Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

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

Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

In State 2 Slight Improvement with Fluids, the patients condition initially improves with a HR in the 90s, BP in the 100s/60s, RR in the mid 20s and SpO2 in the upper 90s on 6 LPM oxygen by nasal cannula. Temperature is 36.0C. Readings from the PA catheter include a central venous pressure (CVP) between 5 and 10, pulmonary artery pressure (PAP) in the upper teens to low 20s/5 to 10 and systemic vascular resistance (SVR) of 1000. Breath sounds are clear bilaterally. His cardiac rhythm reveals sinus tachycardia with no ectopy. He is groaning and moans in response to painful stimuli. Only random spontaneous movement is noted. His skin is cool and ushed. Urine output is dark gold and cloudy at a rate of 25 mL/hr. When the learner calls for lab results, the simulation lab personnel should roleplay the laboratory technician and give a short report of laboratory values CBC: WBC 27.0, Hgb 11.3, Hct 32%, platelets 104,000; Chemistry: Na 145, K 5.0, BUN 20, Creatinine 1.1, Cl 110, Mg 2.2, CO2 18, glucose 76; Lactate level 6; ABG: pH 3.71, PaCO2 78, HCO3 19; Urine: Blood positive, WBC positive, gram stain shows gram negative rods; ScvO2 71%. When the learner calls for chest x-ray results, simulation lab personnel should roleplay the radiology technician and give the following report Portable chest x-ray: Unremarkable, pulmonary artery catheter in proper position; no pneumothorax. The learner is expected to reassess the patient, monitor infusion pumps, obtain and interpret lab and x-ray results, inquire about the status and ndings of the patients advance directives, notify healthcare of signicant ndings and communicate appropriately with patient. After ICU admission orders are received, the learner should call report to the ICU admitting nurse and prepare the patient for transport. In State 3 Deteriorates Upon Admit to ICU, the patients condition worsens with a HR in the 120s, BP in the 60s/40s, RR in the upper 20s and SpO2 in the upper 50s to low 60s on oxygen at 6 LPM via nasal cannula. Temperature is 35.0C. Readings from the PA catheter include a CVP of 1 to 5, PAP in the teens/less than 10, cardiac output of 6.0, SVR of 400 and central venous oxygen saturation (ScvO2) of 40%. Crackles are present in both lung elds. His cardiac rhythm reveals sinus tachycardia. His skin is cool and diaphoretic. He is dyspneic and using accessory muscles to breathe. He exhibits no response to painful stimuli. Urine output remains dark gold and cloudy at a rate of 10 mL/hr. Despite their best efforts, the learners are unable to contact the patients daughter or verify his living will. The learner is expected to order the ABG and obtain results. When the learner calls for the ABG results, the simulation lab personnel should roleplay the laboratory technician and give the following report ABG: pH 7.16, PaCO2 53, PaO2 69, HCO3 18. The learner is expected to reassess the patient, interpret ndings, place the head of bed at, monitor infusion pumps, recognize the need for and prepare intubation and mechanical ventilation and notify the HCP of signicant ndings. After verbal orders are given, the learner is expected to clarify the verbal orders by repeating them back to the HCP. The learner is also expected to assist with intubation and the insertion of arterial line, continually reassess the patient, recognize the need for ABG and a chest x-ray, correctly calculate and initiate norepinephrine infusion, perform nasogastric intubation, verify placement of nasogastric tube and communicate appropriately with the patient. When the learner calls for the chest x-ray result, the simulation lab personnel should roleplay the radiology technician and give the following report Portable chest x-ray: Endotracheal tube in proper position, lungs with patchy inltrates bilaterally.

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

In State 4 Code Blue, MODS, Death the patients condition deteriorates with a HR of 0, BP in the teens/teens and RR per bag-valve-mask device ventilation. His cardiac rhythm initially reveals sinus tachycardia with frequent premature ventricular contractions (PVCs) before rapidly progressing to ventricular tachycardia and subsequently asystole regardless of intervention. There is no urine output and no response to painful stimuli. The daughter has been contacted and is in route to the hospital. When the learner recognizes cardiac arrest, simulation lab personnel should assume the role of the code blue leader and give orders based on advanced cardiac life support (ACLS) protocols. The learner is expected to begin basic life support (BLS) measures, ventilate with the bag-valve-mask device, initiate ACLS measures per protocol, collaborate effectively with healthcare team, communicate effectively with daughter upon her arrival and provide emotional support. This SCE prepares the learner for the following items of the NCLEX-RN test format: NCLEX-RN Test Plan: Safe and Effective Care Environment X Management of Care X Safety and Infection Control Health Promotion and Maintenance X (Aging process) Psychosocial Integrity X (Therapeutic communication, Family dynamics, End-of-life care) Physiological Integrity X Basic Care and Comfort X Pharmacological and Parental Therapies X Reduction of Risk Potential X Physiological Adaptations

