Sepsis

IV Rocephin 1g in NS q24
hr; cephalosporin antibiotic,
disrupts bacterial cell wall
synthesis
Azithromycin 500mg in NS
q24hr; macrolide antibiotic,
interferes with bacterial
protein synthesis

Untreated pneumonia
results in secondary
problems including
sepsis and acute
respiratory failure

Pertinent Physical Examination findings:

Coarse, ronchi sounds bilaterally in lungs
Regular breathing pattern w/dyspnea w/exertion
Even chest expansion
100% SpO2 on 10L non-rebreather mask
100% SpO2 on 5L NC, 97% SpO2 on 4L NC
Productive cough, thin light brown sputum
Urine output 0-10mL/hr; amber, cloudy appearance
PO intake of 480mL
Poor appetite; active bowel sounds; last BM 3.5.14

Impaired gas exchange related to alveolar collapse

as evidenced by hypoxia and change in mentation.
Pt will maintain SpO2 above 94% during my shift.
Nursing interventions:
*Sat pt upright to promote chest expansion.
*Weened pt off 10L via non-rebreather to 4L via NC to
assist pt to breathe more effectively on her own.
*Taught pt incentive spirometer use and rationale to
encourage alveoli expansion.
*Encouraged coughing and deep breathing to cough up
mucus and promote breathing.
*Encouraged pt to suction secretions to promote
breathing.
Evaluation: Pt goal achieved.

Acute Renal Failure

Untreated pneumonia led to
sepsis, systemic
hypotension, poor perfusion
to the kidneys and
IV Rocephin 1g in NS q24 hr;
ultimately acute renal
cephalosporin antibiotic, disrupts
failure
bacterial cell wall synthesis
Azithromycin 500mg in NS q24hr;
(S.F, 78y.o. F)
macrolide antibiotic, interferes with
bacterial protein synthesis
Respiratory Failure

Former smoker,
pneumonia (community
acquired)

Acute

Pneumonia fluid build-up in the lungs alveolar

collapse poor oxygenation of the blood decreased
oxygen delivery to body systems poor perfusion
Healthline.com

IV Rocephin 1g in NS q24 hr;

cephalosporin antibiotic, disrupts
bacterial cell wall synthesis
Azithromycin 500mg in NS
q24hr; macrolide antibiotic,
interferes with bacterial protein
synthesis
10L O2 via non-rebreather 5L
NC 4L NC

Pt is visiting family in VA from NC. She was worried about her

daughter being able to attend to her bills and obligations back home. Pt
is preparing to move to VA from NC to be closer to family; stressful life
events may put stress on the pts mind and body, stress management and
a good family support system should be in place. Pt seemed very
worried about her family and taking care of her daughter, she may need
someone to help her focus more on herself and taking care of her health
over constantly worrying about others.

Taught pt incentive spirometry use and

rationale; taught pt deep breathing and
coughing; taught pt importance of sitting
upright; taught pt how to suction secretions
from back of throat; teach about medications,
disease process (how pneumonia led to sepsis,
acute renal failure); review diet plans (high
protein, small frequent meals)

Chest X-ray showed diffuse pneumonia,

especially in the R apex
WBC 38.1 HIGH pneumonia infection
RBC 3.44 LOW acute renal failure
HgB 9.7 LOW acute renal failure
Hct 29.2 LOW acute renal failure
BUN 44 HIGH acute renal failure
Cr 2.83 HIGH acute renal failure
Lactic acid 3.4
CO2 20 LOW acidosis r/t combination
1
of acute renal and respiratory failure

