Introduction
This essay will center its focus on the application of an evidence-based approach in the management of a patient diagnosed with Sepsis. Sepsis, as defined by Polat et al. (2017), is characterized as a systemic inflammatory response to infection. The significance of adopting an evidence-based approach within nursing practice cannot be overstated. Evidence-based practice has been substantiated to enhance clinical outcomes, heighten patient safety, and even curtail healthcare expenditures, as evidenced by the works of Considine and McGillivray (2010), Peterson et al. (2008), and Fineout-Overholt et al. (2005). Executing an evidence-based approach necessitates a thorough understanding of the robustness of diverse types of studies culled from the literature, as well as the cultivation of a critically analytical mindset, in accordance with Burns et al. (2011). To uphold the principles of patient privacy and confidentiality, as stipulated by the Nursing and Midwifery Council (NMC, 2015), this essay will anonymize and redact the name and patient identifiers of the subject, Mr. K, a 55-year-old male.
Mr. K has a history of chronic hypertension, hyperlipidemia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). He is a chronic smoker with occasional social alcohol consumption but lacks any pertinent surgical history. In the past year, Mr. K has experienced two hospital admissions due to acute exacerbations of COPD. Despite being prescribed a regimen comprising short-acting beta agonist (SABA), long-acting beta-agonist (LABA), anti-cholinergic, and inhaled corticosteroid, he has displayed non-compliance with his prescribed pharmacotherapy. He has repeatedly missed his pulmonology outpatient follow-up appointments.
History & Physical Examination
History taking plays an integral role in clinical decision-making, as emphasized by Kassirer et al. (2010). A focused history of Mr. K’s arrival at the emergency department revealed that he had been enduring chest pain for the past three days, concurrent with a purulent cough. This chest pain exhibited a sharp character and was explicitly localized to the left lower thoracic region, devoid of radiation. Concurrently, he experienced mild nausea without any episodes of vomiting. Notably, Mr. K, who had harbored a chronic cough for an extended period, communicated, albeit with difficulty, that his sputum’s consistency had transformed, becoming notably more viscous and purulent. Moreover, he articulated that the cough had intensified in severity and frequency, and he was experiencing pronounced difficulty
Upon admission to the emergency department, Mr. K’s vital signs were recorded as follows:
- Temperature: 39.1 degrees Celsius
- Heart Rate: 140 beats per minute
- Blood Pressure: 90/50 mmHg
- Respiratory Rate: 28 breaths per minute
- Oxygen Saturation: 86% while breathing room air
- Glasgow Coma Scale: 15
Clinical observation indicated Mr. K’s overall appearance was toxic. He exhibited signs of moderate respiratory distress, evidenced by his recruitment of accessory muscles for inspiration, such as the sternocleidomastoid muscles, and adopting a seated tripod position. He encountered difficulty in completing entire sentences during the aforementioned history-taking process. Peripheral and central cyanosis was not evident. Auscultation of Mr. K’s chest revealed normal heart sounds without murmurs or pericardial rub. Nevertheless, there was a notable decrease in air entry
Pneumonia, Sepsis & Septic Shock
Based on Mr. K’s vital signs, it became apparent that he exhibited an exceptionally elevated NEWS (National Early Warning Score) score of 14. This necessitated an urgent assessment by a rapid response team equipped with critical care competencies. Notably, the NEWS score is a well-validated tool that has supplanted various early warning systems employed throughout the United Kingdom, as explained by Jones (2012). This scoring system bears direct implications for clinical outcomes and mortality rates. It holds predictive value concerning a patient’s likelihood of requiring admission to the intensive care unit, a point underscored by Abbott et al. (2015). Patients whose NEWS scores surpass 6 should be subject to at least hourly monitoring, as NEWS guidelines recommend (2017). Consequently, Mr. K’s location was shifted from the P2 (priority 2) sector of the emergency department to the P1 (priority 1) section, where an exhaustive diagnostic evaluation was initiated.
Although the principal differential diagnosis centered on pneumonia, consideration was still given to the possibility of an acute coronary syndrome (ACS) due to Mr. K’s chest pain. This consideration held particular relevance since COPD is associated with an elevated risk of cardiovascular disease, a risk that Mr. K further compounded through his independent risk factors, such as diabetes and hypertension, as affirmed by Rothnie and Quint (2016). To eliminate ACS from the diagnostic spectrum, a 12-lead electrocardiogram was administered, revealing the absence of any ACS indicators, such as T-wave inversions, reciprocal changes, ST-elevations, or depressions.
