Comprehensive Acute Illness Management

Introduction

Acute diseases are referred to the serious illness that develops suddenly and extends to affect the patients for short amount of time for which they require urgent or short-term care to develop enhanced health and well-being. In this assignment, acute illness management of a homeless patient named Gerald is to be discussed who is currently suffering from sepsis and additional morbidities. For this purpose, ABCDE assessment is to be made and NEWS2 score is to be measured to determine the seriousness of the patient’s condition. Thereafter, pathophysiology of the disease and medical, as well as nursing intervention for enhanced management of the condition is to be explained. The holistic care plan for the patient and his family is to be discussed to ensure his long-term well-being and effective care delivery.

Analysing findings of ABCDE assessment

The ABCDE assessment for any patient is essential because it helps in effective initial examination and treatment of patients in acute surgical or medical emergencies. It laid basis for identifying the seriousness of any condition and assist in determining the prioritisation of key clinical intervention for early and efficient well-being of the patient (Resuscitation Council, 2015). In addition, the values of vitals identified through ABCDE assessment is to be examined through NEWS2 score to determine the level of risk or severity of current health condition of Gerald. This is because NEWS2 score is a potential tool developed by the physicians that assist to make enhanced detection and early response to clinical deterioration in patient to promote their enhanced health outcome and safety (Malik, 2019). The NEWS2 score for each parameter which are breathing, respiration rate, blood pressure, pulse rate, consciousness and temperature extent from 0 to +3 and the total score is determined within 0-20 in which score above 7 indicates patient with high clinical risk (Royal College of Physicians, 2017).

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The ABCDE assessment includes examination of the airways, breathing, circulation, disability and exposure of the patient regarding any disease (Peran et al., 2020). The airway assessment of Gerald indicates that he has no blockage in the airways and is able to speak full sentences with slight shortness of breath. The presence of obstruction in the airways and hindered breathing results to create lack of oxygen within the body which result individual to face sudden physical collapse out of hindered organ functioning due to reduced oxygen in the body (Vicini et al., 2018). Thus, the airway assessment of Gerald is made to ensure avoidance of any blockage as it may have resulted in his sudden collapse. The lack of presence of any obstruction in the airways leads to determine the NEWS2 score to be 0 for the airway parameter. In sepsis, the breathing rate is increased, and oxygen saturation is decreased due to inability of the patient to inhale normal amount of oxygen required by the body leading the individual to gasp to increase breathing rate (Karikari-Boateng, 2017). Thus, breathing assessment of Gerald is performed which informs that his respiration rate is 28 breaths/min with SpO2 being 89% at room air. The normal breathing rate of a healthy adult at room air is 16-20 breaths/min and SpO2 is above 95% (Hartley, 2018). Thus, it can be determined that Gerald is facing shortness of breath that has led to his elevated breathing rate and reduced SpO2 level. Gerald is facing breathlessness and the NEWS2 score for hindered breathing rate is +3 and SpO2 is +3 in case of the patient.

The presence of sepsis also disrupts the normal blood pressure and raises the heartbeat (Shashikumar et al., 2017). Thus, the circulation assessment of Gerald is executed, and his heart rate is recorded that is 118beats/min with blood pressure that is 97/52 mmHg. The normal heart rate is within 100 beats/min and blood pressure is 120/90 mmHg in adults (BHF, 2020). The NEWS2 score for these two parameters is recorded to be +2 separately. The hindered heart rate also indicates that Gerald is suffering from sinus tachycardia in which the body sends signal to the heart to beat faster that can be caused due to hindered body functioning (de Castilho et al., 2017). In Sepsis, the presence of infection in the body raises the level of white blood cells as they function to fight infection in the body and plays part in promoting immunity (Fouda et al., 2021). Moreover, in sepsis, the fluid level is also seen to be decreased (Byrne et al., 2017). Thus, they are assessed in Gerald which indicates that the patient’s white blood cell count is increased, and the urine output measured is lower than normal.

