In this case scenario analysis, I will provide an in-depth outline, discussion, and analysis of the assessment and care plan of a patient admitted in the emergency department. The patients signs and symptoms, presenting pathophysiology, and effective interventions will be analysed using a range of assessment tools. Besides, the essay will put more emphasis on the need for multi-disciplinary working due to the complex condition of the patient to ensure the delivery of quality care and promotion of patient-centred care. As Chen, Ou, and Hollis (2013) indicate, effective response to the patients changing situation needs care providers to carry out a comprehensive and collaborative systematic nursing assessment and care plan, including the involvement of the patient, family, carers, as well as other health care teams. Pseudonyms will be used to maintain the confidentiality of the patient, health providers, and even the health centre, per NMC (2018) code of conduct
The patient, Julia Jones, 68 years old, presented in an A&E department, complaining of pain and tenderness within her left lower arm. She suffered a cut on her index finger. She also has a positive history of type 2 diabetes and hypertension. Julia was diagnosed with cellulitis, which has led to sepsis. Sepsis is characterized by an acute coagulation impairment leading to the reduced blood supply to the tissues, hence resulting in organ dysfunction (Caraballo and Jaimes, 2019). Sepsis and cellulitis are relatable in that cellulitis lead to the development of sepsis. Cellulitis is a deep skin tissue infection occurring when disease-causing microorganisms gain entry through broken skin via the dermis (László et al., 2015).
Critical Assessment and Analysis of Signs and Symptoms of the Patient
The use of the ABCDE approach is vital in assessing and analysing Mrs. Jones case (NICE, 2016)
The patient was talking in full sentences; hence the airway was patent and an indication of adequate brain perfusion as per the RC UK (2020). This indicates 0 score in the NEWS chart
Her respiratory rate was 28 breaths per minute, higher than the normal range, and a 3 score in the NEWS chart. As per the NICE guidelines, the standard respiratory rate ranges between 12-20 breaths per minute, hence a reading higher than that is evidence of tachypnoea (NICE, 2016). Increased respiratory rate is a result of failed lung compliance in oxygen uptake and release of Carbon dioxide, resulting in tissue hypoxia (Hotchkiss et al. 2016). High carbon dioxide(CO2) levels in the blood stimulate the chemoreceptors which increase the respiratory rate in a bid to maintain sustainable oxygen levels while eliminating CO2. Julia’s oxygen concentration in her blood showed 91% on room air, lower than the normal, which ranges between 94% and 98%. This is as a result of reduced cardiac output characterized by decreased oxygen supply to the body tissues, leading to tissue hypoxia.
Julia’s heart rate is 112 bpm, which signifies tachycardia. According to Sapra (2019), the normal heart rate ranges from 60 to 100 bpm. In this case, Julia has tachycardia with a 2 score in NEWS score. Tachycardia is evidence of sepsis occurrence and is a risk factor of mortality (Morelli et al., 2015). The need to maintain blood supply to the tissues activates the baroreceptors which inhibits the parasympathetic action and stimulates the sympathetic nervous system, which acts on the heart muscles, thereby increasing the heart rate. Capillary refill time was 2 seconds, which is within the normal range and 0 score on the NEWS chart. A blood pressure reading of 89/45 mmHg was recorded. According to the UK National Health Service (2017), a blood pressure reading lower than 90/60 mmHg is characterized as hypotension, which makes Julia a victim with a NEWS score of 3. The presence of C-reactive protein (CRP) in the blood was gauged at 285mg/l, which is higher than the normal range. Considering the views of Nehring et al. (2020), the Normal levels of C-Reactive protein should be less than 0.3 mg/L in healthy adults. A high CRP is an indicator of an underlying inflammation caused by infection (Wang et al. 2013). Lactate levels in the blood were found to be 6mmol/L, which is above the normal level that ranges between 0.5 and 2 mmol/L (NICE, 2016). In this case, Julia has a mild hyperlactatemia. Elevated lactate level is as a result of glucose breakdown under anaerobic conditions induced by tissue hypoxia (Alvarez et al. 2014). Urine output decreased from 30 mls/hr to 10 mls/hr over three hours. This is as a result of kidney injury caused by hypotension. The blood glucose level was at 6 mmol/L, signifying hyperglycaemia. This is due to the impaired action of B cells leading to increased cytokine production, which, in turn, causes insulin intolerance. Her temperature was on the feverish side, reading at 39.20C. The average body temperature ranges from 36.1 to 37.5 degrees Celsius (Geneva et al. 2019). Julia had a body temperature of 39.2 degrees Celsius (2 in NEWS chart), as a result, is considered pyretic.
