The other day, I got a call from the nursing home where my loved one resides. The nurse told me that she was congested, the doc was called, and a z-pack was ordered. I asked the vital signs: elevated temp, elevated respiration rate, and satting 92% on 2L NC. I asked for the doc’s number and called him.
He threw the nurse under the bus. “Oh, she didn’t tell me the vital signs!” He repeated it x 3 throughout our conversation, and I asked for her to be sent to the hospital.
When we got to the hospital, her work of breathing was noticeable to even my non-medical husband. Within a couple hours, we watched her get worse—she went from “congested” to severe sepsis right before our eyes—and she was transferred to ICU.
After confirming her DNR/DNI status and our wish to give her a chance with only fluid resuscitation and antibiotics and possible NIV, if necessary, she made a very nice turnaround within 24 hours. She received a short stint on BiPAP overnight. The day dawned to her satting well on 2L NC, work of breathing nearly nil, and almost back to her baseline mental status.
According to Kaplan (2014), definitions for Systemic Inflammatory Response Syndrome (SIRS), sepsis, severe sepsis, septic shock, and Multiple Organ Dysfunction Syndrome (MODS) were developed. SIRS has the same initial s/s of sepsis, but is nonspecific and unrelated to infection.
The first symptoms are an acutely elevated respiratory rate, fever, tachycardia > 90 BPM, and abnormal WBCs (Kaplan, 2014). Two of the four need to be present to diagnose SIRS. In the presence of a suspected or known source of infection, sepsis can be diagnosed, as an infectious source is the key difference between SIRS and sepsis. Of course, a nurse or doctor has to look at the whole picture of the person. For example, tachycardia with elevated RR could be cardiac in origin, and, in that case, the patient fits the criteria of SIRS; however, many acute care protocols use the above s/s as a sepsis screening tool.
Once sepsis has been diagnosed, severe sepsis and septic shock are additive diagnoses as more s/s begin to occur. That’s why sepsis survival is improved with quick action. “The goal is to treat sepsis during its mild stage, before it becomes more dangerous” (Mayo Clinic, 2014).
In non-hospital settings, it is extremely important for nurses to be knowledgeable of SIRS and sepsis signs and symptoms in order to advocate appropriately for patients. Due to the lack of medical resources and the expectation that nurses are the eyes and ears of distant doctors, a complete picture of the patient should be communicated, including all vital signs, nursing interventions done, and evaluation of those interventions.
The Surviving Sepsis Campaign website is a good place to start. While geared toward acute care facilities, much information can be gleaned from the website for use in other care environments. Please see http://www.survivingsepsis.org/Pages/default.aspx.
Flu and PNA shots are offered at each admission if not contraindicated, so follow your protocol!! Don't skip this part of your admission paperwork! If a patient states, “Oh, I’m going to get it at my doctor’s office in a couple weeks,” educate them on early vaccination for flu. Medicare will pay for the shot while inpatient. No need to wait.
I mentioned one of my memorable rapid responses above. One of my patients who eventually died of ARDS in ICU from H1N1 was planning to get the shot the week after she was admitted.
You are spot on with the assessment, rationale and quoted protocols.
However in the real world .. protocols are NEVER carried out according to the book.
Each scenario is dependent on the players.
My father died from sepsis, because.. those involved did not follow the allmighty protocol.
First, my condolences for your loss.
Secondly, it's important for nurses to know not only their own protocols, but also the medical protocols so that we can advocate for patients.
Understanding the reasoning behind protocols will encourage nurses to stick to them, even when they are "inconvenient." Hypoglycemia protocol is one. The checking and rechecking is there for a reason. One of my very talented co-workers followed the hypoglycemic protocol to the letter and prevented hypoglycemic coma by calling a rapid response when our nursing-driven interventions per protocol didn't budge the glucose. D10 was eventually ordered and the patient stabilized without transfer to a higher level of care.
dudette10, MSN, RN
3,530 Posts
Flu and PNA shots are offered at each admission if not contraindicated, so follow your protocol!! Don't skip this part of your admission paperwork! If a patient states, “Oh, I’m going to get it at my doctor’s office in a couple weeks,” educate them on early vaccination for flu. Medicare will pay for the shot while inpatient. No need to wait.
I mentioned one of my memorable rapid responses above. One of my patients who eventually died of ARDS in ICU from H1N1 was planning to get the shot the week after she was admitted.