Acute Care Nursing

The aim of this assignment is to critically discuss the nursing assessment individualised care and nursing interventions of the acutely ill patient. The patient discussed developed severe sepsis due to a urinary tract infection and her condition deteriorated during the recovery process in the nurse’s care. Lovick (2009) defines sepsis ‘as a known or suspected infection accompanied by evidence of two or more of the SIRS criteria’.

SIRS is outlined as a ‘systemic inflammatory response’ consisting of two or more of the following symptoms ‘temperature >38 degrees Celsius or 90 beats per minute, respiratory rates greater than 20 breaths per minute and white blood count higher than 12,000 cells per microliter or lower than 4000 cells per microliter’(Latto 2008). Severe sepsis requires rapid diagnosis and treatment it can be described as ‘the presence of sepsis with organ dysfunction, hypotension or poor perfusion’. (Lovick, 2009).

Mrs Mary Smith was the patient in the nurse’s care who developed severe sepsis; she was a 76 year old female with no-known drug allergies, admitted to the ward with laceration to the forehead due to fall, difficulty coping, upper urinary tract infection and was awaiting long term care. Mrs Smith had a history of chronic back pain, mild asthma and recurrent UTI’s, she had finished a seven day dose of Augmentin three days previous. The patient was MRSA negative and required minimal assistance with her Activities of Daily Living.

The patients baseline observations were blood pressure of 130/ 80, pulse of 80 beats per minute, saturations of 98% on room air, temperature 36. 5oC respiratory rate of 18 and a GCS of 15/15, eyes responded to light and the patient could lift both legs and arms on command. While carrying out routine morning observations deterioration in Mrs Smith’s vital signs were noted, she appeared confused and disorientated this alerted the nurse as ‘confusion may be the first sign of infection and sepsis in elderly patients’. (Brunner & Suddarth, 2008). The nurse placed her hand on the patients arm and Mrs Smith was warm and clammy to touch.

The nurse immediately carried out an ABCDE framework to assess and implement interventions as required to stabilize and treat the patient’s condition. NICE Guidelines (2007) recommends that all staff caring for critically ill patients should be competent in monitoring and interpreting patient’s vital signs to enable appropriate treatment and interventions are conducted. The Resuscitation Council UK (2006) as recommending the use of the airway, breathing, circulation, disability and exposure approach when treating the acutely ill patient to ensure they are treated promptly and effectively.

Necessary interventions should be implemented to prevent further worsening of the patient status before continuing on to the next segment of the framework. The nurse observed Mrs Smith’s airway for any signs of obstruction. The airway is vital when assessing the patient’s condition, as closure of the airway will cause hypoxia and death. The patient was greeted by the nurse and asked how they were feeling they responded clearly and completed their sentences normally therefore it was agreed that the patient’s airway was patent.

The colour of the patient’s lips was observed they were pink, as a result the nurse concluded that no sign of cyanosis was present. No inspiratory stridor or expiratory wheeze was heard when the nurse was performing the airway assessment. The nurse sat the patient in an upright position supported by pillows to ensure the patent airway was maintained, this was the only intervention used for airway management. The nurse then progressed onto the next stage of the framework because no further interventions to maintain Mrs Smith’s airway was required.

The assessment of Mrs Smith’s breathing began with measuring her respiration rate and trend. The measurement of a patient’s respirations is highly important in a clinical area as Robson et al (2008) explain that the ‘respiratory rate is a sensitive indicator of deterioration and is one of the diagnostic criteria for sepsis ,yet in relation to blood pressure and pulse is poorly performed’. The nurse found Mrs Smith to be tachypnoeic, her respirations were recorded as 24 breaths per minute it was observed as being fast and it appeared that her accessory muscles were being used.

Mrs Smith’s pallor also appeared flushed and her saturations were documented as 93%. The nurse used the stethoscope to check for wheeze the patient’s lungs were clear and chest rise was symmetrical. Mrs Smith was commenced on 100% oxygen through a non-rebreathe mask, oxygen as an intervention is necessary as Creed & Spiers (2010) highlight ‘metabolic demand for oxygen throughout the body is hugely increased by sepsis and is essential to ensure the supply of oxygen is maximized’ . The nurse monitored the patient closely because in her confused state the patient may try to remove the oxygen mask.

An evaluation of Mrs Smi th circulation was the next step carried out by the nurse, as in the breathing assessment Mrs Smith pallor was noted as being flushed and the patient appeared confused this could be associated with poor cardiac output. The nurse recorded the patient’s blood pressure using a dinamap it was measured at 88/50, it was then rechecked manually to ensure accuracy. The pulse was checked manually for rate and rhythm it was recorded as 98 beats per minute. Capillary refill was checked, was found to be normal. The next step of the framework is disability.

Mrs Smith’s conscious level was measured using the Glasgow Coma Scale. The patient was agitated and disorientated to time and place, pupils were equal in size and reacted to light and her GCS was 13/15, however her muscle function was normal she was able to lift her arms and legs on request. Measurement of a patient’s level of consciousness is an important task to be carried out because altered consciousness can have an adverse effect on a patient’s airway this is stressed by Steen (2010) who explains that ‘worsening conscious level could be at risk of airway obstruction and loss of gag reflex’.

To ensure that the decreased level of consciousness was not due to hypoglycaemia, Mrs Smith’s blood sugars were tested. A finger was cleaned using cotton wool, was pricked and the blood was tested. The blood sugars were recorded as 5. 4 within the normal parameters of 3. 9-6. 9. Therefore hypoglycaemia was not the cause of the patient’s altered level of consciousness. The nurse also used the numerical pain scale to assess Mrs Smith’s discomfort. The patient reported her pain as 7/10 and complained of soreness in the lower abdomen.

