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The following scenario is about a patient who experienced sepsis secondary to a UTI. The patient, Mrs. June Peters (84), was found by her daughter, Mary Jones, in her apartment in a a state of acute confusion. She was admitted to the ED with nausea, vomiting, acute confusion, shivering, severe right flank pain 8/10, pale and mottled skin, tachypnea, tachycardia, and elevated temperature. Her vital signs were: Temp 102, HR 112, RR 28, BP 85/52 (63), SaO2: 92% on room air. The Physician suspected a possible UTI.

Question 1: Given this information, what should be done?

Code Sepsis was called and orders were placed for the following tests and diagnostics: CBC,  lactate level, ABGs, CMP, coagulation screen, C-reactive protein, Procalcitonin, Gram stains/cultures, blood culture, urinalysis & urine culture, ultrasound of the abdomen and pelvis, and 2 L O2 with nasal cannula. While results were pending, patient was started on Zosyn (Piperacillin-tazobactam 4.5g IV Q8H extended infusion).

When the labs and diagnostic results returned, significant findings were as follows: WBC 13.5, Lactic acid 9.8, CRP 120, urine culture cloudy with sediment and positive for E. coli., ProCT 8.7, blood culture positive for E. coli., creat 2.0, BUN 45, and the ultrasound demonstrated findings of right kidney infection. Mrs. Peters is transferred to the ICU.

Overnight, Mrs. Peters’ status has declined. Her SpO2 was consistently at 76% on 6 L NC, so she was switched to a non-rebreather mask at 10 L O2. The SpO2 remained at 77% with a respiratory rate of 10 and the doctor was called. He decided to put the patient on the ventilator and sedated the patient with propofol before intubation. A chest x-ray was done, which confirmed correct placement of the ET. The patient was placed on the A/C setting on the ventilator and continuous ABG monitoring was ordered. In addition, her blood pressure was unresponsive to the crystalloid ordered the day before as part of the 3-hour sepsis bundle.

Question 2: The nurse would expect what additional new orders since Mrs. Peters was still presenting with hypotension and elevated lactate level even after the 3 hour sepsis bundle was followed?

Doctor’s orders were to initiate endotracheal tube placement, ventilator (Settings: mode – A/C, Rate – 16, TV: 500ml, FiO2: 30%, PEEP: 10), Propofol 20 mcg/kg/min, chest x-ray, monitor V/S Q 15 min x4 at the start of ventilation, then Q 2 hours. Vasopressin 0.01 un/min and titrate by 0.005 un/min Q 10-15 min until target BP achieved.

Nursing actions were to monitor V/S, administer propofol 20 mcg/kg/min IV drip, oral care, reposition patient  Q2 hrs, suction patient PRN, and titrate vasopressin to maintain MAP ≥ 65.

On the fifth day, the patient remained in the ICU and was lethargic & sedated. While she spontaneously opened her eyes in response to her name, she didn’t stay alert for very long before dozing off again. After performing a HTT the nurse found that the patient had a heart rate of 106, a BP of 89/38, and a temperature of 99.8. Doctor notified. Skin was warm and sweaty. Pulses were rapid and +2. Patient had a Foley draining cloudy urine at approximately 30 ml/hr. Respirations were clear. She had no significant GI findings. The ventilator settings were on AC control, PEEP of 6. Tidal volume of 410. FiO2 of 35%. Lactic acid was trending down (1.5) as well as WBC count (12.4). The nurse administered Zosyn, Vasopressin and Tyleonl. The Vasopressin helped regulate the patient’s BP and HR and the Tylenol lowered the patient’s temperature.

The nurse referred the caseworker to talk with the daughter as she expressed concern about her mother returning home to her own apartment. The caseworker came to speak with the daughter and asked about her mother’s living situation. The daughter explained that her mother lived by herself on the 2nd floor of the apartment complex, but the elevator works most of the time. She told the caseworker that she had to help her mother with groceries, cooking, and laundry, but that she is fine by herself. After hearing this, the caseworker told the daughter that it would be advisable for her mother to be moved to an assisted living facility. The daughter became very frustrated and told the caseworker that she was not going to abandon her mother like that. The caseworker was silent and listened until the daughter was done talking. She expressed to the daughter that she seemed frustrated and that this was not the intent of the conversation. She said that the goal was to decide what is best for her mother and she explained that they will include her mother in this conversation once she became more alert. Upon hearing this, the daughter acknowledged that the caseworker was right and that her mother does need more help than she is able to provide. She agreed to hear the options for an assisted living facility.

Question 3: How was therapeutic communication used by the caseworker in this conversation? What types of therapeutic communication did she use?

On day 10, after being extubated for 2 days, Mrs. Peters was discharged from the hospital. She and her daughter decided that she would move into an assisted living facility nearby. The nurse gathered all the discharge paperwork and provided Mrs. Peters with education on UTIs and how to prevent them.

Answer Key:

Question 1: Initiation of Code Sepsis

Question 2: The MD placed new orders to maintain the MAP ≥ 65 using Vasopressin. Mrs. Peters perfusion and volume status were reassessed and documented by the physician. Her lactate level was redrawn.

Question 3: The caseworker used therapeutic communication to diffuse a tense conversation. She was able to help the daughter come to terms with her mother’s changing situation and she helped the daughter focus on doing what was best for her mother. She used the techniques of focusing, restating, recognition, and silence.

By Genevieve Cragoe