De-Escalating Sepsis

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NURSING SCIENCE

Physical assessment competencies for nurses: A quality improvement initiative

Introducing the Nursing Science Team at Houston Methodist

EDUCATION

Strengthen Your Assessment Skills With Elsevier Clinical Skills

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PRACTICE

De-Escalating Sepsis

PROFESSIONAL DEVELOPMENT

Methodist Proficient Assessment Competency^TM (MPAC) in 2023

FROM OUR TEAMS

The PCA's Role in Changing Patient Conditions

Changing Patient Conditions: Your Role as a UAA

ABOUT DISCOVERN

Case Study 1

A 25-year-old female underwent surgical reconstruction of the right fractured femur. Currently, she is on PCA pump morphine post-op. She is drowsy and the food services notified the RN of her drowsiness and incoherence. CERT team was initiated and the ABG results are as follows:

Normal Ranges

7.26

(7.35-7.45)

PaO₂

(80-100)

PaCO₂

(35-45)

HCO₃

(22 – 26)

pH – 7.26 – Low – Acidosis

Cause of change in pH

PaCO₂ – 52 – High – Culprit of the change
HCO₃ – 25 – Normal

Results

Respiratory Acidosis

Discussion: In this case, respiratory depression is being caused by the side effects of Morphine. As a result, the body is no longer exhaling CO₂ at an acceptable rate, causing the CO₂ level to be high at 52. The CO₂ levels in the body are increasing and thereby altering the pH.

NOTE: If this process were to occur chronically, the body would eventually COMPENSATE by adjusting the HCO₃ levels.

Analysis

Case Study 2

ABG values of A 33-year-old male post-op day 3 are as follows:

Normal Ranges

7.32

(7.35-7.45)

PaCO₂

(35-45)

HCO₃

(22 – 26)

pH – 7.26 – Low – Acidosis

Cause of change in pH

PaCO₂ – 40 – Normal CO₂ tension
HCO₃ – 20 – Low – Culprit of the change

Results

Metabolic Acidosis

Discussion: This patient is in metabolic acidosis. In this case, a clinical picture would be necessary to further determine the cause. From his blood gas analysis, we can recognize that the changes in his pH are due to a metabolic component, rather than respiratory. The surgery can cause a pH imbalance due to dehydration, trauma to certain tissues, or kidney disease.

Analysis

Case Study 3

A 27-year-old male patient is admitted with complaints of shortness of breath, chest tightness, and tingling of fingers and mouth. No past medical history. ABG results are as follows:

Normal Ranges

7.49

(7.35-7.45)

PaO₂

(80-100)

PaCO₂

(35-45)

HCO₃

(22 – 26)

(-2 to +2)

pH – 7.49 – High – Alkalosis

Cause of change in pH

PaCO₂ – 25 – Low – Culprit of the change
HCO₃ – 22 – Normal
BE – +2 – Normal

Results

Respiratory Alkalosis

Discussion: Respiratory alkalosis is most commonly caused by hyperventilation. During hyperventilation, the patient is breathing too fast and releasing too much CO2. As a result, the PaCO2 level is low and the pH is high. Treatment for this patient would include slowing their breathing and treating the underlying reason for the hyperventilation.

Analysis

Case Study 4

A 58-year-old female admitted with complaints of profuse vomiting and abdominal distention in the last 24 hours. CT scan reveals a large mass causing bowel obstruction. ABG results are as shown below:

Normal Ranges

7.51

(7.35-7.45)

PaO₂

(80-100)

PaCO₂

(35-45)

HCO₃

(22 – 26)

(-2 to +2)

Analysis

pH – 7.51 – High – Alkalosis

Cause of change in pH

PaCO₂ – 42 – Normal
HCO₃ – 30 – High – Culprit of the change

Results

Metabolic Alkalosis

Discussion: Metabolic alkalosis in this patient is most likely related to bowel obstruction, which is causing vomiting and excessive fluid loss. The bicarbonate level is high as the blood is more concentrated from free fluid loss and the kidneys are unable to eliminate the excess hydrogen ions. As a result, more bicarbonate is produced.

PRACTICE

De-Escalating Sepsis

By Francella Crespo, MSN, CCRN, RN-BC, WTA-C

3 MIN READ

Sepsis is the body’s systemic inflammatory response to an infection that can lead to tissue damage, organ failure, and death (Sepsis Alliance, 2020). The most common infections that trigger sepsis in the adult population occur in the lungs, urinary tract, gut, and skin (CDC, 2020).

Frequently, hospitals admit patients experiencing one of the Sepsis Pathways: Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, or Septic Shock. Understanding the development of sepsis and recognizing incidents that lead to septic shock will result in the identification of symptoms and improve patient outcomes. The more knowledge we have, the quicker we can readily identify triggers that escalate this condition.

Sepsis begins with a systemic inflammatory response and presents with two of the following symptoms:

Hyperthermia (temperature >100.9°F)
Hypothermia (temperature < 96.8° F)
Tachycardia (heart rate > 90 beats per minute)
Tachypnea (respirations > 20 breaths per minute)
White blood cell (WBC) count >12,000 or < 4,000
Normal WBC with >10% bands.

The presence of a suspected or confirmed infection with two of the symptoms listed above is considered Sepsis. When the infection begins to affect organs, Sepsis becomes Severe Sepsis. Lungs begin to require more oxygen. The brain is affected and mental status declines, often displaying acute changes such as confusion or lethargy. The cardiovascular system is affected, and blood pressure may decrease with systolic blood pressure less than 90mmHg and mean arterial pressure (MAP) less than 65 mmHg. Lactic acid accumulation in the blood occurs when the body has a high demand for energy without an adequate supply of oxygen. With Severe Sepsis, lactic acid levels are usually elevated above 2.0 mmol/L. Additionally, the liver may fail to clean the blood system of bilirubin resulting in an elevated bilirubin level of greater than 2.0mg/dL. Kidneys are also affected, which is evident with elevated creatinine levels greater than 2.0 mg/dL. Poor kidney function can also cause urine output reduction resulting in urine output of less than 0.5mL/kg/hr. Lastly, Sepsis causes dysregulation of the hemostatic system, and there is an increased risk for bleeding usually presenting with an INR greater than 1.5, a PTT greater than 60 seconds, or platelet count less than 100,000 (Sepsis Alliance, 2020).

Time is the best tool available when treating sepsis. Early recognition with identification of symptoms is important in patients who develop this condition. A thorough nursing assessment can prevent an escalation of infection responses by monitoring of patient symptoms. Familiarity with signs of organ dysfunction and evaluation of a patient’s co-morbidities can likewise aid in distinguishing between sepsis and other health issues. Sepsis and the body’s reactive inflammatory response are extremely taxing on the body’s resources.

References:

Nguyen, K. (2020). The Sepsis Alliance Institute. The Sepsis Institute | Sepsis Education. Retrieved August 7, 2022, from https://www.sepsisinstitute.org/

Centers for Disease Control and Prevention. (2016). Making Health Care safer. Think Sepsis. Time Matters. Retrieved August 7, 2022, from https://www.cdc.gov/vitalsigns/sepsis/

EDUCATION

Strengthen Your Assessment Skills With Elsevier Clinical Skills

NURSING SCIENCE

Methodist Proficient Assessment Competency^TM (MPAC) in 2023

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