This portfolio will provide evidence of my experience in an acute care setting. I will provide an appendix giving a brief summary of a patient I cared for whilst undertaking a placement in an acute setting. This portfolio of evidence will be based on a patient diagnosed with sepsis secondary to her chest infection. I will discuss extensively the aetiology, pathophysiology and clinical features of a patient presenting with sepsis treated in an acute care setting.
I will explore the role of the different healthcare professionals that were involved in the care of the patient describing how they contributed to her holistic care. I will incorporate evidence base supporting the approach used by the doctors, nurses and microbiologists in the diagnosing and caring for the patient. I will equally evaluate practice using findings from contemporary research policy and practice on the care of the adult with acute care needs.
I will also discuss the value of our practice in accordance with professional, ethical and legal frameworks that ensure the privacy of the patient’s interest and well-being. Finally, I will conclude by summarising this portfolio of evidence in relation to acute care practices and focus on identifying my future learning needs in developing myself personally and my professional practice. It is indicated by Latto (2011) that a meeting between The American College of Chest Physicians and the Society of Critical Care Medicine in 1991 brought about the use of systemic inflammatory response syndrome (SIRS) to define sepsis.
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SIRS being manifestation of two or more of certain medical signs including, a temperature of less than 36 degrees Celsius or greater than 38 degrees Celsius, a heart rate of over 90 beats per minute, respiratory rate of over 20 breaths per minute and white blood cells count of greater than 12000 or less than 4000. Further on to recognise sepsis, a patient has to have at least two signs of SIRS as well as a documented infection. Sepsis, as defined by Matot and Sprung, (2001) “is the systemic inflammatory response to infection. In addition to this definition, Herwald and Egesten (2011) indicate that sepsis could also be defined as the existence of bacteria or other micro-organisms in the blood, hypotension or shock. Rello, Diaz and Rodriguez (2009) emphasise that there is a difference between sepsis and systemic inflammatory response syndrome (SIRS) as sepsis is systemic inflammatory response to infection while systemic inflammatory response syndrome is a tool used to simplify the diagnosis of sepsis.
Sepsis occurs as a result of the body fighting infection that has spread though the body via the blood stream as defined by Sepsis Alliance UK (2012). Barbara presented with low blood pressure, a high temperature, tachycardia and an increased respiratory rate. Patients who present with sepsis can progress to severe sepsis which is defined by Marini and Wheeler (2010) as “a syndrome caused by infection and defined by the presence of vital sign abnormalities and new organ system failure caused by the ensuing inflammation and coagulation. Associated with severe sepsis, there are three integrated responses as explained by Kleinpell, R. (2003) which are; activation of inflammation, activation of coagulation, and impairment of fibrinolysis. As the body detects infection, its natural response is inflammation. “Inflammation is a response of a tissue to injury, often injury caused by invading pathogens. It is characterized by increased blood flow to the tissue causing increased temperature, redness, swelling, and pain. ” Kleinpell (2003).
Ball (2011) in describing the process of inflammation in the body explains that inflammation occurs due to the white blood cells releasing pro-inflammatory mediators called cytokines these are proteins, peptides, or glycoproteins which include tumour necrosis factor alpha, interleukin-1 and interleukin-6, the white blood cells also releases a platelet-activating factor which is a lipid mediator that is well-known for its ability to cause platelet formation. The work of these mediators is to repair damages caused and prevent further damages from occurring.
Normally, the body’s response in order to prevent damage by the release of these pro-inflammatory mediators is to release anti-inflammatory mediators which are interleukin-4 and interleukin-10 these are also cytokines which are a type of protein. In severe sepsis, there are excessive pro-inflammatory mediators which are not regulated by the anti-inflammatory mediators which results in overwhelming inflammatory reactions causing impaired tissue function and organ damage. Due to the pro-inflammatory mediators being released and unregulated by anti-inflammatory mediators, coagulation is promoted which is the clotting of blood.
This happens in the capillaries which obstructs the flow of blood into the tissues causing hypoxia which then leads to the dysfunction of organs. Hypoxia is defined by Wiebe and Machulla (1999) as “reduction of oxygen supply to tissue below physiological levels. ” The activation of coagulation then causes fibrinolysis to be activated. Fibrinolysis is the process of breaking down of blood clots as defined by Leslie, Johnson, and, Goodwin (2011). This happens because the levels of plasminogen rapidly reduce.
