NRS312 - Sepsis Management: A Case Study Critique of Lily Caratti

This case study critically examines the scenario of Mrs. Lily Caratti, an 82-year-old patient admitted with a small bowel obstruction who subsequently develops severe sepsis. The analysis focuses on the recognition of deterioration, escalation protocols, and the appropriateness of nursing interventions. It highlights the importance of accurate vital sign interpretation, the effective use of the ISBAR communication framework for clinical handover, and evidence-based nursing practices in managing sepsis, including infection control and maintaining adequate tissue perfusion. The study concludes by emphasizing the need for comprehensive training and adherence to established protocols to improve patient outcomes in similar cases.

Scenario Critique of a
Patient with Sepsis

Table of Contents
INTRODUCTION...........................................................................................................................1
1. Recognition of deterioration in the case of Mrs Lily Caratti..................................................1
Escalation of deterioration in the case of Mrs Lily Caratti.........................................................2
Management of deterioration in Mrs Lily’s case........................................................................4
REFERENCES................................................................................................................................6

INTRODUCTION
Sepsis is a serious health condition that happens when an infection that have triggered by
patients and in which a chain reaction throughput patient’s body (Cecconi and et.al., 2018).
Infections that are being untreated lead sepsis. This present study is based on an 82-year-old
retired librarian who has been diagnosed with bowel obstruction. This present study is going to
discuss condition of Mrs Lilly on the basis of vital signs that were observed after her diagnosis
of bowel obstruction. Further, it will discuss escalation of deterioration as well as reasons of
situations worsening of Lilly and ways in which she should have been treated. It will discuss
roles of nurses in treating severe sepsis and ways in which they can use nursing interventions for
treating patients with severe sepsis. ISBAR patient’s information communication framework
also plays a vital role in clinical handover.
1. Recognition of deterioration in the case of Mrs Lily Caratti
Before discussing about condition of Mrs Lily, it is important to know about her and in this
context, it can be said that she is an 82-year-old retired librarian who was admitted to the
surgical ward with diagnosis of small bowel obstruction
Clinical indicators: For knowing about current condition, her vital signs were measured
and clinical indicators suggest:
Blood pressure: 135/84 mmHg: The ideal blood pressure for women 80 and above is: 120/80
and if it is measured around 130-139/80 then it is considered as hypertension. So, on the basis of
this, it can be said that Mrs Lily Caratti is at stage 1 of hypertension.
HR 78 bpm: It is found that normal heart rate for woman of 70 and above is 75-128 and on this
basis, it can be said that het heart rate is normal (Catena and et.al., 2019).
RR 18 bpm: 12-18 respiratory is considered as normal range for 80 and above age of women
and accordingly, it can be said that Mrs Lily is not suffering from any heart and respiratory
problem.
Temp 36.5°C: An average temperature is 37° and there is just minor difference between normal
and actual temperature of Mrs lily so, there is no need to worry.
Sats: 99% (RA): Normal oxygen saturation level is 97-100% and Mrs Lily’s Sats is 99% that is
absolutely fine.
Pain 5-6 /10: Pain range is 5-6 out of 10 and it is more than 50% and it can be unbearable if it is
not treated. The reason behind this pain range is bowel obstruction.
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BGL 4.9 mmol/L: Normal blood sugar for 80 and above age of women is 4-6.
Justification: On the basis of above clinical indicators, it can be said that Mrs Lily needs to be
treated with hypertension and high blood pressure.
Pathophysiological changes that occur with severe sepsis: It is stated that Mrs Lily is treated
with Ramipril for hypertension. She takes 4-5 glasses wine per week that is too much and it can
affect her post bowel obstruction surgery and can increase severe problems. As after knowing
her medical condition, she was transferred to theatre for laparoscopy and after that she was
admitted to surgery unit. As it is found from 1-2 days of observation that she is suffering from
severe sepsis. Some changes that have been encountered after sepsis identification include:
confusion, increased work of breathing, slight confusion as she is unable to recognise as where
she is. Ran long to be pale and NGT was also located in the left main bronchus. After sepsis
identification her last clinical documentation indicate: 183/92 BP that was more than normal,
respiratory rate was 26 that was also high, temperature was 36.5 that was normal and SAO was
93% that was not normal (Gyawali, Ramakrishna and Dhamoon, 2019). So, on the basis of these
changes it can be said that Mrs Lily was required to be treated in an effective manner as she was
not treated and being given medication that she was required after identification of bowel
obstruction and high blood pressure as well as hypertension problem. Her daughter Melanie told
to Doctor or specialist that she has never seen her mother in this condition as her mother is
facing problems in identifying as where is she and her confusion increasing fear. After her
request, doctor send her mother for further tests and after that they came to know that Mrs Lily
is suffering from severe sepsis (Nardo and et.al., 2021).