The disability assessment of Gerald indicates that his body temperature is 39.1℃ and his blood glucose level is 8.3 mmols/l. The normal body temperature is 36.5 ℃ and the normal blood sugar level is 7.8 mmols/L (Aleksi and Belba, 2021). This indicates that Gerald has fever and slightly elevated glucose level. His health history informed no presence of known diabetes due to which confirmation cannot be made for the presence of the disease. The exposure assessment of Gerald indicated he has dry mouth and cracked tongue with infected wounds at the bottom of his feet. The presence of infected wounds along with joint pain and dry mouth are common symptoms of sepsis (AL-Haddad et al., 2021). Thus, it can be confirmed through the ABCDE assessment along with previous analysis from the doctor that Gerald is suffering from sepsis. The NEWS2 score for the raised body temperature is +2 and the total NEWS2 score determined from addition score of all other parameters indicated 12 units. Thus, Gerald can be identified as high-risk patient as his NEWS2 score is above 7 which indicates high clinical risk patient. He reports facing pain in each joint. The presence of hyperglycaemia (elevated blood sugar) in patients with sepsis is considered to be common (Fabbri et al., 2020).

Pathophysiology of Sepsis

Gerald is mentioned to be suffering from Sepsis and lack of effective management of sepsis leads to organ damage and makes patients face septic shock which may be fatal (Gyawali et al., 2019). One of the common symptoms of sepsis is breathlessness which is also seen in Gerald. In the study by Wang et al., (2021), it is informed that sepsis causes injury to the lungs by the help of circulatory inflammatory mediators or pro-inflammatory cytokines such as IL-1β and IL-6 which result towards its impaired ability to support enhanced gas exchange through normal ventilation process. In comparison, the study by Lelubre and Vincent (2018) mentions that hindered respiration rate is faced by patients with sepsis due to increased stimulation of the afferent fibres (nonmylenated Type IV and III fibres) out of response to the mechanical stimuli caused by infectious agents. They lead increased efferent phrenic nerve activity and support increased breathing drive. The increased breathing rate causes the diaphragm to consume increased energy that in turn causes further increase in the respiration drive making the ventilator muscles to fail in maintain normal exhalation and inhalation process to maintain enhanced oxygen saturation in the blood (Wang et al., 2019).

The presence of tachycardia is frequent symptom in sepsis patient and it indicates systematic stress response of the body towards the condition which affects mortality in patient and attributed to elevated fatty acid and glucose oxidation in the body (Monnier-Cholley et al., 2018). The study by Leclerc et al., (2017) informs that untreated sepsis leads to release of toxins in the body by the bacteria that creates systematic reaction within the body causing the immune system to release cytokines in fighting the infection. The cytokines act to dilate the blood vessels near the site of the infection with the intension to allow increased blood to pass through the infected area but lead the blood pressure to become lower to make the immune system more effective. Thus, low blood pressure is faced by Gerald which is currently dangerous as the reduced pressure is causing development of condition of reduced blood flow to the vital organs (Ranzani et al., 2017). As argued by Schinkel et al., (2019), decreased blood pressure along with blood clots in sepsis patients leads the heart to compensate to work harder in supporting reach of enhanced amount of blood to the other organs of the body. This condition leads increased heart rate to be faced by the patients with sepsis such as Gerald which create the risk of heart attack.

The presence of tachycardia in sepsis patients which is also seen in Gerald indicates hypovolemia and increased need for repletion of intravascular fluid (Unluer et al., 2017). The sepsis causes leakage of fluids from the surrounding tissues and pathologic vasoplegia leading to lowering of fluid content in the body (Hasegawa et al., 2021). In sepsis patients, the presence of infection creates stress response in the body. This activates the central nervous system along with neuroendocrine axis that stimulates release of hormones like glucagon, catecholamines and cortisol that are known to increase production of glucose leading to hyperglycaemia in sepsis patients (Rivas and Nugent, 2020). Thus, the hormonal change caused by sepsis lead to increased glucose level in Gerald. The presence of fever is sepsis is also seen because the hypothalamus is affected in the condition that influences heat production and heat loss to balance and favour high temperature (Aleman and Guerrero, 2018).

