Critical Analysis on Sepsis and Septic Shock Patient Assessment

This critical analysis focuses on sepsis assessment in acutely ill adult patients, specifically on patient Philomena. The ABCDE assessment was done and critically analyzed, along with the interventions given. The response to patient Philomena was assessed and analyzed, along with the skills and knowledge of the rapid responses given to a deteriorating patient’s condition. The integration of ethical-legal principle and the care that patient Philomena was given was also analyzed. The assessment tools used were evaluated for efficiency. The article concludes with a critical opinion on the care given to patient Philomena.

Running Header: Critical analysis on patient assessment. 1
SEPSIS AND SEPTIC SHOCK.
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Sepsis and septic shock. 2
Introduction
This is a critical analysis on sepsis assessment in acutely ill adult patients. An elderly
woman is suspected to be having sepsis. The paper will: describe patient Philomena
condition/situation briefly. It will describe the ABCDE assessment done on the patient. The
assessment will be critically analyzed. Considering this is an evidence-based analysis, the
rationales for conclusions or interpretations made will be explained. The efficiency of the
assessment tool used to diagnose the patient will be evaluated. The interventions that will be
done will be explained giving a rationale as to why they were done. The rationales will be
evidence-based. The response given to patient Philomena will be assessed and analyzed. The
skills and the knowledge of the rapid responses given to a deteriorating patient’s condition will
be critically analyzed. The integration of ethical-legal principle and the care that patient
Philomena was given will be critically analyzed. Lastly, a summary of all the above will be
given. The writer will also give a critical opinion on the care given to patient Philomena.
Patient Philomena
Patient Philomena is eighty-five years old. She is a widow and she lives in a nursing
home. She has dementia so she requires help with all her daily living chores. Recently it has been
noted that she is less chatty and also she refuses to eat and drink. Today she was found more
confused than the normal days and she was unable to get out of bed. On examination by a
general practitioner, she was found to be having a urinary tract infection. She was rushed to the
hospital in an ambulance. She was admitted to a medical ward for further assessment. she is in
distress and very reluctant to care given to her. on observation, she is sweaty and pale and her
urine has a strong smell. Her vitals are as follows: her temperatures are at 38.6’ C, heart rate 118
beats per minute and the beats are weak, blood pressure of 96/52. The respiratory rate of 22

Sepsis and septic shock. 3
breaths per minute, oxygen saturation of 96%. On neurological assessment, she was alert
although she is disoriented and confused. She is allergic to penicillin.
Response
Identifying a deteriorating situation/condition for early management lies heavily on the
nurses (Collins et al., 2016 p. 54; Odell et al., 2011 p. 1998; Copper et al., 2012 p. 2309; Glynn
and Drake 2014 p. 100). The nurses working at the nursing home where Philomena stays are
skilled at identifying and managing deteriorating conditions. They observed that Philomena had
started to be socially withdrawn, refused to ate and became confused. They immediately called a
general practitioner as patient care is multidisciplinary (Witt et al., 2010, p. 35). After examining
the patient, she is rushed to the hospital using an ambulance. They did this after interpretation the
vital signs. The National Early Warning Score, (NEWS) Patient Philomena scored 10 which
indicated that her condition was emergent/urgent. They clearly showed that the patients’ life was
in danger as she was hypotensive, hyperventilating, hyperthermic, tachycardia with a weak pulse
and strongly scented urine which all indicated signs of septic shock. The response they took
indicates competence, responsibility, and accountability of the healthcare providers.
ABCDE assessment.
According to Olgers, Dijkstra, Drost-de Klerck, and Maaten, (2017) the ABCDE
approach is the primary assessment that is performed on injured or critically ill patients. It helps
in detecting life-threatening conditions early or timely for treatment/ resuscitation. The
interpretations of the ABCDE are important as they help in providing the lifesaving modalities. It

