood cells, hemoglobin, and hematocrit
and the interventions for these values will be addressed in the interventions for adequate
nutrition. The physical therapist establishes interventions for SS to promote active and passive
range of motion exercises, ambulating the patient out of bed into the chair to facilitate gas
exchange, and improve the patient’s morale (Gulanick and Myers 2011). The nurse’s
intervention regarding physical therapy will be through providing patient teaching and
preparation prior to the arrival of the physical therapist. The nurse will explain to the patient that
he should complete all exercises under the direction of the physical therapist, but to also repeat
those exercises throughout the day to prevent venous stasis and clot formation (Gulanick &
Myers 2011).
Other nursing interventions that can be done as necessary include: the bundling of care to
promote rest in the septic patient, collaborating with the physician about abnormal laboratory
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values and determining how to addresses such values, and administering lovenox, an
anticoagulant as prophylaxis against the development of blood clots (Gulanick & Myers 2011).
Decisions made by the nurse that involved critical thinking for ineffective tissue
perfusion were to preserve the functionality of the kidneys and to prevent acute kidney injury.
This was essential in the nurse’s care because the nurse knew that by giving fluids, maintaining
an acceptable MAP range, and strictly monitoring the patient’s intake and output could greatly
reduce the risk of the development of acute kidney injury, or identify the development of the
injury in enough time to reverse it (Urden, Stacy, & Lough 2010).
The patient with imbalanced nutrition will have adequate nutrition. Outcome criteria for
the achievement of adequate nutrition that required nursing interventions included: 24-hour
abnormal laboratory values that indicated malnutrition and patient teaching. Supplementation is a
nursing intervention that can help normalize abnormal values related to malnutrition and also
blood transfusions may also be utilized as a nursing intervention for low red blood cell,
hemoglobin, and hematocrit levels (Gulanick & Myers 2011). The nurse will supplement
electrolytes based on the reported low laboratory values of calcium and potassium. The patient
will receive supplementation as order within a 24-hour period by the physician for potassium
tablets, calcium carbonate, and vitamin D. To help maintain the adequate electrolyte levels on a
daily basis the patient will also be provided with Ensure Plus, a liquid supplement containing
protein, carbohydrates, fat, potassium, and sodium. Along with macronutrients and electrolytes,
Ensure Plus contains Vitamin A, Vitamin C, and zinc, which play a role in the wound healing
process (Grodner, Long, & Walkinshaw 2012). Due to the patient’s oral intake another
intervention by the nurse will be to keep the head of bed elevated to 90 degrees to prevent
aspiration (Gulanick & Myers 2011). The patient’s hydration status will be monitored but is not
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an immediate issue requiring nursing intervention due to 1,040 cc of intake by the patient within
a seven-hour shift. SS also received teaching regarding nutritional intake and proper food
choices. On day one the patient consumed 100% of his breakfast, but did not drink the Ensure.
As the nurse was taking away the breakfast tray she inquired about untouched Ensure and SS
stated that he did not want to keep the Ensure. The nurse then stated, “We provide the Ensure
with each meal because it contains many nutrients and vitamins that play a role in the restoration
of your health as well helping your wound to heal.” SS stated, “Really? I didn’t know that. It’s
just, I don’t feel very hungry and get full so easily.” The nurse replied with, “That’s
understandable, your body is trying to get used to eating and working correctly again! So, instead
of forcing yourself to eat when you are not hungry, lets focus on foods that are high in protein,
potassium, and calcium since those are the nutrients that your body is lacking. The Ensure that’s
provided should be the first thing you drink due to the nutritional value it has, then if you have
cottage cheese, a boiled egg white, turkey, or vegetables those should be consumed next. If you
have any room left over, eat carbohydrates like bread or pasta; they give your body energy.
Remember, Ensure Plus has proteins, carbohydrates, fats, as well as sodium and potassium so if
you cannot tolerate eating anything, attempting to drink your ensure will get the job done.”
A nursing intervention to consider is the administration of Protonix, a proton pump
inhibitor used for gastrointestinal prophylaxis purposes and the prevention of new formation of
gastric ulcers, since SS sepsis was attributed to a perforated gastric ulcer.