Nursing and Medical Intervention

The nursing intervention for Gerald to immediately manage his sepsis is following of Sepsis Six Bundle which includes bundle of intervention to be followed to reduce mortality and intensity of septic condition in the body faced by sepsis patients. It is to be completed within 1 hour for ensuring avoidance of mortality risk for the patient (NHS, 2013). The UK Sepsis Trust mentioned in Sepsis-6 bundle that the first step is titration of the oxygen saturation to 94% in patients (sepsistrust.org, 2020). According to NICE, direct delivery of oxygen to the trachea of the sepsis patients at a fraction of inspired oxygen (FiO) of 0.5-1 through a non-breather oxygen mask is to be provided to the individual (NICE, 2017). Thus, in case of Gerald, artificial oxygen is to be provided by following the NICE guidelines by the nurses caring for the patients and ensure reaching 94% oxygen saturation within 1 hour. This is important to be achieved in sepsis patients like Gerald so that enhanced oxygen saturation is reached in the blood which is important for supporting enhanced organ functioning and avoiding organ damage (Avendaño-Ortiz et al., 2018).

The second step in Sepsis-6 bundle is executing blood culture and develop source control to lower the infection rate (sepsistrust.org, 2020). The source control in sepsis patient is achieved through involvement of multi-disciplinary team (MDT) that consist of surgical or non-surgical health professionals who would act to surgically or percutaneous removes or drain infectious fluid or tissues from the area to control the spread of the infection (Martínez et al., 2017). In case of Gerald, the nurses for source control are to arrange physicians who would percutaneous remove the infected tissues and disinfect the area in the bottom of the leg to control the infection. The third step in Sepsis-6 bundle is administration of empiric intravenous antibiotics (sepsistrust.org, 2020). The antibiotics are to be provided intravenously to Gerald as it leads to administer the drug directly into the bloodstream which leads it to react quickly to act in reducing infection and pain in the body (Nevill et al., 2021). The intravenous antibiotics such as ceftriaxone or azithromycin and others is to be provided intravenously to limit the infection (Walchok et al., 2017).

The mechanism of action of azithromycin includes binding to the 23S rRNA of the 50S ribosomal unit of the bacteria that limit bacterial protein synthesis by inhibiting translocation phase of the synthesis leading the bacteria to die (Patel et al., 2018). In comparison, ceftriaxone acts by inhibiting the synthesis of mucopeptide in the cell wall of the bacteria. The ceftriaxone’s beta-lactam moiety binds with the carboxypeptidases, endopeptidases, and transpeptidases present in the cytoplasmic membrane of the bacteria leading to inhibit cell wall synthesis and cell division (Trinh et al., 2017). The dose of the antibiotics for Gerald is to be determined by the physicians and nurses caring for him are to execute effective medicine management in administering them without error. The fourth step of Sepsis-6 is measuring the serum lactate level to ensure it decreased near to normal in Gerald. This is because serum lactate level in sepsis patients helps to identify the severity of the condition and monitor the progression of the disease (sepsistrust.org, 2020).

The fifth step of Sepsis-6 bundle is delivering intravenous fluid resuscitation to the patient (sepsistrust.org, 2020). It is to be followed by Gerald and he is to be provided initial crystalloid fluid of 30ml/kg for 30-60 minutes. This is because increased delivery of fluid to sepsis patients reduce risk of septic shock and helps in restoring cardiovascular stability along with enhance fluid level in the body to support improved oxygen delivery to other organs to avoid long-term disability of poor tissue perfusion (Lara et al., 2017). The final step of Sepsis-6 bundle to be followed by nurses is ensuring accurate normal urine output by measurement. This indicates that the urine output of the individual with sepsis is required to be at par or over 30ml/hr (sepsistrust.org, 2020). This is to be reached in case of Gerald because it indicates enhanced renal function and circulating fluid volume in the body ensuring enhanced kidney function of the individual (Premuzic et al., 2017).