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

Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

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

Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Assessment: Vital signs: HR 126, BP 102/66, RR 26 and slightly labored, SpO2 has been 96% on room air, Temp 35.7oC Cardiovascular: Sinus Tachycardia on telemetry monitoring Respiratory: Clear in both lobes GI: Active bowel sounds GU: Has not voided Extremities: Random spontaneous movement that is increasingly weak in all four extremities (2+) Skin: Cool and ushed Neurological: Pupils equal, round and reactive to light, moans to painful stimuli altered level of consciousness off his baseline IVs: 20-gauge IV to saline lock in right forearm, patent and non-reddened Labs: Ordered upon admission Fall Risk: High-risk Pain: Moaning Recommendations: Implement admission orders and monitor for instability.

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

Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

State 2 Orders: ICU Orders: IV 0.9% NS at 20 mL/kg until CVP greater than 8 mmHg; Consult healthcare provider for further orders once CVP greater than 8 mmHg Continuous CVP monitoring Vital signs per ICU routine Oxygen at 6 LPM per nasal cannula to maintain SpO2 greater than 94% Heparin 3000 units in 500 mL 0.9% NS at 3 mL per hour Monitor ScvO2 every two hours; Get ABG and notify healthcare provider if less than 70% Consult surgical house ofcer or Acute Care NP for arterial catheter placement Notify healthcare provider for MAP less than 70 mm Hg Vancomycin 1 gm IV every 12 hours Urinary catheter to gravity drainage Hourly Intake and Output Notify healthcare provider if urine output less than 0.5 mL/kg/hour Cefotaxime 1g IVPB every 6 hours Acetaminophen 650 mg rectal suppository every 4 hours for Temp greater than 38C Routine arterial catheter care and monitoring once line inserted CBC, electrolytes, BUN and creatinine with ABG every AM Serum Lactate level every 8 hours NPO Full Code Blue until next of kin contacted to conrm Patient Self-Determination Act (PSDA) documentation PT, INR, Type and Screen Bedrest State 3 Orders: Intubate patient Ventilator settings: Vt 500 mL, RR 16, RR 24, mode AC, PEEP 5, FiO2 100% Insert nasogastric tube and place to low wall suction Portable chest x-ray STAT for endotracheal tube placement Repeat ABG in 30 minutes Start norepinephrine 4 mg in 250 mL D5W at 3 mcg/minute and titrate to keep MAP greater than 70 mmHg Repeat chemistry panel STAT

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

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).

Learner Performance Measures

State 1 Admit to Emergency Department: Performs a physical assessment on a 72-year-old male Documents all ndings appropriately Places on cardiac and pulse oximeter monitors Identies cardiac rhythm accurately Obtains ordered IV uids Initiates ordered IV uid therapy in a timely manner, using the Six Rights and an aseptic technique Monitors the IV infusion for correct operation and adequate infusion rate Assesses the IV site for signs of inltration Applies oxygen per nasal cannula Requests lab values Initiates indwelling urinary catheter using a sterile technique Administers cefotaxime and vancomycin according to the Six Rights Documents medication administration accurately in the MAR Reassesses breath sounds frequently during uid resuscitation Evaluates the effectiveness of the uid therapy by monitoring the response of the blood pressure Collaborates with the healthcare provider regarding the patients vital signs and evaluated non-response to IV uid therapy 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

Collaborates with the healthcare provider regarding the placement of a central venous Communicates appropriately with patient and offers reassurance Determines if the patient has advanced directives in place or on le with hospital
State 2 Slight Improvement with Fluids: Reassesses the patients condition and status Interprets the assessment ndings and documents appropriately Monitors the infusion pump and the patient frequently to ensure the correct operation, ow rate and early detection of inltration Obtains and interprets lab and x-ray results Noties the healthcare provider of abnormal ndings Frequently reassesses breath sounds Calls report to ICU RN; providing relevant information Inquires about the status and ndings of the patients advanced directives Communicates appropriately with the patient and offers reassurance Prepares the patient for transfer to ICU State 3 Deteriorates Upon Admit to ICU Reassesses the patient, interprets ndings and documents appropriately Places the head of bed at in response to hypotension Monitors the infusion pump and patient frequently to ensure the correct operation, ow rate and early detection of inltration Recognizes the need for intubation and mechanical ventilation Calls for assistance Collects equipment, supports patients airway and prepares for intubation Noties healthcare provider of change in patient status Communicates patient data to healthcare provider in a clear and concise manner providing relevant information Interventions After State 3 Orders Received: Prepares for intubation Assists with intubation Reassesses patient status and documents Collaborates with healthcare provider regarding changes in patient status Recognizes the need to repeat ABG and portable chest x-ray Noties lab and radiology of ordered tests Correctly calculates rate and starts norephinephrine infusion according to Six Rights. Performs nasogastric intubation, veries placement and places to suction appropriately Inquires about status of family contact Communicates appropriately with patient and offers reassurance Inquires about results of x-ray in a timely manner State 4 Code Blue, MODS, Death: Begins BLS to identify type of arrest Ventilates with bag-valve-mask device attached to owing oxygen source Begins compressions and evaluated effectiveness Applies debrillation pads in appropriate locations once available Charges debrillator to 200 joules Clears area to ensure no one is touching the patient or bed Ensures the safety of the team Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL

