Escolar Documentos
Profissional Documentos
Cultura Documentos
Edgardo Yoast
Age: 72 Weight: 81.8 kg Base: Stan D. Ardman
Overview
Synopsis
The learner is providing care to an elderly gentleman who is a long-term resident of an extended care facility. He was recently treated for a urinary tract infection. He now presents to the Emergency Department (ED) with an altered level of consciousness and hypotension. However, his history of mid-stage Alzheimers disease complicates the clinical picture. The patients initial presentation meets the systemic inammatory response syndrome (SIRS) criteria. His clinical status improves after initial uid management allowing stable transfer to the Intensive Care Unit (ICU). Once in the ICU, the patients condition dramatically deteriorates as he manifests septic shock and eventually multi-system organ dysfunction despite aggressive intervention including intubation, mechanical ventilation, IV uid therapy and vasopressor support. His status eventually progresses to cardiac arrest despite intervention. This Simulated Clinical Experience (SCE) consists of four states that are transitioned manually at the facilitators discretion. With manual transitions, instructors should advance to the applicable state when appropriate interventions are performed. This SCE is intended for the learner in Semester IV. During State 1 Admit to Emergency Department, the patient demonstrates a HR in the 120s, BP in the 90s/60s, RR in the mid to upper 20s and SpO2 in the mid 90s on room air. Temperature is 35.4C. He weighs 81.8 kg. Breath sounds are clear bilaterally. The patients cardiac rhythm reveals sinus tachycardia. Upon auscultation of heart sounds, S1 and S2 are heard. He is groaning and moans in response to painful stimuli. Only random spontaneous movement is noted. Pupils are equal and reactive to light. His skin is cool and ushed. A 20-gauge IV to saline lock is present in the right forearm. Bowel sounds are normoactive. After the learner inserts the urinary catheter, his urine output averages approximately 10 mL/hr of dark, brown cloudy urine. The learner is expected to perform a complete assessment, place on cardiac and pulse oximetry monitoring, ensure the correct administration of IV uids and medications, monitor respiratory status, administer oxygen, evaluate effectiveness of interventions, collaborate with the healthcare provider (HCP) regarding the placement of a pulmonary artery (PA) catheter and determines if advance directives are in place. Between State 1 and State 2, a PA catheter is inserted. Verbal orders are given for a STAT portable chest x-ray to verify the line placement. After verbal orders are given, the learner is expected to clarify the verbal orders by repeating them back to the HCP.
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Author
Jami Nininger and Dawn Hughes, Mount Carmel College of Nursing - Columbus, OH and Thomas J. Doyle, METI - Sarasota, FL Reviewed by Jami Nininger, The Ohio State University College of Nursing - Columbus, OH, 2008 and Christie Pawley, METI - Sarasota, FL, 2009
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Background
Patient History
Past Medical History: Alzheimers Disease, mild hypertension Allergies: No known drug allergies Medications: Atenolol, metformin Code Status: Has a living will, but no copy is on le at the hospital Social/Family History: Has one adult daughter who rarely visits him in the nursing home
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment ndings where appropriate and necessary The report should follow the SBAR format and include: Situation: The patient is a 72-year-old male who is brought to the ED today from an area nursing home due to increasing unresponsiveness over the past 24 hours. Admission orders have been written. Background: He has been a resident of an area nursing home for the past 10 years because his family is no longer able to care for him due to his development of Alzheimers disease. His medical and surgical history is fairly insignicant but is positive for mild hypertension for which he receives no medications. His blood pressure normally runs 140 to 160/90 to 95 mmHg. His normal mental status includes responsiveness to his name and following the routine of the extended care facility appropriately. He is normally able to feed and toilet himself, but on occasion, he is incontinent of both urine and stool. The nurse at the nursing home reports the patient had just completed a course of antibiotics for a urinary tract infection. He has exhibited increasing unresponsiveness over the past 24 hours. He now only responds to painful stimuli by groaning even though his eyes open spontaneously. He does not follow commands. Additionally, his blood pressure has dropped to the low 100s/60s.
