Pathophysiology of Sepsis
A patient named Mrs. Bery Hayes who underwent laparoscopic cholecystectomy was deteriorating after three days of the surgery. She was diagnosed with sepsis, which could be due to the invasive surgery she underwent during the laparoscopy. Thus in this following report, the pathophysiology of her clinical condition, sepsis will be discussed along with patient assessment and required nursing care followed by proper guidance to the patient during her discharge.
Sepsis is a bloodstream infection with an estimated 750,000 cases every year and the incidental rate increasing to date rates reaching to 85% in which more than four organ functions fail (Bratzler et al. 2013). In understanding the body response to sepsis, the pathophysiology of the condition should be reviewed. Whenever the body fails to restrict a localized infection within its source, the infective organisms disperse in the blood stream thereby causing sepsis condition (Mehta et al. 2014). This condition involves inflammation, maldistributed blood flow and coagulopathy. Therefore the dispersed organism or antigen in the blood releases toxic endotoxin which is linked with gram-negative bacteria. The immune system in response releases mediators for proinflammation such as cytokines in the blood circulation (Kamel and Iadecola 2012). The cytokines released by the white blood cells responding to endotoxins, causes the vasodilation, increased permeability of capillaries along with increase in coagulation (Boisrame-Helms et al. 2013). The patient condition with sepsis in involves uncontrolled healing caused by increased release of immunemodulators stimulated by endotoxins resulting in exaggeration (Neviere Parsons and Finlay 2016). Vasodilatation is a body response to increase the blood flow towards the affected area by transporting more amounts of white blood cells to control the infection (Rajendran et al. 2013). But due to disproportionate blood volume during vasodilatation causes hypotension (Prowle and Bellomo 2015). Increase in the permeability of the capillaries causes the leaking of fluid into the surrounding tissue from the blood stream leading to edema which further decreases the blood pressure (Oakley and Tharakan 2014). Consecutively, fibrinolysis is disrupted causing in decreased clot breakdown which occurs due to body response in antigen confining. Thus the fibrin clots formed causes microthrombi leading to tissue hypoperfusion and necrosis resulting in organ failure (Levi et al. 2012).
In this case, the patient during admission showed temperature 36.5, pulse 82, respiratory rate 18, blood pressure 165/95 with oxygen saturation 98% with 130kg weight. 3 days of her surgery she was not recovering fully and the nurse after assessment found changes in her vital signs showing increase in temperature to 37.7, pulse to 125, respiratory rate also increased to 26 causing hyperventilation, and decrease in blood pressure to 110/60 with reduced saturation to 92%. The patient undergoing invasive surgeries can develop microorganism within their body causing sepsis as in this case. Extreme age causes weak immune system leading to immunosupression (Dellinger et al. 2013). The clinical manifestations in sepsis are recorded with decrease in blood pressure causing hypotension and decreased oxygen saturation. The decrease in oxygen saturation causes the heart to beat faster thereby increasing the pulse rate. The temperature can either rise or decrease. All these signs and symptoms were noted in the patient who correlated with the diagnosis of sepsis as she had recently undergone laparoscopic cholecystectomy.
Assessment of the Patient
Assessment of the patient is one of the major and primary responsibilities of the nurses which should be carried out with preciseness and diligence. The patient who underwent a recent laparoscopic surgery showed altered vital signs after 3 days. Thus in order to properly diagnose the condition; the nurses should perform immediate assessment in order to start the treatment. The assessment will be done by health assessment framework comprising two components such as the primary examination and the secondary examination.
This examination involves assessing the general physical condition of the patient through ABCDE (ie that is airway, breathing, circulation, disability and exposure assessment) along with examining the mental status. The patient with serious infection is observed with flushed, toxic and acutely ill appearance (Adam Odell and Welch 2013).
