Sepsis-UNFOLDING Reasoning Urinary Tract Infection/Urosepsis Jean Kelly, 82 years old

© 2016 Keith Rischer/www.KeithRN.com Urinary Tract Infection/Urosepsis Jean Kelly, 82 years old Primary Concept Infection Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Fluid and Electrolyte Balance 3. Thermoregulation 4. Clinical Judgment 5. Patient Education 6. Communication UNFOLDING Reasoning Case Study: STUDENT History of Present Problem: Sepsis Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know what© 2016 Keith Rischer/www.KeithRN.com day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable to get out of the tub and used her personal life alert button to call for medical assistance. Personal/Social History: Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are active and involved in her life. What data from the histories are important and RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: Increasingly worsening fatigue, painful, burning, and frequent urination fever for 24 hours weakness confusion Confusion is a common sign of UTI, and a change in mental status should be evaluated. Significant signs and symptoms of UTI prompting request for UA RELEVANT Data from Social History: Clinical Significance: Lives independently in a retirement community, wears a life alert button, widowed and 2 daughters who active and involved in her life. The life alert button offers security and assistance to her in case of an emergency when she is alone at home. She has a strong support system from her daughters and can return to a safe environment after discharge What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: Diabetes type 2 1. Allopurinol 100 mg PO 1. Antipruritic and antigout agents 2. Salicylates 3. Antidiabetic/ thiazolidinediones 4. Lipid -lowering agents 5. Beta blockers 6. ACE inhibitors 7. Loop diuretics 8. Mineral & Electrolyte replacements/suppl. 1. Lowering of serum uric acid levels. 2. Reduce platelet aggregation 3. Decrease insulin resistance 4. Decrease cholesterol/lipid levels 5. Decrease BP 6. Decrease BP 7. Diuresis/Decrease BP 8. Prevention/ Correction of K depletion Hyperlipidemia bid Hypertension (HTN) 2. ASA 81 mg PO daily Gout 3. Pioglitazone 15 mg PO daily 4. Simvastatin 20 mg PO daily 5. Metoprolol 25 mg PO bid 6. Lisinopril 10 mg PO daily 7. Furosemide 20 mg PO daily 8. Potassium chloride 20 mEq PO daily One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life?  Circle what PMH problem started FIRST  Underline what PMH problem(s) FOLLOWED as dominoesPatient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 101.8 F/38.8 C (oral) Provoking/Palliative: Nothing/Nothing P: 110 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Right flank BP: 102/50 Severity: 5/10 O2 sat: 98% room air Timing: Continuous The nurse recognizes the need to validate his/her concern of fluid volume deficit and performs a set of orthostatic VS and obtains the following: Position: HR: BP: Supine 110 102/50 Standing 132 92/42 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Pulse: 110 Temperature: 101.8 F BP: 102/50 Orthostatic hypotension Resp. rate: 24 achycardia - the heart is overworking trying to compensate Systemic sign of infection; indication of fever The heart is beating fast to maintain pressure with  blood volume with combination of  HR, also can be an indication of fluid volume deficitSystolic change b/w supine and standing Tachypnea – indication of compensation Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Pink, warm and dry, no edema, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented x2-is not consistently oriented to date and place, c/o dizziness when she sits up GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Dysuria and frequency of urination persists, right flank tenderness to gentle palpation SKIN: Skin integrity intact, lips dry, oral mucosa tacky dry What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Mental changes: disorientation, and dizziness Dysuria, frequency of urination, and right flank pain and tenderness with palpitation Oral mucosa: dry BP changes with orthostatic hypotension, changing position, dizziness, and not knowing of time, and place. Classic signs and symptoms of UTI, flank pain and tenderness with palpation which indicates the involvement of the kidneys and signs of infection Clinical sign of dehydration or fluid volume deficitRadiology Reports: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Results: Clinical Significance: No infiltrates or other abnormalities. No changes from last previous No resp issues Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC): Current: High/Low/WNL? Previous: WBC (4.5-11.0 mm 3) 13.2 HIGH 8.8 Hgb (12-16 g/dL) 14.4 WNL 14.6 Platelets (150-450x 103/µl) 246 WNL 140 Neutrophil % (42-72) 93 HIGH 68 Band forms (3-5%) 2 LOW 1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC and Hgb Platelets Neutrophils Band forms Indicates infection and Hgb likely to rule out from traumatic blood loss contributing to fluid volume deficit A slight change from the previous lab drawn can be due to reactive thrombocytosis Sign of infection and the body is trying to fight off the existing infection Similar to neutrophils, which can be an indicator of infection or at risk of infection WBC worsening and Hg is stable Stable Worsening Stable but can worsen Basic Metabolic Panel (BMP): Current: High/Low/WNL? Previous: Sodium (135-145 