Decisions made by the nurse that involved critical thinking for imbalanced nutrition was
to focus on the importance of nutrition as it related to wound healing and understand how
abnormal laboratory values may suggest more than one clinical problem and how to determine
the appropriate indication. The nurse knew that the retention sutures on the patient’s vertical
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midline incision would be able to be removed once the patient’s nutritional status was strong
enough to take over for the action of the retention sutures. Once the wound was healed, a source
for reinfection could be eliminated (Grodner, Long, & Walkinshaw 2012). The nurse can
determined that the abnormal laboratory values of red blood cells, hemoglobin, and hematocrit
were not due to a kidney injury, but instead malnutrition. The nurse came to this conclusion by
referring to the BUN and Creatinine laboratory values that were within normal limits and a shift
total urine output of 103 cc/hr. Interventions that the nurse can do include blood transfusions and
the administration of erythropoietin to stimulate the production of more red blood cells in the
bone marrow (Gulanick & Myers 2011). However, after the nurse collaborated with the
physician regarding these values, the physician decided against the suggested interventions and
focused on improving the patient’s nutrition.
Interventions in Nursing Research: Literature Review
The three nursing research articles chosen for this case study all relate to achieving the
same outcome: earlier recognition and treatment of sepsis. All articles discuss the difficulty of
identifying sepsis and the high mortality that follows. The articles focus on either standardized
order sets, more effective means of documentation, or care bundles to achieve the outcome and
rely heavily on the nurse’s role of implementation. All of the fundamental ideas of each study
took place in light of the global Surviving Sepsis Campaign, which acknowledged the
importance of diagnosing sepsis swiftly to ensure successful treatment, but did not specify how
to implement timely diagnosis or ensure compliance within multidisciplinary teams in order to
do so (Tromp et. al 2010). Thus, each study proposes ideas in which implementation and
compliance will be the responsibility of the nurse.
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The study for Winterbottom et. al (2011) suggests a conceptual framework that focuses
on nurses utilizing standardized order sets to provide the care necessary for a septic patient.
There are two standardized order sets, one for the emergency department and one for the critical
care unit (Winterbottom et. al 2011). The emergency department implemented 6-hour
resuscitation order sets and the critical care unit implemented 24-hour management bundle; each
bundle was required to have the bundle proposed by the Surviving Sepsis Campaign
(Winterbottom et. al 2011). The study by Winterbottom et. al (2011) hypothesized that in order
to decrease patient mortality, healthcare members needed to improve in their ability to recognize
patients experiencing sepsis or septic shock sooner and improve the process of their care. The
goal of the hypothesis would be met through four steps: (1) The establishment of a Sepsis
Committee responsible for the plan on managing sepsis and appointing a clinical nurse specialist
(CNS), responsible as the link between the clinical setting and the committee, (2) Acquiring
monitoring equipment to measure central venous oxygen saturation and hemodynamic monitors,
(3) the creation of standardized order sets for both the emergency department and critical care
unit, (4) And providing staff education of the pathophysiology, sepsis classification, and the
treatment of sepsis. The method of the study was to establish the four steps and implement them;
the study would be determined as a successful project if the patients were properly identified as a
result of the new standardized order sets (Winterbottom et. al 2011). Data was collected in the
units in which the standardized order sets were used and the timeframe of goal attainment for the
6-hour order sets (Winterbottom et. al 2011). The Sepsis Committee reviewed each individual
case monthly to measure the order sets used, determine goal achievement, and patient outcomes
(Winterbottom et. al 2011). The findings of this study suggest that order sets were used more
effectively in the emergency department to identify sepsis than in the critical care unit to manage
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sepsis (Winterbottom et. al 2011). However, the earlier identification of sepsis due to the 6-hour
order set in the emergency department, led to earlier interventions, which ultimately allowed for
the improvement in the delivery of care in the septic patient (Winterbottom et. al 2011).