Table 1: Primary survey of the patient diagnosed with sepsis
|
Assessment parameters |
Procedure |
Relevant data |
|
Airway (A) |
The airway passage should be examined to confirm whether it is secure and patent. This will be done by listening the flow of air, observing the rise and fall of the chest (Baker 2016) |
|
|
Breathing (B) |
The breathing pattern should be examined by observing the rise and fall of the chest and the patient’s skin should be observed carefully for any signs of pale or gray colour with mottled skin which are caused by the poor perfusion of the tissues that occurs usually in septic shock (THOMAS MAIN MAXWELL and KEILTY 2016) |
The saturation rate of the oxygen should be recorded which gets lowered in sepsis. The tidal volume along with the rate of respiration that increases in order to compensate the oxygen deficiency should also be checked and recorded (Esmond 2013). |
|
Circulation (C) |
The blood circulation should be examined in order to report that the patient is having adequate circulation. This will be done by checking the pulse rate and assessing the pulse strength. The skin colour of the patient will also be observed minutely to check any pale or grayish colouration caused due to reduced flow of blood (Antonelli et al. 2013). |
Heart rate should be recorded that increases in sepsis causing tachycardia, noted as a common feature during sepsis and indicates a response to stress indicating a response to stress. This is usually common indicating pulmonary dysfunction reported in pneumonia and acute respiratory disorders which increases the mortality rates in sepsis (Morelli et al. 2013). The toxic endotoxins stimulate the centre of medullar ventilation causing increased respiratory rate to compensate the metabolic acidosis followed by shortened breath and mild anxious (Ellis Calne and Watson 2016) |
|
Disability (D) |
The patient’s level of consciousness should be checked in order to check any disorientation in the patient which is a common symptom in old people (Oxman Schnurr and Silberfarb 2014) |
|
|
Exposure (E) |
The surrounding of the patient should be checked in order to identify any exposures along with maintain and preserving the dignity of the patient (Grindrod 2012) |
The Secondary examination is done assessing the function of every system of the body individually from head to toe. Early identification of any issues can be enabled by assessing all the system of the body in order to provide appropriate intervention to prevent further complications.
Neurological assessment: The neurological assessment is done performing theGlasgow Coma Score (GCS), a tool used for assessing conscious level related to responses such as arousal and verbal/physical in the patient (Maldonado 2017). Sedatives or muscle relaxants administration should be checked as this influences the GCS accuracy (Couchman et al. 2007). If she was ventilated, then a more advanced tool should be used along with GCS in communicating with her nonverbally such as by using letter boards, mouthing words, note writings. The pupil size along with the reaction should also be accessed as a part for this assessment (Morgan and Wood 2012.). This done as the mental status of the patients deteriorates in this condition.
Assessing the cardiovascular system: This assessment should be done to determine the adequacy of the cardiac output and the complications associated with it (Dellinger et al. 2013). This is done by recording the heart rate, pressure of central venous system, blood pressure, urine output, peripheral perfusion and chest X-ray along with analysing the serum electrolytes. Blood test should be performed to monitor the haemoglobin count as anaemia can impact the oxygen carrying capacity of the patient (Holst et al. 2013). Conservation of blood should be warranted in order to prevent anaemia. The cardiac studies will be carried out by Electrocardiography(ECG) to report any acute myocardial infarction (Kolder Tanck and Bezzina 2012). The nurses conduct this as the blood pressure is reduced causing hypotension due to vasodilation and the heart rate increases to compensate the oxygen need (Rosendorff et al. 2015).
Gastrointestinal assessment: The status of the nutrition is a major part of the assessment and proper care (Volkert 2013). During this condition the intake capacity of the patient is reduced due to presence of any sedation (Couchman et al. 2007). The symptoms are followed by abdominal distension, rebound and localized tenderness along with rectal tenderness and swelling (Budhram and Bengiamin 2014). To combat this situation the nurse should follow a build up feeding protocol in which the feeding pattern and absorption is monitored closely. The feeding rate should be increased by incorporating prokinetics for better results. Ultrasonography of the abdomen can be done if obstruction in bile tract is suspected (Sarkaria et al. 2013).
The Primary Examination
Assessment of metabolic system: The body temperature should be monitored as an increased temperature points out the response of patient to the infection (Young et al. 2012). Along with this, the count of the white blood cells, procalcitonin (PCT) levels and C-reactive protein (CRP), IL-6 should be measured to detect the response to infection (Lee 2013.).