The patient was alert and conscious. With the use of the AVPU scale, the patient is confirmed alert which indicates adequate brain performance (NICE, 2016)
Julia presented with pain and a red swollen shiny skin on her left hand, extending from the fingers to the axilla. Inflammation is due to vasodilation and collection of extra -cellular fluids within the injured area. Disease causing microorganisms are foreign to the body hence they trigger an allergic reaction accompanied by inflammatory response. These set of reactions trigger the mast cells to produce high levels of histamine, which leads to vasodilation and vessel hyperpermeability. As a result, vessel leakage occurs and fluid accumulates at the affected site, making it appear swolen. The tenderness symbolizes presence of infection and dryness is due to dehydration (NICE, 2016)
NEWS is a scoring system that aids in the early detection of a patient who is likely to be vulnerable to sepsis. It does this by comparing 7 variables derived from vital observations such as Oxygen concentration, pulse rate, blood pressure, level of consciousness, pain, alertness, and temperature ( Faisal et al. 2019). As indicated in appendix 1, the patient attained a total NEWS score of 13. This means the patient needs emergency medical assessment by a critical care team and should be transferred to the critical care unit immediately. In sharing Julia’s clinical information during a handoff to the emergency team, I will apply the Situation-Background-Assessment-Recommendation (SBAR) technique of communication. SBAR tool has been recognized as effective, reliable, and valid communication technique during a handoff and transfer of patient, which reduces adverse events in a hospital setting, improves in-communication among health care practitioners, and promotes safety of the patient (Shahid and Thomas, 2018). Situation: Dr. T, this is Julia Jones aged 68 years old. She was admitted to the Accident and Emergency unit complaining of pain and tenderness in her left lower arm. She was diagnosed with cellulitis which progressed to sepsis. Background: she has a history of hypertension and type 2 Diabetes. Assessment: Julia’s pain within her left lower arm and left axilla has increased. Her body temperature is 39.2oC, pulse 112 beats per minute, and blood pressure of 89/45 mmHg. She has a respiratory rate of 28 breaths per minute abnd oxygen saturation of 91%. Her blood glucose level is 9 mmol/L. She has an overall NEWS score of 13, and her condition is deteriorating. Recommendations: She needs an urgent review by the medical emergency team. Oxygen supplementation should begin as soon as possible, equipment required for measuring the blood gases and blood culture. Infuse Hartman’s solution or any other crystalloid and insert a catheter. Monitor the urine output levels and document all actions taken.
Pathophysiology of Sepsis
A classic presentation of red flushed skin, pain, and fever are the key symbolic factors of cellulitis (Sullivan, 2018). Older people suffer reduced immune levels and hence susceptible to several infections, including cellulitis. Mzabi et al. (2017) state that cellulitis is more prevalent in older adults within the age ranges of 65 to 94 years. This is because adults in that age group are immuno-compromised and have poor skin integrity; hence their skin is more vulnerable to invasive injuries, which can easily facilitate entry of disease-causing microorganisms. The patient Julia also has a confirmed history of type 2 diabetes and hypertension. Diabetes is a significant risk factor for skin and skin structure infection (SSSI) (Chisari et al., 2019).