The conceptual framework for Gerber (2010) focuses on the Surviving Sepsis Campaign,
and attempts to establish a better way of implementing those ideals by launching a hospital-wide
event. This resulted in the collaboration from multidisciplinary teams including surgery,
medicine, accident and emergency (A&E), clinical decision unit (CDU), and the intensive care
unit (ICU) (Gerber 2010). Gerber’s study (2010) hypothesized by identifying the weaknesses
within Surviving Sepsis Campaign proposal, they could better identify areas in which to increase
compliance. The method of this study was to determine a reference point through auditing each
multidisciplinary area that chose to participate (Gerber 2010). In the ICU, sepsis was
documented to be the result of surgery but there was not clear documentation regarding when
blood cultures were taken and when administration of antibiotics began (Gerber 2010). In
Medicine, it was found that patients presented to the operation room with sepsis prior to the
procedure, but again the issue with blood cultures and antibiotic therapy documentation proved
incomplete (Gerber 2010). The A&E audit found that staff was lacking education on sepsis and
did not have any compliance with the pre-existing sepsis protocols, to which the study provided
the department with a Sepsis Screening Tool and re-audited at a later time (Gerber 201). In
surgery, the same documentation issues were found with blood cultures and antibiotic therapy,
there was no routine blood glucose monitoring or lactate levels done on the patients diagnosed
with sepsis, and the diagnosis of sepsis was often determined by acute respiratory failure (Gerber
2010). The findings of the study included an overall documentation issue, lack compliance to
pre-existing sepsis protocols, and lack of staff education regarding sepsis (Gerber 2011). The
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findings of the study included in order to achieve better patient outcomes and recovery from
sepsis they must implement a standard of practice that includes: one chart that lists the patient’s
pathway that can be found on the intranet, mandatory blood culture policy, clear cut
documentation of the commencement of IV antibiotics in a timely manner to when the order was
written, measurement of serum lactate, central venous pressure line insertion and care,
implement a screening tool across the board, and provide staff with education and training
(Gerber 2010).
According to Tromp et. al (2010), the conceptual framework of this study was to use the
ideas suggested by the global Surviving Sepsis Campaign, but to establish better means of
implementation and incorporate nurses in the process. Tromp et. al (2010) hypothesized by
implementing a nurse-driven, bundle care of a sepsis protocol in the emergency department
implemented by nurses, followed by training nurses, and then receiving the feedback of the
nurses, would determine whether or not the bundling care would be appropriate to suggest to the
Surviving Sepsis Campaign (Tromp et. al 2010). The care bundle included a sepsis-screening list
to determine if the patient has sepsis and the sepsis performance list that was to be completed
after the physician was notified that consisted of seven bundles (Tromp et. al 2010). Once the
nurse identified the septic patient, the nurse was to immediately do a urinalysis and blood culture
(Tromp et. al 2010). To ensure the nurses’ comfort, six months after the implementation of the
protocol, nurse training began (Tromp et. al 2010). Following the training, the nurses were asked
to give their feedback on the care bundles (Tromp et. al 2010). The method of this study was to
utilize the before and after approach, to measure the before, or introduction of the sepsis
screening list protocol, and the after, or the effectiveness of the training and feedback (Tromp et.
al 2010). The findings of the study included that earlier recognition and treatment of patients
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with sepsis occurred with the implementation of the nurse-driven sepsis care bundle protocol
adjunct with training and feedback (Gerber 2010).
Although these studies predominately incorporate the intervention of the nurses within
the emergency department or only show success within the emergency department, each study
specifically pertains to SS. SS passed through not one emergency department, but two, he also
was admitted to not one critical care unit, but two. His first admission to the emergency room
and the critical care unit, the diagnosis of sepsis went over looked. When he presented the
current hospital’s emergency department, he was diagnosed with sepsis and then transferred to a
critical care unit. The current hospital’s standard of practice (SOP) within the emergency
department gives the nurse the autonomy to chose specific pathways related to what the patient
presents with and create orders that fall under the pathway chosen. Once the nurse chooses the
pathway, all order sets in that pathway must be followed, or the nurse is not able to choose the
pathway. In the emergency department at SS current hospital the sepsis pathway was more than
likely chosen, which allowed for laboratory values to be drawn, a urinalysis, and an
echocardiogram which revealed an ejection fraction of 55%. All of the nursing research articles
suggested better way to diagnosis sepsis earlier and should be implemented across the board so
that the detrimental experiences by SS can be considered a concern of the past.