Plasminogen is a protein that when activated by enzymes transforms into plasmin which promotes dissolving of blood clots. Though the plasminogen levels fall rapidly, the antiplasmin levels remain normal which causes an end result of a decrement in the fibronolytic response. “The imbalance between inflammation, coagulation, and fibrinolysis that occurs in severe sepsis results in systemic inflammation, widespread coagulopathy, and microvascular thrombosis, conditions that can lead to multiple organ dysfunction” Kleinpell (2003) Severe sepsis if not properly treated can then lead to septic shock.
Septic shock is defined as sepsis with hypotension which is unresponsive to fluid resuscitation as well as abnormal perfusion that may include lactic acidosis, oliguria or alteration in mental status, Sepsis Alliance UK. (2012). In relation to the care that Barbara received whilst being treated for sepsis, there were different health care professionals involved throughout her stay in the hospital. An inter-professional team worked together to ensure that she was given holistic care taking into consideration the social aspect of her life, her spiritual values, her emotional and mental state of mind and full physical care.
On recording Barbara’s clinical observations, we passed on our results to the doctors as Barbara was scoring a mews of seven. Guidelines on the Modified Early Warning Signs chart advices that if a patients’ scores a MEWS of four or more, the patient must be referred for urgent medical review, NHS Outer North East London Community Services (2011) The doctors immediately ordered for blood cultures to be taken. The blood cultures were used to investigate the reason why Barbara had an increased temperature as an increased temperature is a sign of infection as described by Hegner, Acello and Caldwell (2009).
The blood tests and cultures taken were also to test for the serum lactate level, white blood cell count, tests to check how the liver and kidneys were functioning. The doctors then prescribed fluids to help in increasing Barbara's blood pressure. Working collaboratively to enhance the care that Barbara received, the microbiologists were involved in the diagnosis and care she received through the involvement by the doctors requesting for blood samples to be taken and investigating the reason why Barbara had an elevated temperature.
By collecting a sputum sample from Barbara, the microbiologists were also involved in looking for the medication sensitive to the bacteria causing Barbara’s chest infection. The microbiologists also took blood for arterial blood gases test. They were very efficient in delivering the results of the blood tests showing that Barbara had an increased white blood cell count. Her serum lactate levels were 3. 4mmols/l. An increased white blood cell count along with an elevated temperature proved to the doctors that Barbara had an infection.
The doctors commenced Barbara on the sepsis six bundle. The sepsis six bundle is a guideline within the Surviving Sepsis Campaign which gives information on what should be done in the first 6hrs that sepsis is diagnosed in a patient in order to aid safe recovery. The nurses ensured that from the moment Barbara was admitted, it was a duty to monitor her clinical observations. With the use of the Modified Early Warning Signs (MEWS) chart, we recorded her observations which enabled us to monitor changes in her blood pressure, respiratory rate, temperature, heart rate and oxygen saturation.
This was also a way for us to assess her consciousness level checking to see if she was alert, responsive to voice alone, responsive to pain alone or unconscious. This enabled us to check for signs of improvement in her health or for deterioration. Our duty as nurses was to provide 24hr care to Barbara. With a blood pressure of 85/42 mmHg we ensured that Barbara got enough fluids as were prescribed by the doctors. These fluids were given intravenously to increase Barbara’s blood pressure.
In a patient with sepsis, due to vasodilation as an inflammatory response to the infection, arterial circulation is ineffective therefore; intravenous fluids are required as advised by Institute for Healthcare Improvement (2011) Apart from receiving care from the nurses, we referred Barbara to the occupational therapist. The role of an occupational therapist as defined by Institute For Career Research, (2007) is to help in the development, recovery and maintaining of daily living and work skills of people with conditions that are disabling mentally, physically, emotionally and developmentally.
Institute For Career Research (2007). They ensured that on returning home, patients will have everything needed to make them comfortable. If need be, they will get their houses modified with a stair lift, a ramp or any additional equipment needed for them to make living at home easier. In relation to Barbara, the occupational therapist focused on her personal care, they assessed how easy or difficult it was for her to wash and dress herself and if she could manage cooking her food in the kitchen.