The condition of cellulitis, which is a form of inflammation of the connective tissue in the skin, leads to sepsis. Julia’s cut on her finger severed the skin structure and the nerves, after which inflammation sets in. Singer et al. (2016) argue that sepsis occurs when an invading pathogen causes an inflammatory reaction and is characterized by abnormally high body temperature, tachycardia, and tachypnoea, thus triggering the body’s immune response. Therefore, sepsis is a critical condition that can lead to the destruction of the body organs if not treated early enough, as it can lead to extensive damage to the surrounding tissues and nerves.
Inflammation is characterized by rubor (redness), valor (warmth), tumor (swelling), and dolor (pain) due to the presence of microorganisms, the concentration of blood in the area, action of body immune system to fight infection, and nervous disturbances within the affected area. Lord et al. (2016) state that raised levels of anti-inflammatory cytokines, persistent inflammation, and immunosuppression can lead to sepsis and possibly multiorgan dysfunction if the body is unable to return to homeostasis. Redness occurs because of the increased blood flow to vessels in the affected area. Inflammation is, as a result, extracellular fluid accumulation in the tissues of the affected area. At the same time, pain is the sensation caused by chemical stimulation of the nerve endings around the affected area (Phillips et al., .2018). Elevated lactate level is as a result of glucose breakdown under anaerobic conditions induced by tissue hypoxia (Alvarez et al. 2014).
In discussing the pathophysiology related to systemic alterations, the impaired fibrin deposition coupled up by ineffective coagulation mechanisms can lead to the development of Disseminated intravascular Coagulation, which in turn blocks blood flow to the tissues (Gotts and Matthay, 2016). Reduced blood flow to the body tissues sequentially leads to increased heart rate to compensate for low oxygen levels in the tissues. Creed and Spiers, 2010) state that the sympathetic nervous system stimulated by increasing stroke volume to maintain oxygen delivery to the tissues. The sympathetic nervous system (SNS) then released the adrenaline and non-adrenaline and activated RAAS. The release of adrenaline causes an increased heart rate to compensate for the reduction in stroke volume and a drop in blood pressure. The non- adrenaline also increases heart contractility.
According to Thatcher (2017), Renin-Angiotensin-Aldosterone-System (RAAS) is a hormonal system that assists in regulating blood pressure, fluids, and electrolyte balance. RAAS is released in the kidney, and then it goes to the lungs, which secretes Angiotensin Converting Enzymes (ACE). These enzymes convert angiotensin 1 to angiotensin 2. The latter a vasoconstrictor that works together with the adrenaline cortex to secrete aldosterone. This goes back into the kidney and causes the reabsorption of sodium and water. As a result, the circulating volume goes up, and blood pressure increases.
The increased heart rate is countered by histamine production by the mast cells.High levels of histamine are produced by the mast cells in response to the inflammatory reaction. Histamine acts on the blood vessel walls leading to vasodilation accompanied by vessel hyper permeability (Ebeigbe and Talabi, 2014). Vasodilation is characterized by increased relaxation of the blood vessel walls and a sequential increase in the lumen circumference. This reduces the peripheral resistance of blood vessel walls to the pumping action of the cardiovascular system. The resultant factor will be a decrease in the blood pressure; better classified as hypotension (Baldo and Pharm, 2012). The reduction of blood pressure lead to a decrease of blood supply to the tissues. This contributes to the general decrease of oxygen supply to the body tissues, known as hypoxia. According to Higgins (2007), Reduced oxygen supply to the cells cause them to undergo anaerobic respiration, leading to increased lactic acid production. This leads to metabolic acidosis which deteriorates the condition of the patient.
Nursing Care and Management of Sepsis
Sepsis is a medical emergency, and therefore the management should be swift and precise and incorporates the sepsis six care bundle (S6CB). As noted by Evans (2018), the use of S6CB ensures immediate optimal management of patients with sepsis. Management of sepsis should commence within an hour of identification.
