Page 114 nursing.elitecme.com Complete Your CE Test Online - Click Here diarrhea, blood/pus in the stool, and increased heart rate and fever, which are signs of C-diff. superinfection. Stress ulcer prophylaxis can also increase risk for bone fracture and could interfere with other medications (Eisa et al., 2014). Stress ulcer prophylaxis in patients with sepsis should be used only in patients at risk for gastrointestinal bleeding, such as patients on prolonged mechanical ventilation (> 48 hours) and patients suffering coagulopathy (Rhodes et al., 2017). Nursing consideration: Although the nurse does not prescribe antimicrobials or order the treatments used to manage sepsis, it is beneficial for the nurse to have a familiarity with therapies that may be prescribed. Support nutritional needs Nutritional needs of patients with sepsis or septic shock should be met as early as possible. In critically ill patients with sepsis or septic shock, enteral feeding is recommended for patients who tolerate feedings (Rhodes et al., 2017). Parental nutrition is not recommended to meet caloric needs, as there is evidence that there is an increase in chance of infection with parental nutrition and no benefit over IV glucose in mortality (Rhodes et al., 2017). in patients unable to begin or tolerate enteral feedings within the first 7 days, IV glucose is recommended, along with advancing enteral feeds as tolerated (Rhodes et al., 2017). The SSC guidelines for 2017 suggest that gastric residual volumes should not be routinely monitored unless the patient is at high risk of aspiration or has a feeding intolerance (Rhodes et al., 2017). Postpyloric feeding tubes and the use of prokinetic agents are suggested for those who are critically ill and have a feeding intolerance or are at risk for aspiration (Rhodes et al., 2017). Set goals of care Sepsis and septic shock are associated with significant mortality rates. Patients often become critically ill and may have an extended stay in an intensive care unit. It is important to discuss goals of care and prognosis with the patient and the patient’s family (Rhodes et al., 2017). End-of-life and palliative care plans should be utilized when appropriate (Rhodes et al., 2017). As the primary caregiver in the hospital setting, the nurse is a supportive, educational, and empathetic resource to patients and their families in a time when it is needed the most. Nursing consideration: Nurses often spend the most time with patients and their families during the course of the hospital stay. Nurses should be understanding of the fear that accompanies a diagnosis of sepsis and should communicate effectively with the patient and the patient’s family to keep them informed as much as possible. Self-evaluation: Question 10 Tom is a 28-year-old active adult. He works full time as a computer analyst and spends his free time playing volleyball or football with friends. Recently, during a weekend volleyball game at his local community center, Tom fell and tore a piece of skin on his leg. Later that evening, unbeknownst to Tom, his wound had become infected and had begun to spread. Tom felt exhausted and pain at the site of his injury. He went to bed early and reassured himself he would feel better in the morning after a night of rest. The next day Tom noticed that the skin surrounding the wound had turned a dark red color and was swollen. He also felt very weak and began having chills and sweating. Tom assumed he must be coming down with the flu and called in sick to work. Later that evening Tom’s girlfriend found him very lethargic, shivering, and breathing rapidly. His forehead was hot to the touch, and he complained of pain in his leg. He was disoriented and said things that made no sense. His girlfriend drove him straight to the local ER for evaluation. Upon arriving at the ER, the nurse gathered information about Tom’s condition. She noted that Tom was complaining of leg pain. His girlfriend relayed the story of the injury he sustained playing volleyball the day before. The nurse also noted that he was disoriented, was breathing rapidly, and looked pale. Upon further evaluation, his vital signs were found to be BP 100/50, pulse 140, respiratory rate of 26 rpm with an oxygen saturation level of 89%, and temperature 39.4˚C (103˚F). The nurse examined his wound, which was very red and swollen. She immediately recognized that he had signs an infection was likely progressing to sepsis. What should the nurse’s first action be? a. Administer vasoactive medications to bring blood pressure up as quickly as possible. b. Notify physician and obtain cultures (blood and wound) as per sepsis protocol and immediately notify the sepsis response team. c. Administer oxygen and start intravenous fluids. d. Begin broad-spectrum antibiotic therapy. EBP alert! Hyperthermia at time of presentation with sepsis has been found to strongly indicate progression of sepsis to septic shock within 72 hours of presentation (Glickman et al., 2010). This progression is believed to be attributable to the increased oxygen demands on the body during the presence of fever. WHAT NURSES CAN DO TO HELP FIGHT SEPSIS Emergency department nurses and triage nurses More than two-thirds of patients with sepsis present to the emergency room and encounter triage nurses and emergency room nurses first (Perman et al., 2012). Historically, sepsis was treated in the intensive care unit, but it is now known that early identification and timely and aggressive intervention are required to improve patient outcomes, and treatment should be initiated in the emergency room (Perman et al., 2012). The oftentimes quick progression of sepsis requires proper identification, and the triage nurse will be the first to assess the patient’s level of urgency. After the patient is properly triaged, the emergency room nurse begins caring for the patient and must ensure that the 3-hour sepsis bundle recommendation is initiated. After the patient is admitted, clear communication with the nurse receiving the patient is mandatory to ensure the continuum of care is followed. The emergency room nurse should give a clear, concise, and thoughtful report to the next nurse caring for the patient to ensure that the 3-hour and 6-hour bundle recommendations are completed and there are no lapses in treatment or diagnostic tests. Reporting and recording the mental status of patients is often overlooked in emergency situations and could be critical in the identification of early sepsis. Responsibilities of emergency department nurses ● ● Triage appropriately by recognizing signs and symptoms. ● ● Be aware of sepsis protocol in their institution. ● ● Implement bundle recommendations in a timely fashion. ● ● Communicate effectively and thoroughly with fellow staff members to coordinate care of the patient with sepsis. Inpatient nurses Patients admitted to the intensive care unit directly from the emergency department with a severe form of sepsis have a 26% mortality rate, compared to a 40.3% mortality rate when admitted from the floor (Levy et al., 2014). These facts demonstrate the need for better and more frequent screening to identify sepsis in patients who have been admitted to the floor rather than the intensive or coronary care unit. The difference in mortality rates between those patients admitted directly to the ICU versus those transferred from the floor may be secondary