Understanding the Pathophysiology of Sepsis Diagnosis

Introduction

This essay is about discussing the pathophysiology of sepsis diagnosis and many health related changes to occur in the patient in the case study. Gerald is a 72-year-old male patient who has been diagnosed with Sepsis due to an unkempt wound on the foot. He has no family. He has been living in the accommodation founded and supplied by the local homeless charity since the last six month. After getting collapsed he has been brought to the hospital. By carrying out Gerald’s health check-up he has been diagnosed with sepsis.

Clinical interventions:

As mentioned by Smith and Bowden (2017), sepsis is the life-threatening health condition that makes body’s immune system works against the infection in such a way that causes severe injury to body’s own organs and tissues. The World Health Organisation defined sepsis as the syndrome-response of the body to infection that causes organ dysfunction that is caused due to deregulated response of host to an infection [WHO, 2019]. The health survey conducted by WHO shows that Sepsis becomes the major health concern worldwide.

Sepsis accounts for more than 11 million premature deaths worldwide due to serious infection in body (Evans et al. 2021). WHO (2017) reported in a survey that, more than 48.9 million cases of sepsis have been registered worldwide. During 2017, nearly 50% of all the sepsis cases worldwide occur in children (WHO, 2017). The WHO (2019) survey also shows that in the UK, nearly 245,000 patients suffer from sepsis in each year, out of which an estimation of 48,000 deaths are registered in each year (WHO, 2019). The evidence suggests that more than 80,000 people in the UK, who are the survivors of sepsis experiences drastic changes in their physiological and psychological condition. In this context, the selection of this case study and the topic are highly relevant and appropriate to the modern health care context which will provides the evidence-based information to modern health care professional regarding managing sepsis.

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This essay will discuss the pathophysiology of sepsis diagnosis and many likely changes to occur with Gerald's health. An understanding of clinical assessments and tools used to evaluate Gerald's level of deterioration will be evident. Finally, the legalities and issues evolving about Gerald's care and the mental effect of the diagnosis of Sepsis will be discussed.

Confidentiality:

This essay will follow and implement the NMC (2018) codes and guidelines regarding maintaining confidentiality of all the personal derails of the patient. In this regard the real name, actual age and location or address of this patient are kept anonymous for protecting patient’s rights towards confidentiality and privacy (NMC, 2018).

The case study:

Gerald lives alone and suffers from poor physical as well as mental health condition. As he got senseless in the morning he has been brought to the hospital. As he looks unkempt and has high fever and infectious wound at feet he is admitted to hospital. Gerald’s responses to the question of health professionals are confusing as well as vague. Both his physical and mental health condition suggest that he suffers from some serious illness that needs immediate and effective treatment. After health assessment it is diagnosed that Gerald has sepsis, the life-threatening infection in which body’s immune system causes injuries to own body organ system.

After admission to the hospital, nurse and doctors have conducted the necessary heath examination of Gerald. Under NMC (2018), nursing professionals must work under their level of best professional knowledge and understanding in terms of ensuring that the right health assessment techniques and tools are used for emulating heath condition of patients. As mentioned by Evans et al. (2021), while it comes to conduct the physical examination of a patient, health care professionals must use the right health assessment tool that will enable them to check the necessary biological parameters that are important for right diagnosis and treatment. In the case of Gerald, the ABCDE (airways, breathing, circulation, disability ad exposure) (Smith and Bowden, 2017) health assessment tool has been used to check the major biological system such as circulatory and pulmonary system, lung function, and pulmonary ventilation and oxygen saturation. As stated by Levy et al. (2018), nurses must ensure that they have strong and clear professional knowledge and understanding on different types of health assessment tools, which will enable them to ensure patient’s safety by using the right health assessment tool and techniques for pained; treatment. The A-E (Phillips, 2021) initial approach gives an immediate, methodical evaluation of a deteriorating patient focused on overseeing brutal conditions, diminishing mortality, and further developing results (Mayo, 2017, Smith and Bowden, 2017).

