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Student Sepsis Case Study

sepsis case study
 University
College of Southern Nevada
 Course
English (ENG223)
 Uploaded by
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Liza Tuble
 Academic year2017/2018
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Preview text

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
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: Diabetes
Type II  Underline what PMH problem(s) FOLLOWED as dominoes: Hyperlipidemia, HTN,
Gout
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101 F/38 C (oral) Provoking/Palliative: Nothing/Nothing
P: 110 (regular) Quality: Ache
R: 24 (regular) Region/Radiation: Right flank
BP: 102/50 Severity: 5/
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/ Standing 132 92/
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
 Pulse: 110  Temperature: 101 F  BP: 102/  Orthostatic hypotension  Resp. rate: 24
 Tachycardia - 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 deficit  Systolic 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:
o Mental changes: disorientation, and dizziness o Dysuria, frequency of urination, and right flank
pain and tenderness with palpitation o Oral mucosa: dry
o BP changes with orthostatic hypotension, changing position, dizziness, and not knowing of
time, and place. o Classic signs and symptoms of UTI, flank pain and tenderness with palpation
which indicates the involvement of the kidneys and signs of infection o Clinical sign of
dehydration or fluid volume deficit
Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6-2 mEq/L) 1 WNL 1. Lactate
(0.5-2 mmol/L) 3 HIGH n/a
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
o Lactate o Indicates sepsis due to hypoperfusion of the kidneys, cell death due to anaerobic
metabolism - considered a critical value of greater than 2
o Worsening
Urine Analysis (UA): Current: ABNL/WNL? Previous: Color (yellow) Yellow WNL Yellow
Clarity (clear) Cloudy ABNL Clear Specific Gravity (1.015-1) 1 ABNL 1. Protein (neg) 2+
ABNL 1+ Glucose (neg) Neg WNL Neg Ketones (neg) Neg WNL Neg Bilirubin (neg) Neg
WNL Neg Blood (neg) Neg WNL Neg Nitrite (neg) Pos ABNL Pos LET (Leukocyte Esterase)
(neg) Pos ABNL Pos MICRO: RBC’s (<5) 1 WNL 0 WBC’s (<5) >100 ABNL 3
Bacteria (neg) LARGE ABNL Few Epithelial (neg) Few ABNL 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.
 Worsening
 Worsening
 Worsening
 Worsening
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
Lactate
Value:
3.
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.
Critical Value:
Greater than 2 to 2.
 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 is the primary problem that your patient is most likely presenting?
 Patient developed urinary tract infection, however based on the clinical signs and symptoms, it
appears that this has progressed to a systemic level and indicates sepsis.
2 is the underlying cause/pathophysiology of this primary problem?
 The underlying cause would be an untreated UTI in which has spread beyond the bladder and
urethra and leading to kidney dysfunction causing a systemic septic effect. Severe sepsis – a
systemic inflammatory response associated to an infection with dysfunction or failure of one or
more organs.
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV
0% NS 1000 mL IV bolus
Acetaminophen 650 mg
Ceftriaxone 1g IVPB.. blood/urine cultures obtained
Morphine 2 mg IV push every 2 hours prn-pain
 Circulatory access for the initiation of treat  Fluid replacement to maintain BP and revitalize
fluid loss from dehydration  Decrease fever  Broad spectrum antibiotics  Pain management
 IV access obtained to start treatment  BP will increase  A decrease in temp.  Will begin
to fight bacterial agents  Report improvement and decrease in pain level
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale: Establish peripheral IV 0% 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
####### 1
####### 2
####### 5
####### 3
####### 4
o Establish venous access before initiating any treatment. The goal is replace fluid loss and
correct/maintain good perfusion. Antibiotics would be administer to stop the infection. Morphine
to control pain management and Acetaminophen is to decrease temperature.
6 is the worst possible/most likely complication to anticipate?
MODS (multiorgan dysfunction) as a complication septic shock and systemic organ
hypoperfusion leading to organ failure
7 nursing assessment(s) will you need to initiate to identify this complication EARLY if it develops?
 Systemic monitoring of organ systems; perform a thorough head-to-toe assessment. Monitor
urine output closely, kidney functions, and patient’s trend. Auscultate lungs sound, bowel
sounds, and monitor breathing pattern. Monitor HR, rhythm, BP, and temperature, administer
acetaminophen, and apply cool washcloths to keep decrease temperature. Perform frequent neuro
assessment to evaluate mental status.
8 nursing interventions will you initiate if this complication develops?
 Immediately notify provider, fluid support, administer oxygen as needed, frequent vital signs.
MODS is severe and life threatening, patient will most likely need ventilation and support from
administration of vasopressors to maintain BP.
9 psychosocial needs will this patient and/or family likely have that will need to be addressed?
 The patient has a strong support system and lives in a safe environment. The family and the
patient should be updated in regards to her condition, complication and improvement to manage
anxiety for both the patient and family.
10 can the nurse address these psychosocial needs?
The nurse can act as a support person and educate both the patient and family of the treatment
plan and answer concerns and questions.
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 F/38 C (oral) T: 101 F/38 C (oral) P: 116 (regular) P: 110
(regular) R: 22 (regular) R: 24 (regular) BP: 98/50 BP: 102/ O2 sat: 98% room air O2 sat: 98%
room air
Current 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
 Pulse: 116
 BP: 98/
 HR: 22
Febrile but a decrease from previous temp. Worsening BP and still demonstrating  HR and 
resp. rate, however O 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 need 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, 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% 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 F/38 C (oral) T: 101 F/38 C (oral)
P: 92 (regular) P: 116 (regular)
R: 20 (regular) R: 22 (regular)
BP: 114/
MAP: 81
BP: 94/
MAP: 63
O2 sat: 98% room air O2 sat: 98% room air
Current Assessment:
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 (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, neutrophils: 93, band forms: 2, glucose: 184, BUN:
35, creatinine: 1, and lactate: 3, specific gravity: 1, protein, nitrites, leukocyte esterase are
present in urine, cloudy urine.
How have you advanced the plan of care? 2 large boluses of 0% 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 provider.
 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? I have learned that urosepsis is a severe and
life-threating condition that require immediate intervention because it can lead to MODS and
death. I think this scenario have develop skills such as decision making in complex situation, and
problem solving, and being to apply to real situations that can occur in the clinical setting.
2. How can I use what has been learned from this scenario to improve patient care in the
future? To improve patient care in the future, this scenario have helped with thinking fast,
problem solving, and develop skills that I thought I did not have, although I do feel like
in the hospital
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Beta
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
Sepsis
History of Present Problem:
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 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
Clinical Significance:
Problem:

Increasingly worsening fatigue,

 
painful, burning, and
frequenturination Confusion is a common sign of UTI, and a change in mental status should be evaluated. Significant signs and symptoms of UTI

prompting requestfor UA

  fever for 24 hours

  weakness
  confusion
RELEVANT Data from Social
Clinical Significance:
History:

The life alert button offers security and assistance to her

widowed and 2 daughters who
in case of an emergency when she is alone at home. She
active
has
Lives independently in a retirement
to a safe environment after discharge.
community, wears a life alert button,
a strong support system from her daughters and can
and involved in her life.
return

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:

 1. Allopurinol 100
mg PO  1. Lowering of
bid serum
 7. Diuresis/Decrease
 2. ASA 81 mg PO  6. ACE inhibitors uric acid levels.
daily 
 3. Pioglitazone 15  2. Reduce
1. Antihyperuricemicsand
mg PO daily plateletaggregation
antigout agents
 4. Simvastatin 20  3. Decrease insulin
 2. Salicylates
Diabetes type
mg PO daily resistance
2 Hyperlipidemia Hypertension  3. Antidiabetic/
(HTN) Gout  5. Metoprolol 25 mg thiazolidinediones  4. Decrease
PO bid cholesterol/lipid levels
 4. Lipid -lowering
 6. Lisinopril 10 mg agents  5. Decrease BP
PO daily  6. Decrease BP
 5. Beta blockers
 7. Furosemide 20 BP
 7. Loop diuretics
mg PO daily  8. Mineral & 
 8. Potassium Electrolytereplacements/s 8. Prevention/Correctio
chloride 20 mEq PO uppl. n of K depletion
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: Diabetes Type II
  Underline what PMH problem(s) FOLLOWED as dominoes: Hyperlipidemia, HTN, Gout
Patient Care Begins:
P-Q-R-S-T Pain Assessment (5th
Current VS:
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 92/42
132

What VS data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT
Clinical Significance:
VS Data:

  Pulse: 110

 Temperature:   Tachycardia - the heart is overworking trying to compensate
101.8 F   Systemic sign of infection; indication of fever
  BP:   The heart is beating fast to maintain pressure with  blood volume with
102/50 combination of  HR, also can be an indication of fluid volume deficit
  Orthostatic   Systolic change b/w supine and standing
hypotension   Tachypnea – indication of compensation
  Resp. rate:
24
Current Assessment:

GENERAL APPEAR Resting comfortably, appears in no acute distress

ANCE:

RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIA Pink, warm and dry, no edema, heart sounds regular-S1S2, pulses strong, equal
C: with palpation at radial/pedal/post-tibial landmarks

Alert and oriented x2-is not consistently oriented to date and place, c/o dizziness
NEURO:
when she sits up

Abdomen soft/nontender, bowel sounds audible per auscultation in all four

GI:
quadrants

Dysuria and frequency of urination persists, right flank tenderness to gentle

GU:
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:

 o Mental changes:  o BP changes with orthostatic hypotension, changing

disorientation, and dizziness position, dizziness, and not knowing of time, and place.
 o Dysuria, frequency of  o Classic signs and symptoms of UTI, flank pain and
urination, and right flank pain and tenderness with palpation which indicates the involvement
tenderness with palpitation of the kidneys and signs of infection
 o Oral mucosa: dry  o Clinical sign of dehydration or fluid volume deficit
Radiology 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  Indicates no respiratory

previous issue

Lab Results:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Compl C H Previous:
ete u ig
Blood r h/
Count r L
(CBC): e o
n w
t: /
W
 N
L
?

WBC 1 H
(4.5- 3 I
8.8
11.0 . G
mm 3) 2 H

1
Hgb W
4
(12-16 N 14.6
.
g/dL) L
4

Platelet
2 W
s (150-
4 N 140
450x
6 L
103/µl)

H
Neutro
9 I 68
phil %
3 G
(42-72)
H

Band forms (3-5%) 2 LOW 1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

C
RE
li
LE
n Signi
VA
i fican TREND: Improve/Worsening/Stable:
NT
c ce:
Lab
a
(s):
l

 A Indic   WBC worsening and Hg is stable

  n ates   Stable
WB infect   Worsening
t
C ion   Stable but can worsen
o
and and
Hgb S Hgbli
 i kely
 Pl g to
atel rule
ets n out
 from
is
 N trau
eutr c matic
ophi a blood
ls n loss
 contr
o ibuti
 B
r ng to
and
for  fluid
ms volu
 me
 defici
t
 slight
 chan
ge
 from
 the
previ
 ous
lab
draw
n can
be
due
reacti
ve
thro
mboc
ytosi
s
of
infect
ion
and
the
body
tryin
g to
fight
off
the
existi
 nginf
ectio
n
Simil
ar to
neutr
ophil
s,
whic
h
be an
indicator of

infection at
risk of
infection

Basic Metabolic Panel High/Low/

Current: Previous:
(BMP): WNL?

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

TREND:
RELEVANT
Clinical Significance: Improve/Worsenin
Lab(s):
g/Stable:

  Diabetes Type II – likely isresponding to the

  Glucose stress of illness and  temp. withincreased insulin
  Elevated demands   Worsening
BUN and   Indication of the dysfunction of kidney which   Worsening
Creatinine means the kidneys are not producingurine and
filtering effectively
Cur High/
Misc.
rent Low/ Previous:
Labs:
: WNL?

Magne 1.8 WNL 1.9

sium
(1.6-
2.0
mEq/L
)

Lactat
e (0.5-
2.2 3.2 HIGH
n/a
mmol/
L)

Clinical TREND: Improve/Worsening/Stable:

RE Significance:
LE
 o Indicates
VA
sepsis due to
NT
hypoperfusion
Lab
of the kidneys,
(s):
cell death due o Worsening
 to anaerobic
o La metabolism -
ctat considered a
e critical value of
greater than 2
Urin
e
Cur
Ana ABNL/
rent Previous:
lysis WNL?
:
(UA
):

Colo
r Yell
WNL Yellow
(yell ow
ow)

Clari
ty Clo
ABNL Clear
(clea udy
r)

Specifi 1.03 ABNL 1.010

c 2
Gravit
y
(1.015
-
1.030)

Prot
ein
2+ ABNL 1+
(neg
)

Gluc
ose
Neg WNL Neg
(neg
)

Keto
nes
Neg WNL Neg
(neg
)

Bilir
ubin
Neg WNL Neg
(neg
)

Bloo
d
Neg WNL Neg
(neg
)

Nitri
te
Pos ABNL Pos
(neg
)

LET
(Leuk
ocyte
Pos ABNL Pos
Estera
se)
(neg)

MICR
O:

RBC 1 WNL 0
’s
(<5)

WB
>10
C’s ABNL 3
0
(<5)