Urine output assessment: Reduced cardiac output lowers the urine output caused by the neural and hormone mechanism such as by the secretion of the antidiuretic hormone and rennin-angiotensin-aldosterone system activation (Cheuvront and Kenefick 2014). This is done because the water is conserved by the body in response to inflammation thereby reducing the urine content (Langley et al. 2013).
All these primary and secondary examination should be done in order to diagnose the condition and provide further treatment for recovering the condition the patient is going through.
Sepsis can result either from cholysistitis, a condition of inflammation of gall bladder or from cholecystectomy, surgical removal of the gall bladder.
The factors that are responsible for sepsis are the exposure of the patient to the bacteria and unsterile operation room. These unsterile surrounding lead to the nosocomial infection followed by sepsis (Mossie 2013). Once the operated part is exposed to the unclean surrounding of the operation room or the hospital premises, the microorganisms get the opportunity to invade the bloodstream and multiply. The increased number of the pathogens triggers the pro-inflammatory mediators which in turn activates the immune system of the body. The sepsis condition of the patient is influenced by the triggered cytokines. The activation of the interleukin 4-10, cytokines, bradykinin and others results in the feedback mechanism.
This affects both the cardiac system by dilating the arteries and the arterioles causing the lungs to be filled with fluids (Bhan et al. 2016). The alveoli get collapsed and lose the capability of gas exchange. Lung failure occurs followed by heart failure due to hypoxia of blood resulting to death.
Sepsis also results in the loss of function of nephrons leading to acute renal failure. This decrease the supply of blood to the brain and dysfunction of the brain occurs due to hypoxia. This makes the patient to be in coma.
The diagnosis of the septic condition can be done by complete blood (CBC) count which may show abnormal blood cell count, bacterial cultures in the blood sample, studying urine samples. Biomarkers such as procalcitonin and presepsin may be used to detect early septic condition (Endo et al. 2014). Chest radiograph, electrocardiography and abdominal ultrasonography to diagnose any obstruction in the biliary tract may be done. Thoracentesis and paracentesis may also be adopted to diagnose sepsis.
The patient with sepsis is recommended to undergo fluid resuscitation which is the most effective way of treatment. Fluid boluses of crystalloid (a volume of 500 mL) is administered repeatedly proves to be an effective measure in correcting hypotension. Normal saline and albumin should also be given in order to control the septic condition.
Effective IV antimicrobials are immediately administered to the patient diagnosed with the symptoms of sepsis. Intravenous broad spectrum antibiotics are given to the patient. Procalcitonin is used to monitor the antimicrobial drugs (Wacker et al. 2013). Procalcitonin monitoring helps to reduce the length the treatment duration. The reduction or the termination of the treatment can be suggested by the procalcitonin monitoring of the antimicrobial drug.
Sepsis is one of the most vital problems faced by the patient. The discharge of the patients suffering from sepsis needs special care (Ortego et al. 2015). The strategies for the prevention of septic shock should be explained by the nurse to the patient. The patient’s family should also be taught to identify the symptoms of the sepsis that may relapse after discharge. The treatment modalities like the administration of drugs during emergency, skin care, ambulation and IV therapy should be explained to the patient’s family.
It is the duty of the nurse to maintain hygiene of the patient. The nurse should regularly monitor the blood glucose level and administer insulin (Drahnak et al. 2016). The vital signs of the patient is monitored by the in every hour, administer medicines and control the dips. It is the duty of the nurse to make the patient comfortable by giving him fentanyl and midazolam. Oral care, endotracheal tube care and suction also become the part of the care a nurse needs to carry out. The nurse should also make the patient aware of the care that he should take after his discharge.
It is the duty of the nurse to arrange a referral for the patient after her discharge. The nurse should provide the personal information of the patient and request to the healthcare organization to provide on behalf of the patient.
Conclusion:
From the above report it can be concluded that sepsis is the infection of the caused by the presence of harmful bacteria and their toxins in the wound of an individual. The above discussion states the pathway, diagnosis and treatment of the patient which requires special care. Thus to conclude, by the extensive care of the nurse the septic condition can be treated.
References:
Adam, S., Odell, M. and Welch, J., 2013. Rapid assessment of the acutely ill patient. John Wiley & Sons.