Airways:

While assessing the airways, the nurse also checks, whether Gerald shows symptoms like bleeding, vomiting, abnormal see movements, central cyanosis, foreign bodies in the mouth. Positively Gerald does not show these symptoms. The way Gerald communicates and speaks, it shows that he faces airways obstruction. Fortunately Gerald does not any difficulties in breathing. Gerald experiences difficulties in speaking and interacting with nurses and doctors. As mentioned by Seymour et al. (2019), in case of partially occluded airways, patients suffer from reduced and restricted entry of air into airways which leads to difficulties in communication and speaking.

Breathing:

While assessing breathing process of Gerald, the nurse carries out different physiological tests such as oxygen saturator test by using pulse oximeter, HRCT (High Resolution Commuted Tomography) test, spirometry (test for checking oxygen supply into lung) (Rubio et al. 2019). These examinations show that Gerald has lower oxygen saturation with 89 SPO2 (Saturation of Peripheral Oxygen) (normal is 98-99 % Ren et al. 2020). The low oxygen saturation is due to Gerald does not receive sufficient oxygen in his lungs. Gerald also shows a breathings rate of 28 breaths / minutes, which is higher than the normal range of 12-20 breaths / minutes (Rubio et al. 2019). As mentioned by Jaiswal et al. (2019), difficulties in breathings are common sign of pneumonia and dyspnoea, in which the lungs cannot be able to receive enough oxygen due to restricted entry of air through the airways. The cause behind these breathing difficulties can be linked to sepsis.

As mentioned by Papazian et al. (2020), sepsis, the life-threatening health condition can affect any other organs in the body such as respiratory, pulmonary, circulatory, and nervous system of patients. In Gerald’s case, his pulmonary system is adversely affected due to occurrence of sepsis, which may lead him to unconsciousness and even death if immediate clinical measures are not taken (Ren et al. 2020). During this assessment, the nurse also checks whether there is any sound of wheezing, rattling and crackles (the sound inside chest that occurs if air is inside the airways and patient suffer from breathing difficulties) inside the chest. Under this examination it is found that there are chest crackles in Gerald, which highlights the high level of breathing difficulties and hypoxia. Hypoxia is the condition, in which body suffers from oxygen deficiency due to the poor oxygen enters into lung alveoli (Schlapbach and Kissoon, 2018). This condition of hypoxia of Gerald shows that as he suffers from the poor entry of oxygen into the airways due to inflammation and narrow passage inside the airways it makes the lung to do not sent sufficient oxygen to different body parts (Venet and Monneret, 2018.).

Circulation:

While assessing the circulatory system in Gerald, the nurse examines that whether there is any body part that becomes pale or blue. The nurse also checks whether body parts are cool or warm. During this assessment, BP is measured which shows a low BP of 97/52 mm/Hg (normal is 120/80 mm/Hg (Venet and Monneret, 2018) ), which shows that the heart is not working in proper way which cause poor pressure of blood on the arteries. . Gerald’s heart rate is cheeked which shows that Gerald has sinus tachycardia with heart rate 118 beats per minute. sinus tachycardia is the health condition, in which the patient has a heart rate that is higher than the normal ranges (normal range is 60-100) (Rudd et al. 2020). Gerald suffers from sinus tachycardia, because as his lungs cannot have sufficient oxygen, the heart beats faster to pump more blood into circulation to meet the oxygen demand of lungs. The circulatory assessment also shows that, that Gerald has higher number of WBC which is due to the infection on his feet (sepsis) (normal range is 4,500 to 11,000 WBC per microliter). During infection the WBC level increases inside the body to support the immune system for preparing body against infection and pathogens. This is why Gerald has higher number of WBC in blood

Disability:

While checking disability of Gerald, many question are asked to Gerald. Under this assessment it is seen that Gerald is responsive to all questions, but his answers are somehow vague and confusing (Venet and Monneret, 2018). The body temperature is also cheeked which shows that Gerald has fever with 39.1C o or 102.4 F which is higher than the normal range (36.4 C – 37.2 C or 97.9-99 F (Evans et al 2021). The high fever of Gerald can be potentially linked to sepsis. As mentioned by Reinhart and Kissoon (2018), any infectious condition that occurs in body rise body temperature than the normal range. This is because the body fights against the pathogens which then than provokes inflammation and raise body temperature. Sepsis is sometimes related to hyperglycaemia, the condition in which the glucose level in blood exceeds the normal range (Rudd et al. 2020). Fortunately Gerald has no symptoms of hyperglycaemia.