Escalation of deterioration in the case of Mrs Lily Caratti
As it is known that Mrs Lily’s health condition was getting worsen day by day. As on the
date of 02/02/2021, her vital signs were almost normal but very next day and on 03/02/2021, she
her condition became worse as she was unable in recognising as where is she (Haddeland and
et.al., 2022). When she states that she is unable to get as which place is she then also nurses did
not take any action regarding this. RN long respond to hearing Mrs Caratti coughing.
Strengths and weakness of the way ISBAR clinical handover has been structured: In
regard to clinical handover, it can be said that it is one of the most critical steps in patient’s
journey and it is a core skill that needs to be taught to health professional students as well as
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junior students. ISBAR framework stands for: introduction, situation, background, assessment
and recommendation (Battula and et.al., 2021). In regard to its strengths, it can be said that it
works well when all students and professionals are trained and they have knowledge about ways
of using this. In this context, it can be said that by using this framework, clinical professionals
can let other professionals know about current situation of patient that has been handover to
them. It enables health care professional, who is one duty, know about their condition and
accordingly, they can take decision regarding medical treatment.
On the other hand, it is found that poor trained professionals and students cannot use this
framework and it leads problems. They may find unable in deciding the best treatment for
patients who have been handover to them. Due to this reason, they may find unable in improving
health of patient and reason of poor health as well as escalation of deterioration of patient’s
health. There are no doubts as it is being structured for communicating about patients’ details so
that they can be provided with appropriate treatment and medications.
In regard to the case of Mrs Lily, it is found that DR Walker was the surgeon who
ordered that NGT did not need to be reinserted and she could commence on clear fluid diet and
there was no nausea she could progress to a light diet. After that Mrs Lily met with her daughter
and her daughter notices that her mother is breathing quite fast and her consciousness level has
changed (Mijares, 2021). She became nervous and she talked to RN Sarah who was looking
after Mrs Caratti. She stated that she did not look after her mother before and now she is handed
over and it is the reason as she did not know much about Mrs Lily. So, on the basis of this, it can
be said that due to lack of knowledge regarding using and getting information from ISBAR
framework, she did not take care of Mrs Lily in the way she needed to be. It is the reason of her
escalation of deterioration.
Adequacy of ways the nurse escalated the care of deteriorating patient: In this regard, it can
be said that RN Sarah to whom Mrs Lily was handed over, could take care of her in an effective
manner. She should have read out all the information, mentioned in the document of Mrs Lily by
using ISBAR framework. What she did on the request of daughter of Mrs’ Lily’s daughter was
measuring vital signs. From her vital sign it is found that her blood pressure was 183/ 92 mmHg,
respiratory level was 26 bpm, temperature was 36.5 °c.
Improvements that nurse could make to escalate person with clinical deterioration: After
taking measurements and vital signs, RN Sarah stated to Melanine that her mother’s vital signs
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are normal because of her age. But Melanine was still concerned and she requested to review her
mother and on her request, she asked her to contact DR LY. The thing that she could have done
as a nurse was: contacting immediately to specialist and she should have told everything about
condition of Mrs Lily. She did not take care of her and also she stated that her vital signs were
normal but her vital signs showed that she may be suffering from sepsis and other severe disease
(Basu, Orr and Aktas, 2020).
Management of deterioration in Mrs Lily’s case
As on the basis of above discussion, it can be said that Mrs Lily was needed to be taken care in
an effective manner as her vital signs was taken for many of the time and it is known from her
signs that she was suffering from hypertension and sepsis.
