1 Week 6 Discussion - Case Study Sepsis – and septic shock – have had a few definitions since the first around twothousand years ago (University of Pennsylvania, 2020). Initially, clinicians managing sepsis would approach it like they would SIRS or systemic inflammatory response syndrome, by seeing if the patient had two or more of the criteria. Recent research has shown that although sepsis manifests a systemic response to an infectious process, it is a dysregulated host response identified by the dysfunction of one or more organ systems, instead of a predictable cascade of the inflammatory process (University of Pennsylvania, 2020). What does that mean, a dysregulated host response and dysfunctional organ systems? Furthermore, how do nurses and clinicians recognize the early manifestations before it presents as septic shock and the patient becomes another statistic, which according to the case study on GeroClinSim, sepsis is the tenth leading cause of death in the United States (Durham RN, MSN et al., 2020). The definition presented in the case study has changed – as cases are not all characterized by SIRS like it states (Durham RN, MSN et al., 2020). Newer research has shown that infection is a dominant factor in sepsis, but not the sole consideration; organ dysfunction that is unexplainable is cause for concern, and thus a vital manifestation when assessing patients (University of Pennsylvania, 2020). The main issue is applying the criteria for SIRS when it doesn't apply to sepsis or the pathophysiology of the disease. This criterion includes a temperature above one-hundred-andfour or below eighty-nine point eight, a heart rate above ninety beats per minute, a respiratory rate higher than twenty breaths per minute, or a partial pressure carbon dioxide of less-than thirty-two millimeters of mercury, and a WBC count of greater-than twelve-thousand mm³ (University of Pennsylvania, 2020). For example, if an elderly patient is brought into the 2 emergency department only fulfilling just one of the SIRS criteria – let's say heart rate of one-ten (he also has chronic atrial fibrillation) - with a new onset of abdominal pain. Additionally, his daughter says that he has been 'acting funny' all day, she can't pinpoint any exact reason though. It could result in a delay of care or delay in transfer to the ICU. Subsequently, the elderly do not manifest signs and symptoms like young or middle-age people do; their immune response is sluggish, and sometimes they unable to manifest an elevated WBC count or temperature (Durham RN, MSN et al., 2020). The heart rate in the elderly can be affected by medications or mechanical devices such as pacemakers and defibrillators, making tachycardia challenging to factor into the SIRS guideline. An inexperienced or new nurse can misinterpret signs and symptoms for other comorbid conditions, delaying care (Durham RN, MSN et al., 2020). The nurse described in the sepsis case study at GeriClinSim.org gave extraordinarily prompt and efficient care, so the recognition of sepsis wasn't an issue. The patient was a seventyyear-old paraplegic who was post-operative after debridement of a sizeable sacral ulcer; comorbidities included diabetes mellitus, hypertension, COPD, multiple urinary tract infections with a permanent foley catheter. In addition to his history of depression, the patient's wife died six-months before hospitalization, and his daughter was a busy and rushed woman. The morning vitals indicated a temperature that was ninety-eight-six, respiratory rate of eighteen breaths-perminute, heart rate at one-oh-five, blood pressure one-hundred over sixty, oxygen saturation ninety-four percent on two-liters of oxygen via nasal cannula. His morning blood-sugar was fivehundred-and-fifteen; this is alarming since it is before breakfast. According to the SIRS checklist, at this point, he doesn't qualify for transfer to ICU. The nurse begins to perform her dressing change to the stage IV ulcer to his sacrum, noticing purulent exudate, erythema, and warmth are present. She attempts to wake the patient, 3 and it becomes apparent that he has an alteration in mental status with no history of dementia when he calls her by his late wife's name – but his blood sugar is astronomically high. His presurgical Mini-Mental State Examination was twenty-nine out of thirty, which is normal. Thinking quickly, she performs a Glasgow coma scale exam on him, and the score is eleven, indicative of a decreasing level of consciousness and a change in condition. She also performs a CAM (confusion assessment algorithm) on the patient, which has four features, requiring either features one and two to be present along with feature three or feature four (Durham RN, MSN et al., 2020). Feature one includes an abrupt onset and fluctuation in nature; feature two is an inattentive patient; feature three includes disoriented thinking, and feature four is an altered level of consciousness (Durham RN, MSN et al., 2020). Currently, the patient has all four features of the confusion assessment algorithm. The SOFA, or sudden organ failure assessment, is mentioned within the context of this case study. The SOFA is a system designed to correlate diagnostic studies with another algorithm for the susceptibility that the patient has or will develop organ failure. This method is useful, but it is effective after a diagnosis of sepsis. What researchers have done is taken the muddled definition of SIRS, like discussed earlier, and created another tool to systematically screen patients for the likelihood for developing septic reactions. They have also removed terms that are either too vague or redundant – like septicemia (too ambiguous) or severe sepsis (redundant) (University of Pennsylvania, 2020). This screening tool is called qSOFA, an acronym for quick sudden organ failure assessment. Earlier in the case study, when the patient had a blood pressure of one-hundred over sixty and altered mentation, he qualified for organ dysfunction and sepsis according to the quick sudden organ failure assessment. The qualifiers include respiratory rate higher than or equal to 4 twenty-two breaths per minute, altered mentation, or a systolic blood pressure less than or equal to one-hundred millimeters of mercury (University of Pennsylvania, 2020). Each criterion is one point, and a score of two or higher, along with a suspected infection, are indicative of a poor outcome (University of Pennsylvania, 2020). Instead of focusing on inflammation, the process with qSOFA focuses on organ dysfunction and treating the infection; even within the case study, monitoring hemodynamics – the MAP, perfusion, fluids and electrolytes, fluid resuscitation, were the main priority. Treatment with glucocorticoids and antihistamines weren't part of the plan of care as they are with inflammatory processes like anaphylactic shock (Durham RN, MSN et al., 2020). No matter what definition is ultimately given to sepsis, septic shock, or any of the other terms in between, the key points that are taken away should remain the same. Prevention and early detection will always be the best treatment for sepsis. Especially in in-home care settings, nurses should be trained to apply qSOFA to each patient seen. If early-detection isn't the case, the family is part of the plan of care, and notifying them of any status changes, plan of care changes, or staff changes is a priority. Even though some nurses find discussing advance directives and power of attorney's uncomfortable, it will be even more painful for the family if the patient is unresponsive, and no one knows what to do. Making these discussions at the top of the to-do list is an essential ethical duty the nurse should handle with empathy. If there are any children or younger school-aged visitors, the nurse can give out the www.icu-usa.com website, which allows the family a virtual tour of an ICU room (Durham RN, MSN et al., 2020). Adults who are anxious about seeing their loved one hooked up to monitors or machines can utilize this website to make their experience not as shocking. References 5 Durham RN, MSN, C., Ouimette RN, MSN, R., Biese MD, MAT, K., & Busby-Whitehead, MD, J. (2020). Sepsis (RN). GeroClinSim. Retrieved June 9, 2020, from http://geroclinsim.org/clinical-simulation-cases/sepsis/rn-overview/ University of Pennsylvania. (2020). qSOFA. qsofa.org. Retrieved July 10, 2020, from http://qsofa.org/index.php