Airway and breathing
I will pay priority to the problems affecting the respiratory system. If the patient is suffering from respiratory insufficiencies, hindering the oxygen supply to the tissues, mechanical ventilation is recommended. I will put the patient on mechanical ventilation to improve tissue oxygen perfusion. Mechanical ventilation helps in correcting tissue hypoxia by offering assisted respiration (Zampieri and Mazza, 2017). Assist control ventilation delivers support for each breath the patient takes. It also takes control when the respiratory rate becomes abnormal (Carpio, 2019). Assist control offers respiratory assistance until the patient can breath oh her own, and able to maintain the SPO2 at 100%. I will Correct tachycardia by giving Amiodarone, an efficient drug used in the management of tachycardia. It is preferred due to its low cardio depressant side effect (Balik et al. 2017). Although, beta-blockers such as atenolol and acebutolol are also preferred because of their excellence in the management of supraventricular arrhythmias and septic shock ( Balik et al. 2017).
I will administer intravenous antibiotics to treat the infection. Broader spectrum antibiotics are recommended as they effectively act on both Streptococcus pyrogens and streptococcus aureus. (Sullivan 2018). Blood culture should be obtained before administering antibiotics. This can help in isolating the causative organisms in the case of bacteraemia. It also helps to provide specific therapy and reduce the risk of antibiotics resistance. I will put administer intravenous antibiotics one hour after sepsis identification. Some of the best antibiotics effective in the management of sepsis, in this case, are vancomycin, ceftriaxone, and ceftazidime. Manage the fever by giving antipyretics and exposing the patient to facilitate the reduction of temperature.
I will Administer crystalloids to restore the circulating blood volume lost through vessel perfusion. According to NICE (2013), it is advisable to give 500 mls of a crystalloid solution such as sodium chloride (NaCl 0.9%), or Hartman’s solution for 15 minutes or less if the patient is characterized as high risk. For example, if the patient has a systolic pressure less than 90 mmHg or lactate levels lower than 4 mmol/L. I will insert a catheter to monitor the urine output levels and also monitor blood glucose levels since the patient had a previous case of type 2 diabetes, and sepsis is associated with hyperglycaemia. I will administer vasopressors to correct hypotension and elevated lactate levels. This is because vasopressors improve the circulatory flow of blood. The administration of vasopressors will be initiated by norepinephrine started at 2-5 mcg/min. Vasopressin is the recommended second-line vasopressor and should be administered at 0.03 U/min. I will Check the lactate levels, and if elevated, then a repeat test will be conducted after 6 hours (Doble,2017).
I will check for signs of phlebitis at the cannulation site. The use of aAVPU score will help check for inflammation, colour, infection, pain, and palpable venous cord (Tzolos and Salawu, 2014). If any of these is identified, the cannula should be removed or changed. A well laid out wound management therapy would be vital in ensuring a successful recovery. Rest the affected limb coupled up by the regular assessment of the wound site, and cleaning using aseptic technique to remove germs and prevent reinfection. The wound swabs should be checked to identify the infection. Administer appropriate antibiotics as prescribed by the doctor.
I will correct the red-hot tender skin by administering corticosteroids. Hydrocortisone is the recommended corticosteroid for use in sepsis management (Briegel, Huge, and Möhnle, 2018). I will administer hydrocortisone 200 mg a day intravenously in four divided doses of 50 mg each.
Holistic care approach
In attaining a successful recovery in Julia’s case, a holistic care approach should be implemented. Jasemi et al. (2017) state that holistic care provides a deep mutual understanding of the patient and their needs for care. It is the right approach that has been successfully used in health care systems. The holistic care approach also results in a better understanding of the effect of illness on the patient’s knowledge of their actual needs. The disease harms the patient’s psychological well-being. It is, therefore, better to adopt a holistic approach when dealing with patients.
It simply starts by knowing the patient’s name and initiating a good rapport with her. I will introduce myself to the patient and explain the whole situation to her by describing the illness and the type of care needed. Answer the patient’s questions and reassure her if need be. All these play a significant role in ensuring the patient does not suffer from anxiety. I will Conduct regular assessments on the patient to ascertain good progress of the disease, and to identify the needs of the patient. Also, I will do regular check-ups on the wound and cleaning it to ensure adequate healing and reduction in a hospital stay. Give the prescribed medications at the right times to promote healing, and continuously monitor the vital signs to determine side effects to the drug, and to have a base knowledge of the patient’s physiological needs. The patient needs to be positioned well to reduce pressure on the wound and to prevent the development of pressure sores. I will manage the patient in a calm and peaceful environment, free from risks of infection. This enhances patient recovery.