When addressing exposure, the nurse carried out a head to toe assessment of Mrs Smith. Sepsis may be apparent by inflamed wounds or red swollen cannula sites. Mrs Smith had no skin breaks or wounds and triple care cream was applied regularly to prevent skin breakdown. No IV cannulas were present on the patient, thus a cannula site was not the cause of infection for Mrs Smith. The patient’s temperature was recorded as 38. 3OC, this was a huge deviation from the normal temperature range as per St. James’ Hospital Policy of 36. 5-37.

2OC. The patient was wearing no excess clothing and was covered by a sheet to maintain dignity and she required no blankets because she complained of feeling hot. The patient’s safety was paramount due to her confused state so side rails were raised and she was continuously monitored by a health care assistant and was not left unattended for any reason. The patient will undoubtedly be distressed and anxious therefore ‘appropriate psychological care to reduce anxiety and stress’ needs to be provided by the nurse. (Bench & Brown, 2011).

From this ABCDE assessment it was clear to the nurse that the patient was hypotensive, tachycardic, had a reduced respiratory function and had neurological disturbances. It was necessary for the medical team to be contacted to prescribe appropriate treatment for Mrs Smith promptly. The ISBAR Tool was used to communicate with the clinical nurse manager and medical team. The nurse identified herself, her position and what ward she was calling from on the phone to the SHO. The nurse explained her concerns about Mrs Smith stating that she believed sepsis was present.

The SHO was informed of Mrs Smith’s reason for admission which was a UTI, laceration to forehead due to fall and awaiting long term care. The nurse stated Mrs Smith’s past medical history of chronic back pain, mild asthma and recurrent UTI’s. The medications prescribed to Mrs Smith were explained. The nurse highlighted the significant change in the patient’s vital signs and voiced her concern. It was recommended to the SHO to review the patient immediately as treatment was required to stop the progression of the severe sepsis into shock.

Lovick (2009) explains that the ‘first six hours after diagnosis present a small window of opportunity in which to reverse tissue hypoxia and prevent established organ failure’. The nurse clarified her expectations with the SHO and agreed with the nurse’s concerns. The SHO was on the ward within ten minutes to assess and provide medical interventions for Mrs Smith. On review of the patient and the nursing assessment Severe Sepsis was diagnosed by the SHO. Both Creed & Spiers (2010) and Daniels & Robson (2008) outline six main steps to follow in the treatment of sepsis. These steps coincide with the treatment prescribed by the SHO.

The first point outlined was the administration of 100% oxygen. As discussed earlier the metabolic demand is raised significantly due to the sepsis, resulting in a higher production of CO2 which in turn will raise the respiratory rate the nurse had already administered oxygen while carrying out the breathing assessment. The second step outlined was to take blood cultures to identify the cause of sepsis before the IV antibiotics are given. Thirdly the use of broad spectrum antibiotics is recommended as soon as possible ‘to delay the giving of antibiotics increases a patient’s mortality by 7.

6% for every hour’s delay’ (Daniels & Robson 2008). The next step outlined is IV fluid therapy to correct the hypotension cause by severe sepsis. Lactate and haemoglobin levels need to be taken to ensure no blood transfusion is needed and that the patient is not entering septic shock and finally the insertion of a urinary catheter to assess kidney function is mutually suggested by Creed & Spiers (2010) and Daniels & Robson (2008) Due to Mrs Smith being tachypnoeic, low in saturations and having a high respiratory rate as outlined by the nurse, the SHO took an Arterial Blood Gas.

Arterial Blood Gases were taken to determine the patients CO2 levels in the blood, lactate levels and pH to determine her acid-base level. The ABG results would be monitored closely by the nurse as ‘metabolic acidosis is a common problem in patients with sepsis and other forms of critical illness and is associated with a poor outcome’ (Kellum 2004). To address the patient’s hypotension fluid resuscitation was prescribed by the SHO. Crystalloid fluids of 0. 9% sodium chloride was ordered by the medical team to re-establish circulatory volume, however ‘fluid resuscitation may consist of colloids or crystalloids.

There is no evidence based support for one type or the other’. (Dellinger at al 2004). During the first 24 hours patients often receive a high dose of fluids to restore their cardiac output and limit organ damage. ‘Fluid resuscitation is replacing some of the circulating volume that has been lost because of capillary leak or oedema’. (Creed and Spiers 2010). Two IV cannulas were inserted by the nurse, they were flushed to ensure they were patent and while the fluids were infusing Mrs Smith was monitored for signs of fluid overload and oedema special attention would also be needed if Mrs Smith had a history cardiac or renal failure.

Mrs Smith cannulas were patent and checked regularly for any signs of infection. Usually the cannula would be removed 72hours after insertion to avoid infection. The SHO also ordered the insertion of a urinary catheter to record the urinary output accurately, also ‘urine output is a good measurement of blood flow to the kidneys and therefore an easily observable measure of cardiac output’ (Creed & Spiers, 2010). The nurse also has an important role in strict fluid intake and output monitoring.

Most patients in severe sepsis will develop oliguria. Brunner & Suddarth (2008) define oliguria as ‘diminished urine output, less than 400ml per 24hours’. Early detection by the nurse of poor urine output can ensure interventions are taken to avoid renal damage. The catheter was inserted by the nurse under strict aseptic technique in order to avoid introducing infection. The urine was measured hourly and the patient was found to have oliguria she voided.