Analysis of nursing care: It is known by DR LY, Surgical registrar that Mrs Lily was suffering
from severe sepsis. She has high blood pressure of 183 mm/Hg, irregular heart rate and high
oxygen saturation on room air. She is confused about where she is but know her name and her
daughter’s name. After knowing about her high blood pressure and her confusion mind state,
nurses and all healthcare professionals including: Jackson, Jayden and Sarah should have
focused on elimination of infection, maintaining adequate tissue perfusion, providing accurate
information about disease process and treatment needs (Gardiner and et.al., 2020).
Evidence based nursing interventions: Some common nursing interventions for severe sepsis
and high blood pressure include: accessing client for possible source of infection including:
urination, localised abdominal pain, open wounds, burns and invasive catheters. In regard to
sepsis, it is found that urinary tract infection and respiratory tract that is followed by abdominal
infection and is one of the main reasons of sepsis. In regard to Mrs Lily, it can be said that she
was diagnosed with bowel obstruction and after that NGT was also removed. So, it was
important for nurses to take extra care of Mrs Lily and identify infection that may cause by
abdominal pain and removal of NGT.
Maintaining sterile technique when changing dressing, providing site care and suctioning
is other effective nursing intervention that can also protect patient from severe sepsis and other
complex situations (Moore and et.al., 2019. Improving 3-hour sepsis bundled care outcomes:
implementation of a Nurse-Driven). This intervention can help out nurses and healthcare
professional in knowing infection type and decreasing the risk of nosocomial infection. Along
with this, it is important for nurses to encourage client to cover mouth and nose with tissue when
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coughing and sneezing. By taking vital signs on regular basis, patient’s temperature level, heart
rate, respiratory and other levels can be known.
CONCLUSION
It has been summarised from the above study that small bowel obstruction can lead
number of problems. Abdominal pain and this obstruction can lead infection that may cause
number of serious problems. It has also been found that for knowing current situation of patient,
nurses need to take or measure vital signs so that they can identify effectiveness of relevant
human body organs and systems. It has discussed some reasons of severe sepsis such as:
bacterial infection. When bacterial infection does not being treated in a timely manner then it
leads problems like sepsis and it damages other tissues. Severe sepsis cause number of other
problems and for improving health, healthcare professionals need to train nurses and others
regarding using ISBAR patients’ communication framework. This framework plays a vital role
in making clinical handover successful as it enables healthcare professionals to whom patients
are being handover, to know all about patient and take better decision regarding medical
treatment.
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REFERENCES
Books and Journals
Basu, S., Orr, S.A. and Aktas, Y.D., 2020. A geological perspective on climate change and
building stone deterioration in London: Implications for urban stone-built heritage
research and management. Atmosphere. 11(8). p.788.
Battula, V. and et.al., 2021. Safety and Feasibility of Antibiotic De-escalation in Critically Ill
Children With Sepsis–A Prospective Analytical Study From a Pediatric ICU. Frontiers
in Pediatrics. 9. p.640857.
Catena, F. and et.al., 2019. Bowel obstruction: a narrative review for all physicians. World
Journal of Emergency Surgery. 14(1). pp.1-8.
Cecconi, M. and et.al., 2018. Sepsis and septic shock. The Lancet, 392(10141), pp.75-87.
Gardiner, C. and et.al., 2020. What is the prevalence of loneliness amongst older people living
in residential and nursing care homes? A systematic review and meta-analysis. Age and
Ageing. 49(5). pp.748-757.
Gyawali, B., Ramakrishna, K. and Dhamoon, A.S., 2019. Sepsis: The evolution in definition,
pathophysiology, and management. SAGE open medicine. 7. p.2050312119835043.
Haddeland, K. and et.al., 2022. Experiences of using the ISBAR tool after an intervention: A
focus group study among critical care nurses and anaesthesiologists. Intensive and
Critical Care Nursing, p.103195.
Mijares, M., 2021. Improving Patient Hand-off Communication by Utilizing the Situation-
Background-Assessment-Recommendation (SBAR) Tool between the Perioperative
Services Departments.
Moore, W.R. and et.al., 2019. Improving 3-hour sepsis bundled care outcomes: implementation
of a Nurse-Driven sepsis protocol in the emergency department. Journal of emergency
nursing. 45(6). pp.690-698.
Nardo, A.D. and et.al., 2021. Pathophysiological mechanisms of liver injury in COVID‐
19. Liver International. 41(1). pp.20-32.
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