A study conducted by Capolongo (2016) explored the views of different patients about the factors within environments that propagated their healing. Many patients described a peaceful holistic environment as the critical factor that made their recovery success. The physical environment provided cognitive, physical, and spiritual support through visual associations with their homes. The patient’s family should be made aware that their involvement in the patient’s healing process plays a significant role, and has positive influences in their recovery (Smith et al. 2013). I will create time and a conducive environment to communicate with Julia’s family in a less busy period to educate and make them aware of the condition and try to observe non- verbal responses and ask for feedback to facilitate understanding to assist with their anxiety issue. I will provide useful information such as a given leaflet, website, and some organisations such as anxiety association, NHS campaign that increase the awareness and alleviate anxiety. Also, I will let them know their responsibilities during the recovery period. This helps in curbing their fears regarding the illness. As Phillips (2016) states, communicating and understanding the needs of the patient lower the intensity of feelings and convey warmth and empathy. Their active involvement in providing psychosocial support while Mrs. Julia is at home will improve the chances of her illness and will hasten her recovery process. The holistic care approach should be focused on addressing the psychosocial impacts of the patient’s disease to their family members. Having a sick family member is a stressful factor to all the close family members (Wittenberg, Saada & Prosser, 2013)
Many legal aspects surround the care of critically ill patients. In as much as the medical team in the ICU are justified to handle patients in their critical conditions, there are legal principles that instil the power of decision making in the patient. Patients can refuse or accept care. As a result, medical personnel should aim towards providing care to critically ill patients while preserving their dignity and ensuring their rights are not violated. According to Grady (2015), clinicians need to obtain informed consent from the patient before taking any medical action. Reportedly, a patient has full rights to deny any form of care, and such should be respected. Legal issues governing the care of critical patients recognise that Julia has the right to refuse resuscitation, ventilation, or any other types of care (Cooper, 2010). Therefore, medical personnel should strive to offer a holistic approach to care while preserving their rights to decision making.
This case presentation has touched the management of a patient with sepsis, and various factors involved in the care of this patient. From this case study, we get to learn of the factors that predispose a patient to sepsis and its step by step management. It has noted that the past medical history of hypertension and type 2 diabetes puts one at a higher risk of suffering from cellulitis, which can progress to sepsis. We learn that increased lactate levels in the blood together with increased heart rate and tachypnoea are the early warning signs of an impending sepsis attack. A holistic approach to care should be effectively applied to the management of an acute patient. Identification of the patient stressors and managing them effectively to influence their healing process. The environment a patient is placed in should be calm and free of the stressors to facilitate good recovery. Patients’ family members should be actively involved in the care of the patient.Moreover, transparency and effective communication need to be adopted by the medical personnel while dealing with their patient to ensure clarity. Consequently, health practitioners must adhere to the legal aspects governing the management of critically ill patients, including recognising their rights to refuse treatments. Therefore, clinicians and other medical personnel must obtain consent from the patient before conducting any therapeutic exercise.
Balik, M., Matousek, V., Maly, M. and Brozek, T., 2017. Management of arrhythmia in sepsis and septic shock. Anaesthesiology intensive therapy, 49(5).
Briegel, J., Huge, V. & Möhnle, P., 2018. Hydrocortisone in septic shock: all the questions answered? Journal of thoracic disease. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036032/ [Accessed May 5, 2020].
Capolongo, S., 2016. Preface, Social Aspects and Well-Being for Improving Healing Processes’ Effectiveness. Preface. Annali dell’Istituto superiore di sanita. Available at: https://pubmed.ncbi.nlm.nih.gov/27033613/ [Accessed May 5, 2020].