Sepsis and septic shock. 4
also helps in breaking down a complex clinical situation into a simple and manageable situation.
This indicates that the health care providers made the right choice by choosing this assessment
tool. With it, they will be able to detect the threatening factors and deal with them accordingly.
Airway assesses the patency of the airway. It is assessed first because its obstruction
causes severe hypoxia which can cause cardiac arrest. The assessment of the airway entails
examining the patient's voice, that is the patients’ ability to communicate verbally. The breathing
sounds are assessed. The skin color is assessed. When there is airway obstruction there are
changes in the patient’s voice, the patient produces noisy sounds and the patient uses accessory
muscles for breathing. this is as a result of the airway narrowing which makes it hard for the air
to rush in or out (Thim, Krarup, Grove and Lofgren, 2012, p. 3267). On the primary assessment
of Philomena, the findings on the above have not been mentioned this can indicate two things:
one, they were done and the results were insignificant. Two, it was not assessed. In nursing
without documentation it simply means it was not done (Hinkle & Cheever, 2013, p.56). This
reflects badly on the nurse’s competence which translates to poor quality in patient care, as
airway assessment is very important. As mentioned above if there is an obstruction and they
missed it, it can translate to cardiac arrest. In case there is deterioration, the patient can be put on
a mechanical ventilation to assist her in breathing.
Breathing is assessed through respiration rate, oxygen saturation, auscultation of the
lungs, chest symmetry and inspection of use of the axillary muscles for breathing. This
assessment is important as it helps in detecting inadequacy in breathing early hence timely
intervention to avoid complications. Inadequate breathing translates to inadequate tissue
perfusion which can result in cardiac arrest. Patient Philomena’s breathing rate is at 22 breaths
per minute (QSOFA=1 point). The normal range for an adult is 12 -18 breaths per minute so she

Sepsis and septic shock. 5
is hyperventilating (Hinkle & Cheever, 2013, p.56). Her oxygen saturation is at 96% at room
temperature this is sufficient as it is within normal range. Incase this deteriorates and the
breathing pathway gets blocked, she can be intubated. She can also be put on mechanical
ventilation to assist with the breathing.
The breathing assessment has so many gaps. The breathing assessment includes listening,
feeling, and looking for the general signs of respiratory distress. This includes abnormal
breathing and the use of accessory muscles for breathing. The respiration rate should be
determined. The depth of the breaths should be determined. The breath sounds should be
auscultated. From the assessment done on the patient Philomena the only findings obtained
included; the saturations of oxygen and the breath rates. All the rest were left. The patient is
hyperventilating although we have no information on whether she is using accessory muscles to
aid her in breathing. There is no information on the breath sounds and the depth of the breaths.
This shows that the patient care given is of poor quality and also the nurses attending are not
competent.
C-circulation, this is assessed through systolic and diastolic blood pressure, capillary
refill, the pulse rate, the extremities temperature feel, the mucosal membrane and capillary refill.
The assessment focusses on the circulation. Its assessment helps in detection of inadequate
perfusion early. This prevents organ death hence saves on life. Patient Philomena has a blood
pressure of 96/52 mmHg and a heart rate of 118 beats per minute (QSOFA= 1 point) The pulse is
weak. Patients Philomena skin is sweaty and flushed. All the above are indications that there is
inadequate tissue perfusion. This is life-threatening as it can cause cell death which in turn
causes organ

Sepsis and septic shock. 6
With this assessment, it is clear that the patient is in shock. Shock is the inability of the
body to achieve adequate perfusion of the tissues. This causes cell death, organ dysfunction
which translates to death. It has four stages, the initial stage, the compensatory stage, progressive
stage and lastly the irreversible stage ((Hinkle & Cheever, 2013, p. 106). The shock is probably
septic shock. Septic shock is as a result of sepsis. Sepsis is a multisystem organ dysfunction as a
result of infection in the host. The non-specific signs of sepsis include confusion, nausea, fever,
anxiety, and fatigue (Colledge, Walker & Ralston, 2013, p. 2315). Septic shock is common to
patients with Urinary tract infections, pneumonia, and gastrointestinal infection. Patient
Philomena presents with confusion. Her temperatures are at 38.9’c which indicates fever. She
has urinary tract infection (UTI). UTI can be as a result of descending or ascending infection. In
most cases in the older patients, the infection is usually as a result of Pseudomonas and/or
Escherichia coli (PFunter et al., 2011 p. 2; Wang et al., 2012 p. 20). In this case, it is the
probable cause sepsis. according to the National Institute for Health and Care Excellence
(NICE), (2016) patient, Philomena has sepsis. Her systolic blood pressure is less than 100mmHg.
Her heart rate is above 100beats per minute, she has a fever and she is confused.
The changes in the blood pressure and the heart rate can all be explained by septic
shock. The hypotension is as a result of vasodilation and the increased permeability of the
endothelium as a result of severe inflammation (McConnell & Coppersmith, 2016 p. 3). The
source of this sepsis is from the UTI. The cytokines produced induces production of nitrous
oxide through the endothelial damage. Nitrous oxide is a powerful vasodilator, this worsens
vasodilation. The endothelial regulatory mechanisms are damaged which renders them
dysfunctional. Despite increased catecholamine levels the vasodilation persists. The cytokines
reset the hypothalamus thermoregulation setting which gives the patient a fever. This is very