mEq/L) 140 WNL 138 Potassium (3.5-5.0 mEq/L) 3.8 WNL 3.9 Glucose (70-110 mg/dL) 184 HIGH 128 BUN (7 - 25 mg/dl) 35 HIGH 14 Creatinine (0.6-1.2 mg/dL) 1.5 HIGH 1.1 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Glucose Elevated BUN and Creatinine Diabetes Type II – likely is responding to the stress of illness and  temp. with increased insulin demands Indication of the dysfunction of kidney which means the kidneys are not producing WORSEurine and filtering effectively Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6-2.0 mEq/L) 1.8 WNL 1.9 Lactate (0.5-2.2 mmol/L) 3.2 HIGH n/a RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Lactate Indicates sepsis due to hypoperfusion of the kidneys, cell death due to anaerobic metabolism - considered a critical value of greater than 2 WORSE Urine Analysis (UA): Current: ABNL/WNL? Previous: Color (yellow) Yellow WNL Yellow Clarity (clear) Cloudy ABNL Clear Specific Gravity (1.015-1.030) 1.032 ABNL 1.010 Protein (neg) 2+ ABNL 1+ Glucose (neg) Neg Neg Ketones (neg) Neg Neg Bilirubin (neg) Neg Neg Blood (neg) Neg Neg Nitrite (neg) Pos Pos LET (Leukocyte Esterase) (neg) Pos Pos MICRO: RBC’s (<5) 1 ABNL 0 WBC’s (<5) >100 ABNL 3 Bacteria (neg) LARGE Few Epithelial (neg) Few Few RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Cloudy urine Elevated specific gravity Protein in urine Nitrites, leukocyte esterase, WBC, bacterial & epithelial Sign of infection Increased concentration of urine due to fluid volume deficit Present in Type II Diabetes & UTI Indicative of UTI; nitrites indicate presence of bacteria, LET and WBC indicate the WBC trying to fight & attack the infection. ALL WORSE Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Lactate Value: 3.2 Critical Value: 2 Lactate is a major sign of sepsis demonstrating hypoperfusion of systemic organs Notify provider of critical value. Assess vital signs: HR, BP, and temp. Perform sepsis screen and notify sepsis team. Enact orders as prescribed: fluid replacement, cultures, and administer broad spectrum antibiotics.Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Creatinine Value: 1.5 Critical Value: Greater than 2 to 2.5 Indicative of kidney function, elevated creatinine levels signify dysfunction of the kidneys and are not able to effectively filtrate Strict I/O, monitor urine characteristics, and quality. Administer fluids, and assess ability to urinate Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem?Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV 0.9% NS 1000 mL IV bolus Acetaminophen 650 mg Ceftriaxone 1g IVPB…after blood/urine cultures obtained Morphine 2 mg IV push every 2 hours prn-pain PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale:  Establish peripheral IV  0.9% NS 1000 mL IV bolus  Acetaminophen 650 mg  Ceftriaxone 1g IVPB… after blood/urine cultures obtained  Morphine 2 mg IV push every 2 hours prn-pain Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Ceftriaxone 1g IVPB 50 ml Hourly rate IVPB: Collaborative Care: Nursing 3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY)4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessment(s) will you need to initiate to identify this complication EARLY if it develops? 8. What nursing interventions will you initiate if this complication develops? 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? 10. How can the nurse address these psychosocial needs? Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two Hours Later… Current VS: Most Recent: T: 101.4 F/38.6 C (oral) T: 101.8 F/38.8 C (oral) P: 116 (regular) P: 110 (regular) R: 22 (regular) R: 24 (regular) BP: 98/50 BP: 102/50 O2 sat: 98% room air O2 sat: 98% room airCurrent Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Color flushed. Skin is warm and dry centrally, but upper/lower extremities are mottled in appearance and cool to touch, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented x2-is not consistently oriented to date and place GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: No urine output the past two hours. SKIN: Skin integrity intact 1. What clinical data are RELEVANT and must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Temp: 101.4F Pulse: 116 BP: 98/50 HR: 22 Febrile but a decrease from previous temp. Worsening BP and still demonstrating  HR and  resp. rate, however O2 stat is WNL RELEVANT Assessment Data: Clinical Significance: Cool, mottled extremities, no urine output, and disoriented No urine output is a sign of worsening sepsis and renal deterioration. The nurse should notify the provider immediately. Mottled extremities and cool skin is a sign of decrease cardiac output, unable to meet the demands and trying to compensate due to fluid volume deficit. 1. Has the status improved or not as expected to this point? Status has worsened and the provider should be contacted for additional orders to provide more hemodynamic stability to support the patient and to preserve organ functions. 