Bact
LA
eria
RG ABNL Few
(neg
E
)

Epit
helia
l Few ABNL Few
(neg
)

TREND:
RELEVANT Lab(s): Clinical Significance: Improve/Worse
ning/Stable:

 • Cloudy urine  • Sign of infection

 • Elevated specific  • Increased concentration of urine due to fluid
gravity volume deficit  • Worsening
 • Protein in urine  • Present in Type II Diabetes &  • Worsening
 • Nitrites, UTI  • Worsening
leukocyteesterase,  • Indicative of UTI; nitrites indicate presence  • Worsening
WBC, bacterial & of bacteria, LET and WBC indicate the WBC
epithelial trying to fight & attack the infection.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Nor
mal
Lab: Clinical Significance: Nursing Assessments/Interventions Required:
Valu
e:

Lact Critic  Notify provider of critical value. Assess vital

ate al  Lactate is a major sign of signs: HR, BP, and temp. Performsepsis screen
Valu Value sepsisdemonstratinghypoperf and notify sepsis team. Enact orders as
e: : usion of systemic organs prescribed: fluidreplacement, cultures, and
 2 administer broad spectrum antibiotics.
3.2
Crea Critic  Indicative of kidney  Strict I/O, monitor urine characteristics, and
 al
tinin Value
e : function, elevated creatinine
Valu levels signify dysfunction of quality. Administer fluids, and assess ability to
e: Great the kidneys and are not able urinate.
er to effectively filtrate
 than 2
1.5 to 2.5

Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting?
  Patient developed urinary tract infection, however based on the clinical signs and
symptoms, it appears that this has progressed to a systemic level and indicates sepsis.
2. What is the underlying cause/pathophysiology of this primary problem?
  The underlying cause would be an untreated UTI in which has spread beyond the bladder
and urethra and leading to kidney dysfunction causing a systemic septic effect. Severe sepsis – a
systemic inflammatory response associated to an infection with dysfunction or failure of one or
more organs.
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:

  IV access
obtained to start
treatment
Establish peripheral IV 0.9% NS 1000
 Circulatory access for the   BP will
mL IV bolus Acetaminophen 650 mg
initiation of treat  Fluid increase
Ceftriaxone 1g IVPB…after
replacement to maintain BP   A decrease in
blood/urine cultures obtained and temp.
Morphine 2 mg IV push every 2 hours   Will begin to
revitalize fluid loss from dehydration  Decrease fever  Broad spectrum
prn-pain antibiotics  Pain management fightbacterial agents
  Report
improvementand
decrease in painlevel
PRIORITY Setting: Which Orders Do You Implement First and
Why?
Orde
Care Provider r of
Rationale:
Orders: Prior
ity:
  Establish
peripheral IV
  0.9% NS
1000 mL IV bolus
 o Establish venous access before initiating any treatment. The goal
 Acetaminophen 1 2 is replace fluid loss and correct/maintain good perfusion.
650 mg 5 3 Antibiotics would be administer to stopthe infection. Morphine to
  Ceftriaxone 4 control pain management and Acetaminophen is to decrease
1g IVPB… after temperature.
blood/urine
cultures obtained
  Morphine 2
mg IV push every
2 hours prn-pain
Medication Dosage Calculation:
Medicat Mechanis Volume/time
ion/ m of frame to Safely Nursing Assessment/Considerations:
Dose: Action: Administer:

  Assess history of allergies to cephalosporins

3rd & penicillin
50 ml   Complete full dose of antibiotics
Ceftriax 
one 1g   Obtain cultures prior to initiating therapy
 generatio Hourly rate IVPB:
  Monitor side effects: diarrhea, GI upset, oral
n
IVPB & vaginal candidiasis
cephalospo 30
rin   Monitor for signs of infusion reaction:
urticaria, pruritus, wheezing, laryngeal edema and
patency of IV access.
Collaborative Care: Nursing
 3. What nursing priority will guide your plan of care? (if more than one-list in order of
PRIORITY)
 o Provide adequate hemodynamic stability
 o Frequent assessment of vital signs, administer orders as prescribes to ensure no further
complication of organ failure.
 4. What interventions will you initiate based on this priority?
Nursing
Expected
Intervention Rationale:
Outcome:
s:

 • Monitor   Monitoring will be indicative of response to therapy  BP will improve

vital signs: and need to notify provider of significantchanges and be maintain
 after fluid
BP, pulse, replacement
and urine  Will receive
output broad
  Obtain cultures prior to initiation of therapy, assess
 spectrumwhile
history ofallergies and monitor infusion reactions
• Antibiotic cultures are
  Apply nonskid socks, set bed alarm, call light, table
infusion as pendingwithout any
near the patient, and due to orthostatic hypotension.
order further
 • Initiate   MODS can be a life threateningand severe
complication of sepsis. Hemodynamic instabilitydue to complications
fall
precautions organ hypoperfusion. Close monitoring of I/O,  Decrease &
 • Monitor urineoutput, renal functions, and resp.status are important prevent fall
sign of to trend in order to address significantchanges and treat
organdysfunc promptly.  Will not
tion and developMODS as a
progression complicationof
sepsis

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
  Cardiovascular: monitor BP & HR
  Renal: urine output, BUN, & creatinine
6. What is the worst possible/most likely complication to anticipate?
  MODS (multiorgan dysfunction) as a complication septic shock and systemic
organhypoperfusion leading to organ failure
7. What nursing assessment(s) will you need to initiate to identify this complication EARLY if it
develops?
  Systemic monitoring of organ systems; perform a thorough head-to-toe assessment.
Monitor urine output closely, kidney functions, and patient’s trend. Auscultate lungs sound,
bowel sounds, and monitor breathing pattern. Monitor HR, rhythm, BP, and temperature,
administeracetaminophen, and apply cool washcloths to keep decrease temperature. Perform
frequent neuro assessment to evaluate mental status.
8. What nursing interventions will you initiate if this complication develops?
  Immediately notify provider, fluid support, administer oxygen as needed, frequent vital
signs. MODS is severe and life threatening, patient will most likely need ventilation and support
from administration of vasopressors to maintain BP.
9. What psychosocial needs will this patient and/or family likely have that will need to be
addressed?
  The patient has a strong support system and lives in a safe environment. The family and the
patient should be updated in regards to her condition, complication and improvement to manage
anxiety for both the patient and family.
10. How can the nurse address these psychosocial needs?
  The nurse can act as a support person and educate both the patient and family of the
treatment plan and answer concerns and questions.
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 air

Current Assessment:

Resting
comfortabl
GENERAL APPEARANCE:
y, appears
in no acute
distress

Breath
sounds
clear with
equal
aeration
bilaterally,
nonlabored
respiratory
effort

CARDIAC: Color
flushed.
Skin is
warm and
dry
centrally,
but
upper/lowe
r
 extremities
are mottled
in
appearance
and cool to
touch,
heart
sounds
regular-
S1S2,
pulses
strong,
equal with
palpation at
radial/peda
l/post-tibial
landmarks

Alert and
oriented
x2-is not
NEURO: consistentl
y oriented
to date and
place

Abdomen
soft/nonten
der, bowel
GI: sounds
audible per
auscultatio
n in all four
quadrants

No urine
output the
GU:
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 Febrile but a decrease from previous temp. Worsening BP and still
 • Pulse: 116 demonstrating  HR and  resp. rate, however O2 stat is WNL.
 • BP: 98/50
 • HR: 22
RELEVANT
Clinical Significance:
Assessment Data:

• Cool, mottled No urine output is a sign of worsening sepsis and renal deterioration. The
extremities, no nurse should notify the providerimmediately. Mottled extremities and cool
urine output, skin is a sign of decrease cardiac output, unable to meet the demands and
anddisoriented 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 need to notify the provider, plan of care should continue by providing
hemodynamicstability.
 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 BP: 94/48

MAP: 81 MAP: 63

O2 sat: 98% room air O2 sat: 98% room air

Current Assessment:

GU:

200 cloudy urine in bag

1. Has the status of the patient improved or not as expected to this point?
 o Patient has improved.
2. What data supports this evaluation assessment?
 o 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, cooland
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 requireadditional
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 theprovider.
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’sknowledge
of the condition, use simple terms when communicating with patient, making sure the patient
understand the medication as you administer, and making sure the patientunderstand how and
when to refill medications, ask the patient to tell you how they wouldexplain 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 preventthe
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?
I have learned that urosepsis is a severe and life-threating condition that require immediate
intervention because it can lead to MODS and death. I think this scenario have develop skills
such as decision making in complex situation, and problem solving, and being to apply to real
situations that can occur in the clinical setting.
2. How can I use what has been learned from this scenario to improve patient care in
the future?
To improve patient care in the future, this scenario have helped with thinking fast,
problemsolving, and develop skills that I thought I did not have, although I do feel like in the
hospital you have different people who can help in case you are unsure of what to do next. I will
be able to use this scenario and apply it to a real life scenario.