Sepsis and septic shock. 7
important as it a distinguishing feature in shock. Unlike the other type of shock where the patient
is cold and clammy, patients with septic shock experiences fevers (Kalil, 2018 p.8).
The assessment of the circulation system is indeed very important. Its assessment helps in
describing the patient’s condition in a nutshell. The interpretation of the assessment helps in:
one, coming up with a diagnosis. Two, formulation of the resuscitations strategy or the
interventions to be taken. This helps in saving a patient’s life by preventing complications. The
circulatory assessment was sufficiently done. The only findings that were missing was the
capillary refill and assessment for the cyanosis. This reflects good on the nurses as it shows that
they were competent which translates to high quality patient care.
D-disability assessment. This assessment entails assessing the level of consciousness of
an individual. The level of consciousness is assessed through AVPU (Alert, Verbal, Pain and
unresponsive). It can be assessed through the Glasco comma scale. It can be assessed through the
pupil reflexes to light, limb movement and the blood glucose levels. The level of consciousness
influences airway and breathing. It is also assessed through activities of daily living (Barrett,
Barman, and Boitano 2017, p.45). Patient Philomena is alert although she is confused and
disoriented. Her activities of daily living have been impaired. It was reported that she is being
assisted in doing everything. She even forgets to eat. This is as a result of dementia. Dementia is
a syndrome. It affects mental cognition. This affects the communication ability of a person. It
affects their performance of the daily activities and lastly, it causes confusion. All these renders a
patient disable. Patient Philomena has been rendered disabled by both dementia and the sepsis.
The missing points in this assessment included the measuring the glucose level, doing a
Glasgow comma scale to assess the level of consciousness in details. It also missed pupil
assessment and a review on the medication the patient was on. All the above are important as

Sepsis and septic shock. 8
they help in further determining the level of unconsciousness and in diagnosis. This shows that
the patient received high quality care and the nurses were competent.
E-exposure assessment. The key feature in this is the head to toe physical assessment and
the body temperatures. The physical assessment helps in detecting deep venous thrombosis,
trauma and skin reactions. It is important as it helps in early recognition/detection of
hyperthermia, hypothermia, allergic reaction and trauma. Patient Philomena experiences low-
grade fever, exposing her will help in regulating the temperatures. While exposing her, her
dignity should be observed and maintained (Hinkle & Cheever, 2013 p. 47). The report on
patient Philomena did not include a physical assessment. This shows that the assessment on
exposure was not properly done. This shows that the nurses were not competent. It also means
that the patients did not receive proper care and the nurses were not competent.
Assessment tools
The following assessments were carried out on patient Philomena: the vital signs as a
measure of stability. An ABCDE assessment, it has been explained above. The AVPU
assessment of the level of consciousness. History taking which helps in identifying the chief
complains and the characteristics of her symptoms. History taking accounts to over 80% when
diagnosing a patient (Hinkle & Cheever, 2013, p.67). It also helps in identifying medical
allergies The vital signs indicated that the patient has hypotension, tachycardia, hyperthermia,
and tachypnea. This indicates that the patient is vitally unstable and requires immediate
intervention. It is an alert alarm. The use of ABCDE as an assessment tool was helpful. With it, it
was possible to capture the low perfusion, patient’s disability, the tachypnea, and hyperthermia.
With this, it is possible to plan the resuscitation strategy. The AVPU assessment is useful when
assessing the level of consciousness of a patient. Patient Philomena is alert although she is