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Orders
Initial Healthcare Providers Orders: IV 0.9% NS 500 mL IV bolus wide open, may repeat x2 if breath sounds are without rales and systolic blood pressure is below 90 CBC, electrolytes, BUN and creatinine, urinalysis, urine culture and sensitivity with gram stain, sputum culture and sensitivity with gram stain, ABG, blood cultures x2, lactate level, coagulation prole STAT Oxygen at 6 LPM per nasal cannula, may titrate to maintain SpO2 greater than 94% Chest x-ray STAT Insert urinary catheter Cefotaxime 1 g IVPB every 6 hours rst dose STAT Acetaminophen 625 mg rectal suppository for Temp greater than 38C Continuous ECG and SpO2 monitoring NPO Bedrest Vancomycin 1 g IV every 12 hours rst dose STAT State 1 Orders: STAT portable chest x-ray to verify line placement
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Preparation
Learning Objectives
Uses patient history and assessment data in the early identication and management
of patients at risk for or with sepsis, septic shock and multisystem organ dysfunction (ANALYSIS). Formulates, prioritizes and individualizes a plan of care based on assessment ndings (SYNTHESIS). Anticipates diagnostic orders and therapies including medications for the management of patients with sepsis, septic shock and multi-system organ dysfunction (COMPREHENSION). Discusses the possible sequela and consequences of unrecognized and untreated sepsis (COMPREHENSION). Evaluates and documents the patients response to therapies and identies follow-up intervention based on patient assessment data (EVALUATION). Discusses the legal, ethical and moral implications of care delivery in the acute care setting and discusses the concept of medical futility (COMPREHENSION). Identies the emotional implications of patient death on healthcare personnel involved in the care delivery of a patient (SYNTHESIS).
Preparation Questions
Differentiate the following terms: ooSystemic Inammatory Response Syndrome (SIRS) ooSepsis ooSevere sepsis ooSeptic shock ooMultiple organ dysfunction syndrome (MODS) Identify the nursing priorities in the care of the patient with sepsis and septic shock. What class of bacteria is responsible for more than one half of the cases of septic shock? Explain why myocardial depression is almost always present in a patient with septic shock Discuss the cascade of host inammatory responses that produce the major detrimental What is early-goal-directed therapy in the management of sepsis? Identify the treatment guidelines currently recommended for the management of sepsis Discuss how the drug dobutamine affects cardiac output. Identify the nursing implications Discuss how norepinephrine works and its indications for use. Identify the nursing Discuss how drotrecogin alfa works and its indications for use. Identify the nursing Describe the concept of ScvO2 monitoring. Identify the signicance of abnormally high and Describe the nursing responsibilities in assisting with central line insertion. Discuss the importance/rationale for central line placement in a patient with sepsis. Describe the physiologic alterations of each organ system identied below that may be
low ScvO2 readings. implications with the administration of this drug. implications with the administration of this drug. with the administration of this drug. and septic shock. effects seen in sepsis due to gram-negative bacteria. despite an initial rise in cardiac output. What are some common causes of this?
associated with aging and potentially impact a patients ability survive sepsis or septic shock. ooCardiac ooRenal ooImmune ooHematologic If a patient has no advanced directives and no immediate family to make a decision regarding his care, what options are available to the healthcare team? Discuss if you feel this patient should or should not be a full Code Blue. Defend your position. Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI Equipment and Supplies
IV Supplies Distilled water 1000 mL (label 0.9% Normal Saline) (4) Distilled water 500 mL (label 0.9% Normal Saline) (3) IV pump (3) Pulmonary artery catheter IV tubing for pump (3) Macrobore IV tubing Pressure infuser Medication Supplies Distilled water 10 mL syringe (label Epinephrine 1 mg/mL) (label Amiodarone 50 mg/mL) (label Lidocaine 10 mg/mL) (3) Distilled water 250 mL (label Norepinephrine 4 mg/250 mL) (label Drotrecogin alpha 2 mg/mL) (2) Distilled water 50 mL (label Cefotaxime 1g) Distilled water 250 mL (label Vancomycin 1 gram) Distilled water 500 mL (label Heparin 3000 units) Oxygen, Airway and Ventilation Supplies Oxygen owmeter Oxygen source Nasal cannula Resuscitation bag Non-rebreather mask Intubation tray Endotracheal tube 7.0 Suction Equipment and Supplies Closed system suction for ventilator Tonsil tip suction device Suction tubing (2) Suction canisters (2) Sputum trap Dressing Supplies Central line dressing kit Cloth tape (endotracheal tube) Silk tape (nasogastric tube) Genitourinary Supplies Urinary catheter insertion tray with gravity drainage bag with urimeter Distilled water 1000 mL with 2 mL yellow food coloring for urine source
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
10
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
11
Notes
Facilitator Notes