Exposure:

While carrying out the exposure-assessment, the nurse checks that whether Gerald has rashes, bleeding, swelling and fractures in any body part. Under this examination it is seen that Gerald has dry mouth, cracked tongue and dry skin. This can be linked to the health outcomes of sepsis. Clinical intervention suggests that the bacteria infections during sepsis can also attack the skin, mouth, feet, and bottom part of body by forming bacterial colonisation (Rudd et al. 2020). As Gerald has sepsis, there is high chances of rash, dryness, or infections in these body parts. Gerald's dry mouth and cracked tongue are symptoms of dehydration and a thrush infection caused by an overgrowth of the candida fungus, which is naturally prevalent on the tongue (Marchione, 2016). Gerald has a NEWS2 score (Gyawali et al. 2019) of fifteen, which indicates that he is clinically sick. He will be escalated to the critical care outreach team and urgent care unit using the SBAR (RCN, 2019), a clinical communication tool that facilitates systematic and accurate patient escalation. Gerald's observation will be recorded on the NEWS2 chart every 15 minutes (RCP, 2017).

Pathophysiology of sepsis:

As compared to the localised and common infection, sepsis is the multifaceted disruption of immune balance of anti-inflammation and inflammation (Lin et al. 2018). During this infection changes that occurs in the anti and pro inflammatory pathways lead to the massive secretion of mediators, cytokines and different pathogen related molecules that result into the activation of the complete cascade and coagulation. The occurrence of sepsis is related to status of host’s immune system and factors that are associated with the invading pathogens. During the initial stage of sepsis, the recognition of the pathogen-derived molecular patterns (PAMPs or starting of the endogenous host-derived danger signals is considered as the starting signal for the entire pathway (Schlapbach and Kissoon, 2018.). The binding of pathogen-derived molecular patterns (PAMP) to APCs and TLRs leads to signal transduction that causes nuclear factor-kappa-light-chain-enhancer to translocate from activated B cells to cell nucleus (Levy et al. 2018).

This process triggers the “early activation genes,” such as different pro-inflammatory interleukins (IL) including IL2 IL1, IL 18 and IL 12, tumour necrosis factors (TNF) and various interferon (IFN) (Gyawali et al. 2019). These molecules cause the activation of high number of cytokines such as IL-6, IL-8 and IFN Y which lead to the negatives feedback of the coagulation and complement pathways thereby leading to down-regulation of different complements of adaptive immune system (Rubio et al. 2019). As a net result there is development if immunological phenotype which acts against the normal body system thereby causing different health complications. These molecules then activate and provoke specific receptors for activation. These receptors are called tool like receptors (TLR) that are located on the surface of specific antigen presenting cell (APC) (Fleischmann-Struzek et al. 2018). Therefore, the clinical syndrome of sepsis is initiatives by caring out the transcription of genes that are involved in metabolism, inflammation, and adaptive immunity. The activation of the specific receptors that cause the up gradation of the pro and anti-inflammatory pathways which then cause the severe inflammation thereby causing tissue damage (Evans et al. 2021).