Sepsis and septic shock. 9
confused and disoriented. The measure of the level of consciousness is important as it indicates
whether a patient is disabled or not. It can also help in detection of airway and breathing
complication. An SBAR, assessment was done. qSOFA (Quick Sequential Organ Failure
Assessment) was done to assess the level of organ failure. The score indicated tissue perfusion
inadequacy with early tissue death.
The tools of assessment used were effective. The assessments done captured the patient’s
condition and situation although, the level of consciousness could have been assessed using a
Glasgow Coma scale. It would have described the level of consciousness in a more detailed
manner. Considering that Philomena has sepsis, a BUFALO assessment should have been done
in addition to qSOFA. The BUFALO assessment entails assessing the blood cultures, the urine
output measurement, the intravenous fluids, antibiotics, lactate measurements and oxygen
saturation. It was reported that the patient is less chatty, a Glasgow depression scale should be
done so as to assess patient’s depression. Early detection ensures timely response (Kreimeirer,
2016, p. 7).
Interventions
As mentioned earlier sepsis and septic shock is a medical emergency. Sepsis and/ or
septic shock that is not responsive to fluid therapy causes the death of every one patient out of
four. In the united states, every two patients out of a hundred admitted to a hospital have severe
sepsis. half of these patients are treated in the intensive care unit (ICU). This population accounts
for 10% of all ICU admission. Patients older than 65 years makes a total of about 50 % of ICU
admissions (Tiruvoipati et al. 2011 p. 56; El Sohl et al. 2013 p275; Starr and Saito 2014 p. 130).
Therefore, severe sepsis should be intervened promptly so as to reduce mortality and morbidity.

Sepsis and septic shock. 10
The major nursing diagnosis for a patient with severe sepsis and septic shock include one,
fluid volume deficit related to increased permeability of the intravascular system. Two, tissue
perfusion inadequacy. Three, metabolic acidosis as a result of renal failure (Hinkle & Cheever,
2013, p. 121). The intervention of severe sepsis and septic shock aims at correcting the
hypoperfusion, improving tissue perfusion, stabilizing the vitals of the patient and restoring the
patient’s consciousness (Angus and Van Dell, 2013, p.378). These are achieved through the
sepsis six within the first one hour. They include: administering oxygen, taking blood cultures,
giving IV antibiotics, giving fluids, checking serial lactates and measuring the urine output.
Patient Philomena has severe sepsis and she is in shock. This is deduced from her
circulation assessment, breathing assessment, disability and exposure assessment. As mentioned
earlier the sepsis is as a result of a urinary tract infection which probably was caused by
Escherichia coli or/and Pseudomonas (Rauen and Munro, 2015, p.66, Vaughan and Parry, 2016,
p.958). In the emergency department, the nurse reported that the patient needs to be started on
antibiotics to the doctors. She also reported that the blood culture samples should be interpreted.
This is important in determining the specific antibiotic to use after susceptibility test.
The patient should be started on fluid therapy. On the assessment of the circulatory
system, it indicated that her tissue perfusion is inadequate. Her blood pressure was at
96/52mmHg, heart rate at 118 beats per minute and it is weak which indicates that there is low
cardiac output. Her skin is pale and sweaty. Her urine smell is very strong which is an indication
that the urine is very concentrated as a result of dehydration and hypovolemia (Thim et al., 2012
p.3265). All this is as a result of sepsis which has caused vasodilation reducing the peripheral
resistance. The patient should be started on volume expanders for example 0.9% normal saline.
With this, the blood pressure will be increased by increasing the intravascular volume due to the