This enhanced collaborative working as this enabled the nurses to be aware of what steps needed to be taken to provide optimum care to Barbara. We were informed by the occupational therapist that she would need all care in the area of her personal hygiene and assistance in most areas of her activities of daily living. With the information derived from the occupational therapist, we were able to refer Barbara to the social services to ensure that when she was fit for discharge, extra measures were taken to provide her with care in her own home.
Barbara also received care from the physiotherapist. The role of the physiotherapist is to work as part of the multidisciplinary team to assess the patient and then provide treatment. Treatment would include exercise, movement, hydrotherapy, electrotherapy, massages and manipulation. A physiotherapist is also involved in providing health education this is elaborated by NHS Scotland (2002). In relation to Barbara, after we had referred her to the physiotherapy, they ensured that she received physiotherapy for her chest which was a series of claps on her chest, back and under her arms.
This was very helpful to Barbara as due to her chest infection, she had a lot of mucus in her breathing passages and with treatment from the physiotherapist; she managed to cough it up. This positively enhanced the care that Barbara received as through collaborative working, the physiotherapist encouraged the loosening of mucus from her breathing passages which enabled us as nurses to acquire a sputum sample to send to the microbiologist to test for what antibiotics were suitable to treat Barbara’s chest infection.
In addition to having lung cancer, Barbara also had liver and bone metastasis. With her consent, we involved the Macmillan nurses in her care. They focused on the social, emotional and practical impact cancer had on Barbara. They also gave her information on different support groups which were accessible to her and meetings where she could share her experience and listen to others experiences. Involved in the care of Barbara was the church priest.
As Barbara was too ill to attend the hospital Sunday services as were her wishes, we invited a priest who could give her communion, emotional and spiritual support through her stay in the hospital. Barbara had a reduced appetite so we commenced her on a food diary in which we recorded everything that Barbara ate and how much of it she ate. After three days of commencing Barbara on the food diary, we showed it to the dietician. Barbara was quite ill and did not have the strength to take part in most of her activities of daily living including feeding herself.
The dietician came to the ward to review Barbara and then prescribed ensure drinks and little cups of procal shots. These are nutrient supplements which provide protein, fat and carbohydrate in the body. All healthcare professionals worked together to enhance the quality of care that Barbara received although because Barbara had been diagnosed with sepsis, the decision of the dietician to provide Barbara with medication to boost her nutrition arguably caused deterioration in Barbara’s health.
Studies show that when treating a patient with sepsis, permissive underfeeding is required to ensure that recovery is enhanced as encouraging a lot of dietary intake would cause lipogenesis which would result to excess production of carbon dioxide and respiratory overload, hyperglycaemia and over usage of energy which would lead to stress for the patient. Vincent, Carlet and Opal (2002).
In supporting the doctors’ decision to prescribe intravenous fluids for fluid resuscitation on Barbara, Evidence has shown from the Surviving Sepsis Campaign (2011) under the sepsis resuscitation bundle that patients who are suspected of being in septic shock should be commenced on fluid resuscitation immediately. Guidelines on the Surviving Sepsis Campaign states that, “In the event of hypotension and/or lactate ;gt; 4mmols/L (36 mg/dL) deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). ” As explained by Winters and Glatter (2009), serum lactate levels are used to identify patients who have sepsis.
They explain that an elevated serum lactate level is a method of forewarning of an increased mortality in patients with sepsis or septic shock. This proves that ordering for blood tests to check the serum lactate level of Barbara was a positive step in treating Barbara by identifying the diagnosis of Barbara’s condition. Current evidence from the Surviving Sepsis Campaign (2011) indicates that analysing serum lactate levels in septic patients is not conclusive as “a number of studies have suggested that elevated lactate levels may result from cellular metabolic failure in sepsis rather than from global hypo perfusion.
Elevated lactate levels can also result from decreased clearance by the liver. Although blood lactate concentration may lack precision as a measure of tissue metabolic status, elevated levels in sepsis support aggressive resuscitation. ” This gives reason to why the doctors ordered for blood tests to be taken so as to measure Barbara’s serum lactate level. Through continuous input of intravenous fluids, Barbara’s blood pressure increased to 99/55 and remained stable and she was now scoring a MEWS of 3 as her respiratory rate was still elevated at 24 breaths per minute and a heart rate of 105 beats per minute.