Guide for Reflection

Guide for Reflection Using Tanners (2006) Clinical Judgment Model
Introduction
This was my first week in critical care and I was taking care of a 78y.o F admitted with acute respiratory failure r/t
pnuemonia.
Background
I had no previous relationship with the patient. In past clinical experiences, I have taken care of patients in acute respiratory
failure. I was prepared to monitor her SpO2, respiration rate, listen to her lung sounds and assess for symptoms of hypoxia.
I was also prepared to teach her about incentive spirometry, deep breathing, coughing and repositioning. My role as the
nurse in this situation was to carry out previously described tasks, as well as to make the patient comfortable, assess her
pain and administer medications and prescribed. I did not have any strong emotions about the situation. Most emotions of
the day I had related to an anxious energy about my first critical care experience.
Noticing
Initially I noticed that my patient was awake, not on a ventilator, lying in bed with a non-rebreather mask on. As I read
through her chart I noticed that she was admitted for acute respiratory failure and that her lab values were all over the place.
When I first went in to assess my patient I realized she looked exhausted. She told me she hadnt slept at all and as I spoke
with her more she became more dyspnic and tired. As the day went on I realized that she was completely exhausted and
needed rest. I tried to go in and do some teaching about deep breathing and incentive spirometry, but she was so tired she
could barely get the spirometer to move. She was too tired to even eat. I sat with her and tried to feed her, but her secretions
were so thick and the effort to chew was so much that it seemed futile. I spent the rest of my day checking on her hourly,
monitoring her output and reminding her to suction out secretions from the back of her throat.
Interpreting
Her respiratory failure was related to pneumonia. Her untreated pneumonia further manifested as sepsis. The sepsis resulted
in systemic hypotension, decreasing perfusion to the kidneys which led the pt to experience acute renal failure. This posed a
problem because to treat sepsis, they flood the pt with fluids, and the pt was not putting any fluids out. Her urine output was
0-10mL/hr. As her nurse, my nurse advocated that my pts fluids be cut back and that nephrology be consulted. The
intensivist agreed and cut back on her fluids. I made it a priority to assess her respiratory status as well as her urine output. I
enjoyed working with my preceptor for the day because she really taught me how to connect the dots in pt assessment and
pt care. I gained valuable critical thinking skills from this experience.
Responding
My goal for this patient was to maintain SpO2 above 94%. In the morning she was maintaining 100% on 10L via nonrebreather. We received orders to cut this back to 5L via NC where she continued to maintain 100%. Later, we weened her
down to 4L and she was consistently at 97%. My goal from here was to teach her to use the incentive spirometer. The pt
was too exhausted to participate, but I would check in periodically and remind her how to use it. I kept her in an elevated
position and encouraged her to cough up secretions and to use suction as necessary. I was very comfortable teaching my
patient these interventions and was not stressed in any of my interactions with her. I was comfortable talking to her, helping
her with breakfast and lunch and felt comfortable in my assessment skills. The patient was receptive to me throughout the
day, she just seemed tired and like she needed to catch up on rest from being admitted over night that morning. As far as
monitoring her urine output, it ranged from 0-10mL/hr. The nurses expected this as did the doctors since she was septic and
hypotensive. All I felt that I could do in this situation was perform Foley care, monitor output and chart my findings.
Reflection-on-Action and Clinical Learning
One way my nursing skills expanded in that I learned about the nurses role in a critical care setting. Another way my skills
expanded is that I was able to observe patients on ventilators. One last way my skills expanded is that I got a lot of
experience with IV meds and helped my nurse hang FFP for my pt. One thing I might to differently in this situation is
engage the doctors more. They seemed open and willing to talk to us and help us learn. Another thing I would do differently
is be more engaged in my surroundings. One pt kept going into VTach and instead of going in the room immediately I kept
watching the EKG screen at the station. Another way I would change my practice is that I would try to be more comfortable
with my surroundings. I was overwhelmed initially, not knowing what to expect and it wound up being a great learning
experience. I didnt have anything to be afraid of. Critical care nursing is definitely a different beast than MedSurg nursing.
I would love to expand my skills with the vents and trachs and suctioning skills and tube feeding process. Expanding my
repertoire of nursing skills would definitely help in this kind of nursing setting. As a result of this experience I gained an
appreciation for higher level nursing skills, critical thinking skills and ACLS prepared nurses. The nurses were more
engaging, possessed higher levels of thinking and acted professionally on a multidisciplinary team.
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment
Model. Journal of Nursing Education, 46(11), p. 513-516.

List two goals for the next practicum experience:

1. Learn differences between VCU and Bon Secours Health Systems
2. Gain appreciation for how the VCU ER functions