Sepsis and septic shock. 11
increased osmotic pressure. (Choi, Yip, Quinonez, & Cook, 2014, p.205). The NICE guidelines
indicate that the patient should be infused with 500ml of crystalloids bolus IV so as to increase
the blood pressure.
In addition to this; her renal output and lactate levels should be monitored. Two are a
measure of organ failure. A lactate level of more than 2mm/l indicates tissue perfusion
inadequacy. Lactate levels in the blood indicate the level of anaerobic respiration/ metabolism
which is as a result of reduced tissue perfusion. A urine output of less than 0.5mm/kg/hour
indicates renal failure as a result of tissue perfusion inadequacy (Barret, Barman and Boitana
2017, p. 109; Guyton 2015, p.77; Bridge and Duke, 2015, p.98; Gotts and Mathhay, 2016, p.
1585). The patient should be catheterized so as to monitor the urine output constantly. Constant
blood tests of lactate. The nurse at the emergency department advocated for catheterization
which shows they are competent.
Lastly, On the breathing assessment, her breathing rate is higher than normal. The high
breathing rate indicates sepsis as sepsis causes pain and anxiety. The oxygen saturation is 96%.
This is within the normal range as stipulated by the NICE guideline; 94-98%. Her case just
requires monitoring.
Ethical consideration
When intervening the patient condition. It is important to integrate the ethical principles.
The principle of beneficence was applied by the health care providers by; one, they called a
general practitioner noting that her condition was deteriorating. Two, she was rushed to the to the
emergency department after an assessment which revealed that she was in danger. This also

Sepsis and septic shock. 12
shows that the health care providers executed non-maleficence. Three, in the emergency unit, her
blood samples were taken for culture and the nurses consulted the doctors on the antibiotics and
fluids that she should be started on. Autonomy was also respected by trying to calm her so that
she can allow treatment as she was reluctant. The interventions were just as they followed the
sepsis resuscitations procedure (Terry, Carr and Halpin, 2017, p.60).
Conclusion
Acutely ill older patients require to be attended with dignity and promptly to avoid
complications as their conditions deteriorate quickly. The care of patient Philomena can be
reported to be of high quality although some aspects of care were left out. For example, in the
ABCDE assessment some key elements were not assessed. It was of the standard because one,
there was a prompt response. Two, she was assessed thoroughly. The assessments include the
ABCDE, AVPU, SBAR, QSOFA (Quick Sequential Organ Failure Assessment). All these were
important as they helped in diagnosis of the patient, in planning the patient care and
resuscitation. Three, the interventions are undertaken were in line with the NICE sepsis
guideline. These include antibiotic therapy, fluid resuscitation, lactate monitoring, renal
functioning evaluations and oxygen therapy. The patient is to be started on fluids, antibiotics and
to be catheterized. Four, while executing the interventions, they were integrated with the ethical
principles. The care was just and fair. The care providers observed the right of the patient to be
heard and lastly, the care provided aimed at benefiting the client and not harming her. the care
provided depicts the nurses as responsible, highly skilled, competent, committed and accountable
to their patients.

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References
Barrett, E., Barman, M., Boitano, S. (2017). Ganong’s Review of Medical Physiology.
(24th ed). New York, N.Y: McGraw Hill Medical.
Bridges, J. & Dukes, S. (2015). Cardiovascular aspects of septic shock: pathophysiology,
monitoring, and treatment. Critical Care Nurse, 25(2), 14-40.
Choi, P., Yip, G., Quinonez, L., & Cook, D. (2014). Crystalloids vs. colloids in fluid
resuscitation: A systematic review. Critical Care Medicine. 27(1), 200–209.
Colledge, N., Walker, R, & Ralston, S. (2013). Davidson’s Principles and Practice of
Medicine. (21st ed). New York, N.Y: Edinburgh.
Glynn, M. & Drake, W. (2014). Hutchinson’s Clinical Methods: an integrated approach
to clinical practice. London: Elsevier.
Gotts, J. & Matthay, M. (2016). Sepsis: pathophysiology and clinical management. The
British Medical Journal. 353(1). 1585.
Guyton, A. C. (2015). Textbook of Medical Physiology. (13th ed.). Philadelphia: W. B.
Saunders
Hinkle, J.L, Cheever, K.H. (2013). Brunner and Saddarth’s Textbook of Medical and
Surgical Nursing, (13th ed) Philadelphia, PA: Wolters Kluwer Health/Lippincott
Williams & Wilkins.