Simultaneously, while these investigations were underway, a series of nursing interventions were carried out in adherence to the ABCDE approach, a widely endorsed framework in emergency medicine that swiftly evaluates the patient’s airway, breathing, circulation, disability, and exposure, as described by Smith and Bowden (2017). In the initial stage, Mr. K’s airway was determined to be patent, as he could communicate verbally. Subsequently, supplemental oxygen was administered to facilitate his respiratory effort by enhancing oxygen saturation. Maintaining his oxygen saturation within the range of 88% to 92% to avoid dampening his hypoxic drive remained essential, an imperative elucidated by Brill and Wedzicha (2014). Mr. K’s respiratory distress exhibited signs of improvement shortly after administering supplemental oxygen, so the decision was made to forego invasive ventilation, specifically rapid sequence intubation. Thirdly, in light of Mr. K’s borderline blood pressure, two large-bore intravenous cannulae were inserted into his antecubital fossae, and 500 ml of normal saline was promptly infused to counteract his circulatory decompensation.
Song et al. (2016) underscored that Sepsis and septic shock convey alarming mortality rates of 30% and 50%, respectively. It is crucial to appreciate that shock is an acute physiological disturbance leading to systemic manifestations and symptoms arising from compromised organ perfusion, as elucidated by Bonanno (2011). Furthermore, septic shock is characterized as a systemic inflammatory response triggered by infection, a definition reinforced by Polat et al. (2017).
In light of these grave statistics and definitions, the healthcare community has introduced the Surviving Sepsis Guidelines (SSG), which mandate the implementation of a specific bundle within the first hour of patient contact. This bundle comprises the early recognition of Sepsis, the acquisition of blood cultures, the administration of intravenous broad-spectrum antibiotics, and the assessment of serum lactate levels, with the consideration of vasopressor administration if deemed necessary, in accordance with Milano et al. (2018).
Consequently, the establishment of circulatory access through intravenous cannulation assumed paramount importance. This same access facilitated the intravenous administration of antibiotics. Before this intervention, blood cultures were diligently obtained, serum lactate levels were measured, and other pertinent hematological assessments were aimed at gauging end-organ perfusion and identifying ischemic episodes.
Septic Workup
After stabilizing Mr. K’s condition, a comprehensive septic workup was initiated. A plain chest radiograph unveiled the presence of lobar pneumonia within the left lung. A point-of-care urinalysis was conducted to explore the possibility of a urinary tract infection, revealing no nitrites or leukocytes, thereby negating the likelihood of such an infection. Simultaneously, an arterial blood gas analysis was performed to assess Mr. K’s acid-base status. It is worth noting that patients experiencing acute exacerbations of COPD typically manifest respiratory acidosis secondary to hypercapnia, as Bruno and Valenti (2012) outlined.
An additional one-liter infusion of normal saline was administered intravenously to bolster Mr. K’s hemodynamics and ensure a mean arterial pressure above 60 mmHg. Moreover, Mr. K’s capillary glucose levels were monitored to ascertain that he did not present with hyperglycemia or hypoglycemia. It is noteworthy that severe hyperglycemia upon admission is associated with a heightened 30-day mortality risk in both diabetic and non-diabetic individuals, as elucidated by van Vught et al. (2016). Given Mr. K’s septic shock, his anti-hypertensive medications were temporarily suspended, and adjustments to his oral hypoglycemic agents, such as metformin, were made in response to his glycemic status. Prednisolone, an oral steroid, was prescribed in the interest of his COPD exacerbation, aligning with robust evidence of its efficacy in severe COPD exacerbations, as Wedzicha et al. (2017) emphasized.
Management
Subsequently, Mr. K was transferred to the high-dependency ward, where he received vigilant monitoring. His family was regularly updated regarding his diagnosis and informed of his progress during his stay in the high-dependency unit and the subsequent general ward. Mr. K’s care was overseen by a multidisciplinary team, encompassing a medical social worker, pulmonologist, dietician, and pharmacist. As his blood cultures identified Streptococcus pneumoniae, his intravenous antibiotics were transitioned to an oral course of Augmentin (co-amoxiclav).
In line with a patient-centered approach, Mr. K’s financial circumstances were considered, prompting a referral to a medical social worker to provide him and his family with pertinent financial counseling.
Conclusion
Mr. K presented a complex clinical picture characterized by an acute exacerbation of COPD, attributed to lobar pneumonia, and further complicated by Sepsis and septic shock. His critical condition warranted an immediate transfer to the P1 section of the emergency department, primarily due to a markedly elevated NEWS score. A comprehensive framework was initiated in alignment with the Surviving Sepsis Guidelines (SSG). This case exemplifies the imperative nature of evidence-based nursing interventions in delivering optimal patient care. These interventions encompassed the establishment of intravenous access, the administration of supplemental oxygen, the collection of essential blood cultures and hematological assessments, and the implementation of fluid resuscitation, among other measures.
It is incumbent upon nurses to diligently practice evidence-based medicine in their daily clinical endeavors, with the ultimate aim of attaining the best possible patient outcomes. This case study underscores the instrumental role of evidence-based practice in shaping clinical decision-making processes and rationalizing the decisions executed by the healthcare team.