Evaluation
The patient’s progress toward the outcome of effective tissue perfusion and adequate
nutrition was noteworthy. While the outcomes remain unmet for the nurse’s time with the
patient, the nurse can conclude from evaluation of the provided patient teaching that the patient
has the information necessary to meet both desired outcomes in time.
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20
The evaluation of the nurse’s teaching intervention for physical therapy exercises
revealed solely objective data over the course of the next day, while in bed or in the chair SS
would repeat the exercises learned during his physical therapy sessions. Although he did not
verbally state the importance of the exercises, the explanation provided to him was understood
due to his nonverbal compliance.
The evaluation of the nurse’s teaching intervention for adequate nutrition revealed the
objective data of SS listening intently to the explanation provided by the nurse and then by
stating, “Okay, well please leave the Ensure, I will drink it in a little while.” On day two the
nurse arrived onto the unit and completed the morning assessment. SS stated, “Hey! I wasn’t
hungry for breakfast today, but I drank two Ensures.” This statement by SS indicates an
understanding of the teaching intervention provided by the nurse and a successfully met outcome
criterion. The teaching intervention was necessary to establish better food choices throughout SS
lifetime and can be considered a long-term outcome criterion to meet the outcome of adequate
nutrition.
Cultural considerations identified by the nurse for SS included lifestyle factors and
chronic illness factors that related to his decision making in his care. SS reported unhealthy
eating habits during his nutritional screening, which directly related to his lifestyle and choices
that he made. However, do his extensive hospitalization, SS showed objective data that
suggested that he was assuming control of his recovery. SS appeared ready to learn as evidenced
by the effort that he put in during his physical therapy sessions and repeating exercises on his
own time. SS also was ready to learn the nutritional benefits that would assist in his wound
healing and followed the guidelines provided by the nurse to healthy eating without being
prompted.
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Case Study
An alternative plan suggested for this patient includes going back to the start, to the first
admission to the emergency department with complaints of abdominal pain and a CT scan
showing the need for surgery. All three nursing research articles by Winterbottom et. al (2010),
Gerber (2010), and Tromp et. al (2011) suggest that the emergency department should
implement standards that allow for early sepsis identification and Winterbottom et. al (2010)
suggests that critical care units should be able to identify and manage sepsis through a 24-hour
management protocol. The patient should not have been discharged from first hospital without a
sepsis screening and with only the diagnosis of peritonitis.
Alternatively, protocols would have been established at the first hospital SS was admitted
to, emulating the protocols suggested by Winterbottom et. al (2010). The emergency department
would use 6-hour resuscitation protocols to identify and fundamentally treat the sepsis while the
patient awaited surgery, after the surgery was completed the study conducted by Gerber (2010)
should have been implemented by conducting a sepsis screening list in which the patient would
have been determined to have sepsis, and the study conducted by Tromp (2011) would have also
been incorporated by providing the staff with training and education on how to use the protocols
and the pathophysiology of sepsis.
Conclusion
The purpose of this study was successfully met through the identification and description
of the diagnosis of sepsis and how the diagnosis pertains to the nursing care provided to the
patient. Such information was supported through relevant and current literature, as well as
applicable nursing research articles that discussed how to enhance a swifter identification and
treatment of sepsis. It is surprising that the mortality rate of sepsis is so high because it widely
under identified and under diagnosed. By remaining informed with current nursing research, the
Case Study
22
nurse can refine his or her learning process to tailor to the needs of the patient. The education of
the nurse is emphasized in the conclusion of the case study regarding the implementation of the
nurse’s ability to identify the septic patient suggested in all three research articles, which is why
nursing education on the disease process is critical in not only treating our patients, but also
saving the lives of our patients.
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Case Study
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