Sepsis and septic shock. 14
Kalil, A. (2018). Septic shock treatment and management. Medscape. Retrieved 19
March 2018, from https://emedicine.medscape.com/article/168402-treatment
Kreimeier, U. (2016). Pathophysiology of fluid imbalance. Critical Care, 4(2): S3–S7.
Kumar, A., Roberts, D., Wood, E., Light B., Parrillo E., Sharma, S., …, Cheang, M.
(2013). Duration of hypotension before initiation of effective antimicrobial therapy is the
critical determinant of survival in human septic shock. Critical Care Medicine.
34(6):1589-96.
McConnell, W. & Coopersmith, M. (2016). Pathophysiology of septic shock: from bench
to bedside. PubMed. Retrieved 19 March 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868872/
McKinley, M. G. (2014). Introduction to critical care nursing. (10th ed.). Philadelphia:
W. B. Saunders.
Olgers, T., Dijkstra, M., Drost-de Klerck, M., & Maaten, J. (2017). The ABCDE primary
assessment in the emergency department in medically ill patients; an observational pilot
study. The Netherlands Journal of Medicine, 2017(3).
Rauen, C. A., & Munro, N. (2015). AACN’s Clinical Reference for Critical Care
Nursing. (12th ed). New York, N.Y: McGraw-Hill
Thim T., Krarup, N., Grove, L. & Lofgren B. (2012). ABCDE – a systematic approach to
critically ill patients. International Journal of General Medicine.2010;172(47):3264–
3266.

Sepsis and septic shock. 15
Van der Vegt, A., Holman, M. & ter Maaten, J. (2012). The value of the clinical
impression in recognizing and treating sepsis patients in the emergency department.
European Journal of Emergency Medicine.19:373-8.
Vaughan, J. & Parry, A. (2016). Assessment and management of the septic patient: part
1. British Journal of Nursing. 25(17). Retrieved 19 March 2018, from
https://doi.org/10.12968/bjon.2016.25.17.958
Vaughan, J. & Parry, A. (2016). Assessment and management of the septic patient: part
2. British Journal of Nursing. 25(21). Retrieved 19 March 2018, from
https://doi.org/10.12968/bjon.2016.25.21.1196.
Vincent, L., Ferreira, L., (2016). Evaluation of organ failure: We are making progress.
Intensive Care Medicine, 26(6), 1023– 1024
Terry, L., Carr, G., Halpin, Y., (2017). Understanding and meeting your legal
responsibility as a nurse. Nursing standards. 32(12) 52-62.
National Institute of Health and Care Excellence, (2017). Sepsis recognition diagnosis
and early management. accessed 17th April 2018.
Collins T., Price A., and Angrave P., (2011). Pre-registration education on making a
difference to critical care. Nursing in critical care. 11(1), 52-57.
Cooper S., et al. (2011). Managing the deteriorating patients in a simulated environment:
nurse students’ knowledge, skills and situation awareness. Journal of clinical nursing. 19,
2309-2318.

Sepsis and septic shock. 16
Odelle M., et al. (2014). Nurses’ role in detecting deterioration in ward patients: a
systematic literature review. Journal of advanced nursing. 65(10), 1992-2006.
Witt S., Borden S., and York N., (2011). Stimulating rapid response in undergraduate
critical care education. Dimensions of critical care nursing. 29(1), 33-38.
PFunter A, Wier LM, Stocks C., 2011. Most Frequent Conditions in US Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality.
Wier LM, PFunter A, Steiner C. (2012). Hospital Utilization Among Oldest Adults,
Rockville, MD: Agency for Healthcare Research and Quality.
Starr ME, Saito H. (2014) Sepsis in old age: a review of human and animal studies.
Aging Diseases; 5(2):126-136.
Tiruvoipati R, Ong K, Gangopadhyay H, Arora S, Carney I, Botha J. (2011).
Hypothermia predicts mortality in critically ill elderly patients with sepsis. BMC
Geriatric.
El Sohl AA, Akinnusi ME, Alsawalha LN, Pineda LA. (2013). The outcome of septic
shock in older adults after implementation of the sepsis “bundle.” J Am Geriatric Soc.
56:272-278.