This SCE was created with the patient Edgardo Yoast, and only this patient can be used. The physiological values documented indicate appropriate and timely interventions. Differences will be encountered when care is not appropriate or timely. If using the Muse platform, dont hit Run until you are ready to start the scenario. If using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the simulated clinical experience. Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize physical ndings the learner is seeking but not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to learner questions if present on your simulator. Where appropriate, do not provide information unless specically asked by learner. In addition, ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them. If the patient becomes unconscious in the SCE, remember the patient stops speaking. It is important to moulage the simulator to enhance the delity, or realism, of the simulated clinical experience. For this patient, dress the simulator in casual clothing and place the simulator in supine position. Apply rose-colored blush to the simulator skin to simulate ushed appearance. For simulators without the diaphoresis feature, spray the face and other appropriate body areas with water. When the learner initiates cardiac monitoring, the tracing and heart trate appear on a real ECG monitor for those simulators with this feature. For simulators without ECG monitoring, have the learner apply ECG electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchPro or Waveform display ECG tracing. Prime the Genitourinary system per simulator feature. Remove the catheter as the learner is to insert the urinary cathether in State 1. Add one drop of yellow food coloring to 1000 mL of distilled water. Urine color should be dark and cloudy. Add yellow and red food coloring to distilled water to achieve desired color of urine and add to drainage bag and tubing. Also add a small amount of chalk dust and ammonia to urine mix in drainage bag to complete the effect. Note that this mixture should not be used to prime the simulators genitourinary system. Simulation center personnel should play the following roles: Healthcare provider Code Blue Leader Laboratory technician EMS personnel bringing patient to ED Radiology technician Daughter Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
12
Debrieng Points
The facilitator should begin by introducing the process of debrieng: Introduction: Discuss faculty role as a facilitator, expectations, condentiality, safediscussion environment Personal Reactions: Allow students to recognize and release emotions, explore student reactions Discussion of Events: Analyze what happened during the SCE, using video playback if available Summary: Review what went well and what did not, identify areas for improvement and evaluate the experience
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
13
Teaching Q&A
State 1 Admit to Emergency Department: Does this patient meet the criteria for systemic inammatory response syndrome (SIRS), sepsis or septic shock? SIRS, possibly septic shock due to presentation with hypotension What is the rationale behind the large uid resuscitation orders? To improve tissue perfusion in light of low blood pressure Why is it necessary to frequently assess breath sounds in this patient while administering large volumes of crystalloid solutions? The elderly are more likely to have co-existing cardiac disease and have some decrease in left ventricle (LV) performance with aging Will manifest uid volume overload more quickly than those without a history or less than 65 years of age Sepsis causes cardiac suppression that can lead to heart failure manifestations Why would cefotaxime and vancomycin be chosen as initial treatment for this patient? Broad spectrum coverage is indicated in the initial management of sepsis Cefotaxime covers gram-negative organisms commonly associated with urosepsis Vancomycin is appropriately added to increase the spectrum of organisms covered because the patient is coming from an extended care facility (ECF) and the source may be nosocomial in nature How are two sets of blood cultures obtained? Requires adequate cleansing of site and obtained from two separate peripheral accesses How will the sputum culture and sensitivity be obtained in this patient? Most likely through nasotracheal suctioning and the use of a sputum trap Patient will not likely produce a spontaneous cough and cannot follow instructions for obtainment
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
14
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
15
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
16
17
Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI References
Bridges, E. & Dukes, M. (2005). Cardiovascular aspects of septic shock: Pathophysiology, monitoring and treatment. Critical Care Nurse 25, 14-41. Dellinger, R., Levy, M.M., Carlet, J.M, Bion, J., Parker, M.M., Jaeschke, R., et al., (2008). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine 35, 296-327. Dries, D. (2007). Cardiovascular support in septic shock. Air Medical Journal 26, 240-247. Finfer, S. (2008). Corticosteroids in septic shock. The New England Journal of Medicine 2, 188190. Hernandez, G., Bruhn, A., Romero, C., Larrondo, F., De La Fuente, R., Castillo, L., et al. (2005). Management of septic shock with a norepinephrine-based haemodynamic algorithm. Resuscitation 66, 63-69. King, J. (2007). Sepsis in critical care. Critical Care Nursing Clinics of North America 19, 77-86. Lee, C. (2006). Role of exogenous arginine vasopressin in the management of catecholaminerefractory septic shock. Critical Care Nurse 26, I17-23. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare 2(6), 207-230. McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia: Saunders. Merx, M. & Weber, C. (2007). Sepsis and the heart. Circulation 116, 793-802. Nelson, D.P., Lemaster, T.H., Plost, G.N., & Zahner, M.L. (2009). Recognizing sepsis in the adult patient. American Journal of Nursing 109(3), 40-45. Otero, R.M., Nguyen, H.B., Huang, D.T., Gaieski, D.F., Goyal, M., Gunnerson, K.J. , et al. (2006). Early goal-directed therapy in severe sepsis and septic shock revisited: Concepts, controversies, and contemporary ndings. Chest 131(4), 1579-1595. Powers, J., & Jacobi, J. (2006). Pharmacologic treatment related to severe sepsis. AACN Advanced Critical Care 17(4), 423-432. Rivers, E.P., & Ahrens, T. (2008). Improving outcomes for severe sepsis and septic shock: tools for early identication of at-risk patients and treatment protocol implementation. Critical Care Clinics 24(Suppl. 3), S1-47. Robson, W., Newell, J. & Beavis, S. (2005). Severe sepsis A and E. Emergency Nurse 16, 24-30. Russell, J. (2006). Management of sepsis. The New England Journal of Medicine 355, 1699-1713. Springhouse (Eds). Best practices: Evidence-based nursing procedures (2nd ed.). (2006). Philadelphia: Lippincott Williams & Wilkins. Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
18
Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL
19