That up-regulation of pro inflammatory and anti-inflammatory pathways keep continuing which initially cause the multi organ dysfunction. Therefore, Gerald suffers from complex health condition such as pneumonia, infectious wound on both feet and sinus tachycardia. In case of many patients there is high risk of concomitant immunosuppression, which is occurred due to the downregulation of different activating cell surface molecule that increase the apoptosis of T cell and immune cells thereby causing immune paralysis. As mentioned by Rubio et al. (2019), immune paralysis is the condition that occurs at the final stage of sepsis, in which patient suffers from severe immunes dysfunction which makes the immune system of patient unable to protect body from any pathogen and thereby body system becomes susceptible to any infectious health condition. In case of Gerald , he has high risk of immune paralysis, as he reaches the final stage of sepsis, which adversely impacts on his immune balance thereby effecting on how different organ system work such as circulatory, pulmonary, and respiratory system.

Care interventions::

Gerald has a NEWS Score (Phillips, 2021) of 15, suggesting that he needs quick attention and reaction (RCP, 2017). According to the RCP (2017), the healthcare professional team should include clinical care expertise in airway management. Clinical reasoning for nursing intervention uses signs and data received from the patient to help improve the patient's health (Rhodes, et al., 2017). A care plan has been developed for Gerald by using the Sepsis 6 pathway

Maintain oxygen level:

As Gerald suffer from hypoxia, bronchodilators are administered into his body through using the intramuscular medicine administration. Bronchodilators are used in case of treating breathing difficulties in which the medicine that are administered intramuscularly dilate the airways thereby improving passing of air through airways The bronchodilators that are used in Gerald’s case are Short-acting β 2 -agonist (SABA) and Long-acting muscarinic antagonists or LAMA (Gyawali et al. 2019.). These bronchodilators are used to dilate the inner passage of the bronchiole thereby allowing me oxygen to enter into airways (Jaiswal et al. 2019). By treating Gerald by using these bronchodilators, Gerald’s oxygen saturation level has been improved with an oxygen saturation of 96 %spO2

Intravenous antibiotics:

Antibiotics that are used for treating sepsis in case of Gerald are ceftriaxone, piperacillin-tazobactam, vancomycin and ciprofloxacin (Gyawali et al. 2019). The doses are adjusted as the body’s requirement. Nurses check regularly that whether there are any side effects for administering these antibiotics onto Gerald’s body.

Blood culture:

Blood culture is done, to identify the source of the infectious wound in the feet on Gerald. This culture shows that, this is the bacterial infection which occurs due to repeated bacterial colonisation on the feet. Poor health routine, lack of healthy lifestyle and poor maintenance of hygiene are associated with spread of this infection

Intravenous fluid:

As the BP is low with 97/52 mm/Hg, 500mL - 1000mL bolus of Hartmann’s is given to Gerald for treating sepsis (Levy et al. 2018)

Check lactate level:

Lactate, venous and arterial sample of Gerald is collected. The; lactate level of Gerald sows normal with 5 milligrams per deciliter (normal is 4.5 to 19.8 milligrams per deciliter) (Papazian et al. 2020)

Monitor urine level:

The blood lactate concentrate is checked in case of Gerald which shows that Gerald has normal urine function with normal fluid balance.

Based on this sepsis 6 pathway the following integrated care is conducted:

Integrated care:

The MDT working with Gerald will ensure he receives holistic treatment must treat him holistically in order to enhance his results following his deterioration (Goldfarb, et al., 2017).

Gerald is most likely worried and nrvous (Jasemi, et al., 2017). The RN must respond with empathy and compassion, exemplifying the six Cs of care (Chadwick, 2017). This will create a trusting relationship, which is the first and most crucial step in providing real, compassionate, comprehensive patient-centered treatment (Hatch et al., 2018).

Proper communication is essential for Gerald to understand his therapy and offer informed permission to continue treatment. Having Gerald’s approval will assist him in gaining autonomy; ethical notion . (Griffith and Tengnah, 2017).

Gerald’s dignity and privacy must be protected at all times, both in and out of his doctor's presence (NMC, 2018b). Gerald’s privacy can be protected in order to ensure patient confidentiality (Data Protection Act, 2018).