Antonelli, M., Bonten, M., Cecconi, M., Chastre, J., Citerio, G., Conti, G., Curtis, J.R., Hedenstierna, G., Joannidis, M., Macrae, D. and Maggiore, S.M., 2013. Year in review in intensive care medicine 2012. II: pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues. Intensive care medicine, 39(3), pp.345-364.
Baker, D.J., 2016. The Management of Respiratory Failure: Airway Management and Manual Methods of Artificial Ventilation. In Artificial Ventilation (pp. 77-106). Springer International Publishing.
Bhan, C., Dipankar, P., Chakraborty, P. and Sarangi, P.P., 2016. Role of cellular events in the pathophysiology of sepsis. Inflammation Research, 65(11), pp.853-868.
Boisrame-Helms, J., Kremer, H., Schini-Kerth, V. and Meziani, F., 2013. Endothelial dysfunction in sepsis. Current vascular pharmacology, 11(2), pp.150-160.
Bratzler, D.W., Dellinger, E.P., Olsen, K.M., Perl, T.M., Auwaerter, P.G., Bolon, M.K., Fish, D.N., Napolitano, L.M., Sawyer, R.G., Slain, D. and Steinberg, J.P., 2013. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surgical infections, 14(1), pp.73-156.
Budhram, G.R. and Bengiamin, R.N., 2014. Abdominal pain. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders.
Cheuvront, S.N. and Kenefick, R.W., 2014. Dehydration: physiology, assessment, and performance effects. Comprehensive Physiology.
Dellinger, R.P., Levy, M.M., Rhodes, A., Annane, D., Gerlach, H., Opal, S.M., Sevransky, J.E., Sprung, C.L., Douglas, I.S., Jaeschke, R. and Osborn, T.M., 2013. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), pp.165-228.
Drahnak, D.M., Hravnak, M., Ren, D., Haines, A.J. and Tuite, P., 2016. Scripting nurse communication to improve sepsis care. MedSurg Nursing, 25(4), pp.233-239.
Ellis, H., Calne, R. and Watson, C., 2016. Lecture Notes: General Surgery. John Wiley & Sons.
Endo, S., Suzuki, Y., Takahashi, G., Shozushima, T., Ishikura, H., Murai, A., Nishida, T., Irie, Y., Miura, M., Iguchi, H. and Fukui, Y., 2014. Presepsin as a powerful monitoring tool for the prognosis and treatment of sepsis: a multicenter prospective study. Journal of Infection and Chemotherapy, 20(1), pp.30-34.
Esmond, G., 2013. Nursing patients with respiratory disorders. Alexander’s Nursing Practice4: Alexander’s Nursing Practice, p.51.
Grindrod, A., 2012. Patient assessment: The ABCDE approach to patient assessment and early warning scoring systems. Developing Healthcare Skills Through Simulation, p.18.
Holst, L.B., Haase, N., Wetterslev, J., Wernerman, J., Åneman, A., Guttormsen, A.B., Johansson, P.I., Karlsson, S., Klemenzson, G., Winding, R. and Nebrich, L., 2013. Transfusion requirements in septic shock (TRISS) trial-comparing the effects and safety of liberal versus restrictive red blood cell transfusion in septic shock patients in the ICU: protocol for a randomised controlled trial. Trials, 14(1), p.150.
Kamel, H. and Iadecola, C., 2012. Brain-immune interactions and ischemic stroke: clinical implications. Archives of neurology, 69(5), pp.576-581.
Kolder, I.C., Tanck, M.W. and Bezzina, C.R., 2012. Common genetic variation modulating cardiac ECG parameters and susceptibility to sudden cardiac death. Journal of molecular and cellular cardiology, 52(3), pp.620-629.
Langley, R.J., Tsalik, E.L., Van Velkinburgh, J.C., Glickman, S.W., Rice, B.J., Wang, C., Chen, B., Carin, L., Suarez, A., Mohney, R.P. and Freeman, D.H., 2013. An integrated clinico-metabolomic model improves prediction of death in sepsis. Science translational medicine, 5(195), pp.195ra95-195ra95.
Lee, H., 2013. Procalcitonin as a biomarker of infectious diseases. The Korean journal of internal medicine, 28(3), p.285.