catheter or central venous catheter with ScvO2 capability

Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Continues CPR Administers ordered emergency medications in accordance with the Six Rights (in Collaborates with the healthcare team to facilitate care delivery (environmental Ensures documentation is occurring Communicates effectively with daughter on her arrival Considers emotional support for daughter (hospital chaplain)
management) accordance to ACLS protocol)

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

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Gastrointestinal Supplies 14 Fr nasogastric tube 50 mL piston syringe Miscellaneous Crash cart and debrillator Ventilators Pressure tubing and transducer system Spray bottle lled with distilled water Yellow and red food coloring Bottle of ammonia Rose-colored blush Stethoscope BP cuff adapted for use with simulator Non-sterile gloves (1 box) Sharps container Patient identication band Patient chart with appropriate forms and order sheets Audio and visual recording devices Monitors Required ECG Arterial line NIBP SpO2 CVP Temperature

Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

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

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners to utilize. The chart should include the specic patient identication information. Begin simulation with the EMS personnel/Paramedic providing verbal handoff to the admitting unit using SBAR. Have the learners roleplay inter-professional communication by reporting the patients response to interventions. If the data presented is disorganized or missing vital components, have the healthcare provider become inappropriate in response. Emphasize the importance of data organization and completeness when communicating. Roleplay intra-professional communication by having the learner hand off to the admitting or transferring unit or have the learner hand off to the next shift. Role-play therapeutic communication with patient to encourage expression of feelings about being a victim of violence. When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option or Treatment Scenario and choose the appropriate ow rate. If using the HPS, no software command is necessary when real oxygen is applied. When learners provide pharmaceutical interventions, the facilitator should open the Medication Intervention Option or Treatment Scenario and choose the appropriate medication. If using the drug recognition feature of the HPS, no software command is necessary when a drug is administered using that system. When learners provide IV uid interventions, the facilitator should open the Intervention Option or Treatment Scenario and choose the appropriate uid and volume to be administered. Debrieng and instruction after the scenario are critical. Learners and instructors may wish to view a videotape of the scenario afterward for instructional and debrieng purposes.

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
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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Questions to be asked during debrieng: What was the experience like for you? What happened and why? What did you do and was it effective? Discuss your interventions (technical and non-technical). Were they performed appropriately and in a timely manner? How did you decide on your priorities for care and what would you change? How did patient safety concerns inuence your care? What did you overlook? In what ways did you personalize your care for this patient and family members (recognition of culture, concerns, anxiety)? Discuss your teamwork. How did you communicate and collaborate? What worked, what didnt work and what will you do differently next time? What are you going to take away from this experience?

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

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

Would a consent be required for the placement of a central line in this patient? Given the severity of illness and the patients inability to provide consent, it would be medically prudent to proceed with central line placement as it is standard of care in the management of septic shock What are the nursing responsibilities in assisting the healthcare provider with placement of a central line? Help obtain supplies Be certain that baseline assessment is established (especially vital signs, including SpO2 and lung sounds) Witness if non-emergent consent Performance of timeout procedure for site placement Trendelenburg positioning prior to insertion Monitor patient status during and after insertion (assessing for potential complications) Dress site as per policy Notify radiology for portable chest x-ray Verify radiologic placement of the catheter (healthcare provider verication) SvO2 and CVP set up for monitoring per manufacturer/ institutional policy Begin venous infusion once radiographic conrmation of placement What are post-placement pulmonary artery catheter nursing considerations? Monitor for potential complications (bleeding, pneumothorax, dysrhythmias) Monitor ongoing respiratory status of a patient lying at What is ScvO2 monitoring? Monitoring the venous saturation of oxygen that represents the oxygen reserve of the body How might ScvO2 be of use in the patient with sepsis or septic shock? ScvO2 can provide information about tissue oxygenation Low ScvO2: oo Decreased cardiac output (CO) oo Decreased Hgb oo Decreased SaO2 oo Increased oxygen consumption (SIRS, Sepsis, Septic shock) High ScvO2 oo Increased cardiac output oo Increased Hgb oo Increased SaO2 oo Decreased oxygen consumption How is a MAP calculated? 2x diastolic + systolic/3 What is the signicance of a MAP less than 65 mmHg? Inadequate tissue and organ perfusion

Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

State 2 Slight Improvement with Fluids If no advance directives are found, does that mean the patient is automatically a full-code? Why or why not? Yes, there is no legal documentation on which to base a change in code status No legal next of kin present to make the decision for change What would be the safest mode of transport to the ICU for this patient? On a cart/bed Side rails up Cardiac and SpO2 monitoring Portable oxygen on Need RN and assistive personnel for transport Has the patient progressed to septic shock? Why or why not? Meets the criteria for SIRS and sepsis but not the denition for shock as it includes hypotension that is unresponsive to uid resuscitation Currently the patient is responding to uids SIRS is dened as the presence of two or more of the following objective sings of systemic inammation: oo Temp is greater than 38C or less than 36C oo HR is greater than 90 beats per minute oo RR is greater than 20 breaths per minute oo White blood cell count is greater than 12,000 or less than 4,000 or greater than 10% immature forms Sepsis is dened as SIRS in the presence of a presumed or conrmed infection Septic shock is SIRS and cardiovascular failure manifested by hypotension unresponsive to uids, requiring inotropes and/or vasopressors State 3 Deteriorates Upon Admit to ICU Why do the breath sounds now indicate rales? Cardiac suppression accompanying septic shock is causing manifestations of heart failure What is the rationale or intubation for this patient? Clinically manifesting respiratory distress ABG conrms respiratory failure Demonstrating hemodynamic instability Securing airway and supporting respiratory system What is the rationale behind changing the position of the patient? Lying at causes a temporary increase in venous return Provides a means to support BP as other intervention is being prepared What is rationale for drotrecogin alfa infusion? Human activated Protein C exerts an antithrombotic effect Inhibiting factors Va and VIIIa Anti-inammatory effect Patients with sepsis rapidly produce endotoxins that cause inammation

Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
2009 METI, Sarasota, FL

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Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome PNCI

What are the nursing responsibilities in assisting with patient intubation? Monitoring vital signs and SaO2 throughout procedure and communicating changes to the healthcare team Assessing breath sounds once intubated to ensure bilateral breath sounds Secure airway Assess depth (centimeter marking at the lip line) of the endotracheal tube and recording Monitoring patient respiratory and hemodynamic status on initiation of ventilatory therapy How does norepinephrine work? Potent vasoconstrictor What is the purpose for using norepinephrine in septic shock? Profound vasodilation secondary to the release of inammatory mediators is a hallmark contributor to the profound hypotension seen in septic shock Norepinephrine vasoconstricts the dilated vascular bed to support blood pressure State 4 Code Blue, MODS, Death: What predisposed this patient to cardiac and respiratory arrest? Age Chronic illness Severity of septic shock Impaired tissue perfusion results in multi-system organ dysfunction including pulmonary and cardiac dysfunction Could this have been prevented? Early aggressive goal directed therapy is the best practice to promote survival and was instituted for this patient Prevention and early detection needed also to occur at the extended care facility How aggressive should the healthcare team be? Legally, full intervention should be given as a living will could not be found and next of kin could not be contacted prior to arrest Is this patient a candidate for receiving activated Protein C (drotrecogin alfa)? Current guideline recommendations indicate adult patients with severe sepsis, low risk of death (APACHE II less than 20) or one organ failure not receive activated Protein C as studies do not support benet of decreased mortality in these patients. Only patients with and APACHE II score greater than or equal to 25, with a high risk of mortality or multiple organ failure should receive this medication as long as no contraindications exist. This patients APACHE II score in State 3 is 18. What is the rationale for drotrecogin alfa infusion? Inhibits macrophage production of tumor necrosis factor, blocks leukocyte adhesion and limits thrombin induced inammatory responses Ethically, what would the quality of life be for the patient if he did survive? Who should make that decision? Learners should discuss feelings regarding this situation Program for Nursing Curriculum Integration (PNCI) Sepsis, Septic Shock and Multiple Organ Dysfunction Syndrome
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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
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Steen, C. (2009). Developments in the management of patients with sepsis. Nursing Standard 23(48), 48-55. Wagenlehner, F., Weidner, W. & Naber, K. (2007). Optimal management of urosepsis from the urological perspective. International Journal of Antimicrobial Agents 30, 390-397. Wagenlehner, F., Weidner, W. &Naber, K. (2007). Pharmacokinetic characteristics of antimicrobials and optimal treatment of urosepsis. Clinical Pharmacokinetics 46, 291-305. Yasser, S., Vincent, J.L., Schuerholz, T., Filipescu, D., Romain, A., Hjelmqvist, J., et al. (2007). Early-versus late-onset shock in European intensive care units. Shock 28, 636-643.

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