Caraballo, C. & Jaimes, F., 2019. Organ Dysfunction in Sepsis: An Ominous Trajectory From Infection To Death. Yale Journal of Biology and Medicine, 92(4), pp.629–640. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913810/ [Accessed May 5, 2020].
Carpio, A.L.M., 2020. Ventilator Management. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK448186/ [Accessed May 5, 2020].
Chen, J., Ou, L. & Hollis, S.J., 2013. A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting. BMC Health Services Research, 13(1). Available at: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-211 [Accessed May 5, 2020].
Cooper, S., 2010. Taking No for an Answer—Refusal of Life-Sustaining Treatment. AMA Journal of Ethics, 12(6), pp.444–449. Available at: https://journalofethics.ama-assn.org/article/taking-no-answer-refusal-life-sustaining-treatment/2010-06 [Accessed May 5, 2020].
Doble, M., 2017. Sepsis: What nurses need to know. Sepsis: What nurses need to know. Available at: https://www.nursingcenter.com/ncblog/september-2017/sepsis-what-nurses-need-to-know [Accessed April 30, 2020].
Ebeigbe, A.B. & Talabi, O.O., 2014. Review: Vascular Effects of Histamine. Nigerian Journal of Physiological Sciences. Available at: https://www.ajol.info/index.php/njps/article/view/120209 [Accessed May 5, 2020].
Evans, T., 2018. Diagnosis and management of sepsis. Clinical medicine (London, England). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303466/ [Accessed May 5, 2020].
Faisal, M. et al., 2019. Computer-aided National Early Warning Score to predict the risk of sepsis following emergency medical admission to hospital: a model development and external validation study. Canadian Medical Association Journal, 191(14), pp.E82–E89. Available at: https://www.researchgate.net/publication/332274255_Computer-aided_National_Early_Warning_Score_to_predict_the_risk_of_sepsis_following_emergency_medical_admission_to_hospital_a_model_development_and_external_validation_study [Accessed May 5, 2020].
Geneva, I.I. et al., 2019. Normal Body Temperature: A Systematic Review. Open Diseases Forum, 6(4). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456186/ [Accessed May 5, 2020].
Grady, C., 2015. Enduring and Emerging Challenges of Informed Consent. New England Journal of Medicine, 372(9), pp.855–862. Available at: https://www.nejm.org/doi/full/10.1056/NEJMra1411250 [Accessed May 5, 2020].
Hotchkiss, R.S. et al., 2016. Sepsis and septic shock. Nature reviews. Disease primers. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5538252/ [Accessed April 29, 2020].
Jasemi, M. et al., 2017. A Concept Analysis of Holistic Care by Hybrid Model. Indian journal of palliative care. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5294442/#__ffn_sectitle [Accessed April 19, 2020].
László et al., 2015. Sepsis: From Pathophysiology to Individualized Patient Care. Journal of Immunology Research. Available at: https://www.hindawi.com/journals/jir/2015/510436/ [Accessed April 30, 2020].
Martinez, R.M. & Wolk, D.M., 2016. Bloodstream Infections. Diagnostic Microbiology of the Immunocompromised Host, pp.653–689. Available at: https://doi.org/10.1128/9781555819040.ch25 [Accessed May 5, 2020].
Mzabi, A.B. et al., 2017. Cellulitis in aged persons: a neglected infection in the literature. Pan African Medical Journal, 27(1). Available at: https://www.ajol.info/index.php/pamj/article/view/159932 [Accessed May 5, 2020].
Morelli, A., D’Egidio, A. & Passariello, M., 2015. Tachycardia in Septic Shock: Pathophysiological Implications and Pharmacological Treatment. SpringerLink. Available at: https://link.springer.com/chapter/10.1007/978-3-319-13761-2_9 [Accessed May 5, 2020].
National Health Service UK, 2017. Low blood pressure (hypotension). NHS Choices. Available at: https://www.nhs.uk/conditions/low-blood-pressure-hypotension/ [Accessed April 29, 2020].