Holistic care of patients and families

The case study of Gerald informs that he has no family to support in his care and he is solely responsible to manage his health. In this condition, to deliver holistic care to Gerald, the person-centred care approach is to be implemented (NHS Improvement, 2016). Person-centred care ensures holistic assessment of the specific needs and demands of the patients along with ensures their active participation in deciding care support for themselves to develop enhanced health and well-being (Tessier et al., 2019). Thus, the nurses caring for Gerald to deliver holistic person-centred care are to engage in active communication with him to gather informed consent regarding the way care is to be provided to him and the care that needs to be fulfilled specifically for him. This is because it would help the nurses to show value towards the patient’s opinion which would make them feel respected and dignified to be willing to accept the care without hindrance (Tait et al., 2021).

The psychological impact of acute illness on the patients is that it makes them feel stressed and anxious regarding their health (Schuler et al., 2018). This is because of the sudden onset of the illness which makes the patient feel confused regarding the symptoms and lack of knowledge along with fear regarding the way to overcome the situation. It is evident as he is reluctant in slipping to hospital clothes out of lack of knowledge and fear of way he is to be further cared so that he does not feel cold anymore. As argued by Kerasidou (2019), the lack of compassion and empathy in care by the nurses leads them to fail to provide holistic support to the patients. This is because compassion and empathy lead the nurses to build trustful relation with the patients to determine their holistic needs and support them accordingly. Thus, to deliver holistic care to Gerald, the nurses are to act in empathetic and compassionate manner. The challenge of living homeless is that proper medication could not be afforded by the patients (Klein and Reddy, 2015). In this context, Gerald being homeless, it is responsibility of the nurses to arrange medication and care free of cost for him till his well-being is ensured.

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The legal issue of confidentiality is faced in acute illness as patient information are shared with others to gather immediate information of the way to care for the individual (Fleischmann-Struzek et al., 2018). The Data Protection Act 1998 informs regarding the way to safely share patient information and maintain confidentiality (legislation.gov.uk, 1998). Thus, the nurses caring for Gerald are to follow the Act to maintain confidentiality under all condition during his treatment as also mentioned in the NMC Code which informed patient confidentiality in all aspect is to be maintained for their safety and care (NMC, 2018). The ethical issue of autonomy and disruptive justice is faced in delivering care to acute ill patients. This is because in delivering urgent care often the patients are not allowed to take decision regarding their treatment and lack of justice in care may prevail by creating discrimination to treat acute ill patients according to social status (Bellou et al., 2018). Thus, in holistic care for Gerald, the nurses are to act without discrimination and ensure maintaining autonomy in care by allowing active participation of Gerald to decide regarding his care.

Conclusion

The above discussion mentions that Gerald is suffering from sepsis which is evident from his unkempt and infectious wound at the bottom of the leg. The ABCDE assessment for Gerald is made to detect the severity of the vital related with sepsis and prioritise the care accordingly. The NEWS2 score of Gerald is 12 indicating he is high-risk patient and requires immediate healthcare. The Sepsi-6 bundle is to be followed by nurses in delivering care to Gerald which is to be completed within 1 hour. According to it, Gerald is to be provided artificial oxygen as supplement and his infection source is to be managed. Intravenous antibiotics are to be provided to limit the infection and urine output is to be ensured. In delivering holistic care to Gerald, the person-centred care approach is to be followed according to effective communication is to be established with him and care support is to be provided by the nurses compassionately and empathetically. The informed consent regarding care is to be gathered from Gerald and multi-disciplinary team (MDT) is to be involved in delivering holistic care to him.

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