Levi, M., van der Poll, T. and Schultz, M., 2012, January. Systemic versus localized coagulation activation contributing to organ failure in critically ill patients. In Seminars in immunopathology (Vol. 34, No. 1, pp. 167-179). Springer-Verlag.
Maldonado, J.R., 2017. Psychiatric Aspects of Critical Care Medicine, An Issue of Critical Care Clinics, E-Book (Vol. 33, No. 3). Elsevier Health Sciences.
Mehta, Y., Gupta, A., Todi, S., Myatra, S.N., Samaddar, D.P., Patil, V., Bhattacharya, P.K. and Ramasubban, S., 2014. Guidelines for prevention of hospital acquired infections. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 18(3), p.149.
Morelli, A., Donati, A., Ertmer, C., Rehberg, S., Kampmeier, T., Orecchioni, A., D’Egidio, A., Cecchini, V., Landoni, G., Pietropaoli, P. and Westphal, M., 2013. Microvascular effects of heart rate control with esmolol in patients with septic shock: a pilot study. Critical care medicine, 41(9), pp.2162-2168.
Morgan, J. and Wood, I., 2012. Initial Assessment of the Acute Medical Patient. Initial Management of Acute Medical Patients: A Guide for Nurses and Healthcare Practitioners, p.1.
Mossie, A., 2013. Pathophysiology of sepsis. World Journal of Medicine and Medical Science, 1(8), pp.159-68.
Neviere, R., Parsons, P.E. and Finlay, G., 2016. Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis.
Oakley, R. and Tharakan, B., 2014. Vascular hyperpermeability and aging. Aging and disease, 5(2), p.114.
Ortego, A., Gaieski, D.F., Fuchs, B.D., Jones, T., Halpern, S.D., Small, D.S., Sante, S.C., Drumheller, B., Christie, J.D. and Mikkelsen, M.E., 2015. Hospital-based acute care use in survivors of septic shock. Critical care medicine, 43(4), p.729.
Oxman, T.E., Schnurr, P.P. and Silberfarb, P.M., 2014. Assessment of cognitive function in cancer patients. Psychosocial Assessment in Terminal Care, p.99.
Prowle, J.R. and Bellomo, R., 2015, January. Sepsis-associated acute kidney injury: macrohemodynamic and microhemodynamic alterations in the renal circulation. In Seminars in nephrology (Vol. 35, No. 1, pp. 64-74). WB Saunders.
Rajendran, P., Rengarajan, T., Thangavel, J., Nishigaki, Y., Sakthisekaran, D., Sethi, G. and Nishigaki, I., 2013. The vascular endothelium and human diseases. International journal of biological sciences, 9(10), p.1057.
Rosendorff, C., Lackland, D.T., Allison, M., Aronow, W.S., Black, H.R., Blumenthal, R.S., Cannon, C.P., De Lemos, J.A., Elliott, W.J., Findeiss, L. and Gersh, B.J., 2015. Treatment of hypertension in patients with coronary artery disease. Hypertension, 65(6), pp.1372-1407.
Sarkaria, S., Lee, H.S., Gaidhane, M. and Kahaleh, M., 2013. Advances in endoscopic ultrasound-guided biliary drainage: a comprehensive review. Gut and liver, 7(2), p.129.
THOMAS, A., MAIN, E., MAXWELL, L. and KEILTY, S., 2016. CLINICAL ASSESSMENT. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems.
Volkert, D., 2013. Malnutrition in older adults-urgent need for action: a plea for improving the nutritional situation of older adults. Gerontology, 59(4), pp.328-333.
Wacker, C., Prkno, A., Brunkhorst, F.M. and Schlattmann, P., 2013. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. The Lancet infectious diseases, 13(5), pp.426-435.
Young, P.J., Saxena, M., Beasley, R., Bellomo, R., Bailey, M., Pilcher, D., Finfer, S., Harrison, D., Myburgh, J. and Rowan, K., 2012. Early peak temperature and mortality in critically ill patients with or without infection. Intensive care medicine, 38(3), pp.437-444.
Couchman, B.A., Wetzig, S.M., Coyer, F.M. and Wheeler, M.K., 2007. Nursing care of the mechanically ventilated patient: What does the evidence say?: Part one. Intensive and Critical Care Nursing, 23(1), pp.4-14.
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