Barbara’s temperature was still a little bit elevated at 37. 4? C but not scoring on the MEWS chart. The MEWS chart played a very important role in helping us evaluate Barbara’s health status. Although different studies show that there are pros and cons of using the MEWS system to evaluate patients’ health status. Studies show that the modified early warning scoring systems in the accident and emergency department or an acute care setting can help healthcare professionals identify patients that are at risk of deterioration.
Though, concerns have been raised questioning the sensitivity of this system as a risk assessment tool in comparison with the early modified warning score (EWS). Griffiths and Kidney (2011), in their survey assessing the use of MEWS in the UK’s acute care departments found out that over 90% of respondents in the survey supported the use of the Early Warning Score in helping identify deterioration or improvement in patients who are admitted to the acute care departments to the use of the Modified Early Warning Score.
This is evidence that supports the practice of nurses in monitoring Barbara’s condition through the use of modified early warning score. On the other hand, another study shows that many issues arose in implementing the MEWS chart in recording patients’ observation. The problems encountered with the MEWS chart include complaints of font size, size of the boxes provided to write in and due to this, some staff members have been reluctant to engage with the process making it difficult to monitor deterioration in acutely ill patients.
NICE (2011) I think that the MEWS chart was very effective in helping us monitor Barbara’s condition because we were able to use the information recorded on it as a means of communication with other healthcare professionals involved in her care. In caring for Barbara, we ensured that her confidentiality was optimised. This is a professional requirement for every nurse by the Nursing and Midwifery Council (2008). Through the use of a model called ‘Situation – Background – Assessment – Recommendation’ (SBAR), we ensured that communication between all health care professionals were detailed and solely on a need to know basis.
This model did not only protect the confidentiality of Barbara, it also encouraged assessment skills helping to provide all information to health care professionals in a manner that makes it difficult to omit any information. In communication with other bodies involved in Barbara’s care, SBAR stood as a guideline in divulging information. Stating the situation Barbara was in, giving background information only in relation to her present condition, providing results of assessments carried that would relate to their function in the care of Barbara and finally getting the recommendation from the other body.
This way, disclosure of information is kept to a minimum. Confidentiality is a key concept in protecting people that are vulnerable. Apart from being an ethical requirement, confidentiality also is a legal requirement. The legal principle of confidentiality lies within the Data Protection Act (1998), which simplified by Mind (2005) states that “Confidence is breached by the unauthorised use or disclosure of confidential information. ” This act emphasises the principles that define confidentiality one of which includes sensitive personal data.
This has to do with matters relating to a persons’ ethnicity, religious and political beliefs, physical and mental health, sexual orientation as well as criminal offences. In relation to Barbara, whenever we received a phone call from people claiming to be family members, in order to protect Barbara’s confidentiality, we never disclosed results of tests or doctors’ orders. We always gained consent from Barbara before giving information out to other parties involved in her care.
Timing when caring for critically ill patients is a valuable commodity which makes it important to be able to identify when a patient is in need of urgent medical attention. In the course of looking after Barbara through her admission in the hospital, I realised that prioritising care was the main issue surrounding her treatment. Observing my mentor who was in charge of Barbara’s care as well as nine other patients, using the ABC technique she was able to prioritise the care that Barbara received.
Ensuring that she had open Airways, Breathing with addition of oxygen therapy, Circulation through constant monitoring of her blood pressure. Prioritising of care is a skill that is essential in a care setting because if it was decided that all patients would be cared for in respect of their bed position on the ward, that would have had a negative impact on Barbara because she would not have received the urgent attention that she needed which could lead to a tragedy.
Through prioritising care, my mentor was able to organise herself in caring for the other patients she was in charge of placing Barbara on the top of her list because she was in constant need of urgent care as when it was time for her intravenous fluids to be commenced because she had organised her time accurately she was able to meet up with demands placed by Barbara’s condition as well as demands of her duty to the other patients.
In conclusion, this portfolio of evidence has defined the different stages of sepsis. It has explored the causes, pathophysiology and clinical manifestations. Fluid resuscitation was highlighted as the most important step to take in recognising a patient with sepsis. I described the different roles of the healthcare professionals in relation to the care that Barbara received.
Using information from the surviving sepsis campaign, I explained the guidelines used in the treatment of sepsis and related it to the steps taken by the doctor to treat Barbara. I identified the key strength of my mentor in working under pressure by prioritising care. This is an area that I will need to develop myself in the course of attending placement in the future. I will research on techniques of prioritising patient care and research on the process of triage in relation to a care setting.
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