Post-sepsis syndrome emerges as a mental, bodily, and functional impairment in severe sepsis survivors; having their everyday life activities decreased significantly reduces their independence (Hatch, et al., 2018). As a result, physical therapy must be performed following hospitalization in order to maintain mobility. This should be followed by goal-directed rehabilitation after a severe illness (Kalil, et al., 2017). NICE (2017d) also suggests support groups such as the UKST for guidance and assistance throughout rehabilitation and recovery from sepsis.

Proper communication is essential for Gerald to understand his therapy and offer informed permission to continue treatment (NMC, 2018b). Having Gerald’s consent will assist him in achieving autonomy and the idea of ethics (Griffith and Tengnah, 2017).

Gerald’s dignity and privacy must be protected at all times, both in and out of his doctor's presence (NMC, 2018b). Gerald’s privacy can be protected in order to ensure patient confidentiality (Data Protection Act, 2018).

Survivors of severe sepsis develop post-sepsis syndrome, which manifests as mental, physical, and functional impairment. Having their daily life responsibilities decreased drastically reduces their independence (Hatch, et al., 2018). Following hospitalization, physical rehabilitation must be performed (Kalil, et al., 2017). NICE (2017d) also suggests support groups such as the UKST for guidance and assistance throughout rehabilitation and recovery from sepsis.

Conclusion

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Gerald grew worse with flu-like symptoms, a strong cough with fever. His condition was exacerbated by the development of respiratory failure. He was admitted to the high dependency unit due to bacterial pneumonia and subsequent sepsis. Evidence-based nursing treatments were implemented, including establishing IV access, administering supplementary O2, collecting blood cultures and other relevant haematological testing, and performing fluid resuscitation. This demonstrates the need of RNs practicing evidence-based medicine to improve patients’ outcomes. This paper also presented evidence-based clinical decision making through systematic evaluation, such as the A-E method and NEWS2. When dealing with an AIP, it was reinforced to be methodical and thorough. Using A-E evaluations, Gerald’s deterioration was immediately detected, allowing for early intervention and improvement. The RN was able to distinguish between normal and abnormal results and relate them to underlying causes and pathophysiology, allowing for early action. Gerald’s illness necessitates the involvement of additional health experts (MDTs) and nurses in order to be properly managed. In addition to clinical management, patients receive holistic care to improve their outcomes.

Reference list:

  • Cui, S., Chen, S., Li, X., Liu, S. and Wang, F., 2020. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis, 18(6), pp.1421-1424.
  • Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C.M., French, C., Machado, F.R., Mcintyre, L., Ostermann, M., Prescott, H.C. and Schorr, C., 2021. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), pp.1181-1247.
  • Fleischmann-Struzek, C., Goldfarb, D.M., Schlattmann, P., Schlapbach, L.J., Reinhart, K. and Kissoon, N., 2018. The global burden of paediatric and neonatal sepsis: a systematic review. The Lancet Respiratory Medicine, 6(3), pp.223-230.
  • Gattinoni, L., Chiumello, D. and Rossi, S., 2020. COVID-19 pneumonia: ARDS or not?.
  • Gyawali, B., Ramakrishna, K. and Dhamoon, A.S., 2019. Sepsis: The evolution in definition, pathophysiology, and management. SAGE open medicine, 7, p.2050312119835043.
  • Jaiswal, A.K., Tiwari, P., Kumar, S., Gupta, D., Khanna, A. and Rodrigues, J.J., 2019. Identifying pneumonia in chest X-rays: a deep learning approach. Measurement, 145, pp.511-518.
  • Levy, M.M., Evans, L.E. and Rhodes, A., 2018. The surviving sepsis campaign bundle: 2018 update. Intensive care medicine, 44(6), pp.925-928.
  • Lin, G.L., McGinley, J.P., Drysdale, S.B. and Pollard, A.J., 2018. Epidemiology and immune pathogenesis of viral sepsis. Frontiers in immunology, 9, p.2147.
  • Mandell, L.A. and Niederman, M.S., 2019. Aspiration pneumonia. New England Journal of Medicine, 380(7), pp.651-663.

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