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? The RN needs to notify the provider, plan of care should continue by providing hemodynamic stability 3. Based on your current evaluation, what are your nursing priorities and plan of care? Nursing priorities are: maintain hemodynamic stability by monitoring vital signs, urine output, I/O, administer antibiotics and fluids, monitoring for signs of complications such as MODS, and the patient may need Dobutamine.Because you have not seen the level of improvement you were expecting in the medical interventions, you decide to update the physician and give the following SBAR: Situation: Jean Kelly, age 82, admitted for sepsis secondary to UTI. Administered 1L fluid bolus and 1 G ceftriaxone. BP is not improving and no urine output Background: History of Type II Diabetes, Hyperlipidemia, and HTN. Admitted after 3 days of UTI symptoms and acutely altered mental status and has respond to initial orders, BP, HR, urine out, respiration rate continue to deteriorate Assessment: Cool, mottled extremities, fever at 101.4F, BP: 92/50, pulse: 116, oriented to self but not to time or place. Oral mucosa: dry and tacky. Oliguric over the last two hours. Recommendation: Patient requires additional support, more fluid bolus recommended and if hemodynamic stability is not achieved then Dobutamine may be needed The physician agrees with your concerns and decides to repeat the 0.9% NS bolus of 1000 mL and insertion of Foley catheter. After one hour this has completed and you obtain the following set of VS: Current VS: Most Recent: T: 100.6 F/38.1 C (oral) T: 101.4 F/38.6 C (oral) P: 92 (regular) P: 116 (regular) R: 20 (regular) R: 22 (regular) BP: 114/64 MAP: 81 BP: 94/48 MAP: 63 O2 sat: 98% room air O2 sat: 98% room air Current Assessment: GU: 200 mL cloudy urine in bag 1. Has the status of the patient improved or not as expected to this point? Improved 2. What data supports this evaluation assessment? 200 mL of urine output, elevation in BP, pulse: WNL, temperature lowered and decreased resp. rate.Your patient, who is still in the emergency department, is now being transferred to the intensive care unit (ICU) for close monitoring and assessment. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: Jean Kelly, 82 yrs. old BRIEF summary of primary problem: admitted for sepsis secondary to UTI. Administered 1L fluid bolus and 1G ceftriaxone. BP is not improving and no urine output Day of admission/post-op #: Today Background: Primary problem/diagnosis: sepsis secondary to urinary tract infection RELEVANT past medical history: Type II Diabetes, Hyperlipidemia, and HTN. RELEVANT background data: Admitted after 3 days of UTI symptoms and acutely altered mental status and has respond to initial orders, BP, HR, urine out, respiration rate continue to deteriorate. Assessment: Most recent vital signs: Temperature: 100.6F (oral), BP: 114/64, MAP: 81, pulse: 92, RR: 20, O2 stat: 98% on room air. RELEVANT body system nursing assessment data: GU: 200mL; cloudy urine in Foley bag, mottled, oriented to self but not to time or place. Oral mucosa: dry and tacky, cool and mottled extremities. RELEVANT lab values: WBC: 13.2, neutrophils: 93, band forms: 2, glucose: 184, BUN: 35, creatinine: 1.5, and lactate: 3.2, specific gravity: 1.032, protein, nitrites, leukocyte esterase are present in urine, cloudy urine.How have you advanced the plan of care? 2 large boluses of 0.9% NS and inserted Foley catheter Patient response: patient has definitely improved, 200 mL of urine output, elevation in BP, pulse: WNL, temperature lowered and decreased resp. rate. INTERPRETATION of current clinical status (stable/unstable/worsening): STABLE Recommendation: Suggestions to advance plan of care: Continue to monitor patient and may require additional support, and if hemodynamic stability is not achieved then Dobutamine may be needed.Education Priorities/Discharge Planning 1 What will be the most important discharge/education priorities you will reinforce with Jean’s medical condition to prevent future readmission with the same problem? Wash the perineal area front to back and wear cotton underwear, avoid bath tubs, increase fluid intake to promote renal blood flow and to flush bacteria from the urinary tract, adhere to the antibiotic regiment prescribed by the provider, encourage frequent voiding every 2 to 3 hours to empty the bladder completely in which can lower urine bacterial counts, reduce urinary stasis,and prevent reinfection. Avoid urinary irritants such as coffee, tea, colas, and alcohol. Provide the patient with information about s/sx that they will need to notify the provide 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? The RN can assess the effectiveness of teaching with this patient by setting goals together, allowing to demonstrate how to promote the proper perineal hygiene, test the patient’s knowledge of the condition, use simple terms when communicating with patient, making sure the patient understand the medication as you administer, and making sure the patient understand how and when to refill medications, ask the patient to tell you how they would explain the condition or treatment to someone Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient might feel anxious, overwhelmed, and concerned of the condition and wants to know is the plan of their care while they are in the hospital and how they can avoid or prevent the condition. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? You can engage with the patient by making sure that they understand the treatment plan, by including family member, consider the patient’s limitations and strengths, and determine the patient’s learning style.Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? Alot 2. How can I use what has been learned from this scenario to improve patient care in the future? SO much