Sepsis Case Studies

Competency Development:

1. Reflection on demonstrating competence in caring for the patient with

Impaired and/or altered haemostatic function.

In one of the meetings with the mentor regarding altered and/or impaired homeostatic function, a case study of a patient admitted with sepsis was discussed. Assessment, care and evolving treatment provided was looked into. Following the discussion, the management of sepsis has been examined further by the learner as she was not familiar with the bundle of six sepsis mentioned by the mentor. The learner looked on the situation and reflected back on the occurrence that took place realizing if appropriate measures were implemented and how things can be different in future practice (Schon, 1987). This

is called “reflecting on action”, a kind of reflection introduced by Schon (1987). It is not a choice between theory and experience but it is the assimilation and combination of the two in practice to develop professionally (Fullan and Hargreaves, 2000) and better our decision-making in delivering safe care.
To know more about sepsis six, the learner has decided to look onto data base and read more about it.

Daniels (2011) said that sepsis is one of the leading causes of death in hospital patient worldwide and severe sepsis causes around 37,000 deaths in the UK every year. Czura (2011) has defined it as a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs and sepsis can be present in any patient and in any clinical setting. Based on the learner’s reading, she became aware of the importance of identifying the early inflammatory markers such as temperature less than 36 degrees or more than 38.3 degrees, heart rate greater than 90 beats per minute (bpm), respiratory rate greater than 20 breaths/minute, altered mental state, white cell count lesser than 4g/l or greater than 12g/l and blood glucose greater than 7.7 millimoles for non-diabetic patients. Presence of any two of these will follow further test and if sepsis is indicated then commence the sepsis six care bundle within the hour, contact the doctor and critical care outreach team. The sepsis six care bundle which was developed by Daniels et al (2010) has shown to improve delivery of reliable care across a range of clinical settings which is now used in many UK

hospitals.
The author has realized that as nurses play a vital role in identifying patients with sepsis and starting essential treatment (McClelland & Moxon, 2014), it is important that nurses raise awareness on the best available evidence and new guidelines to
Improve both the identification of patients at risk of developing severe sepsis and the delivery of early treatment. The competency, knowledge and experience gained from sepsis has altered the learner’s practice. The learner is now proactive in responding to systemic inflammatory response syndrome (SIRS) or sepsis. Now upon identification of symptoms of infection (SSI), patient is commence quickly on sepsis pathway (Daniels, 2011). Early identification following clear guidance and implementation of evidence-based care can prevent deterioration and reduce mortality among patients with sepsis. Good dissemination of information and accessibility of guidelines will also be suggested to the PDN ex. to provide copies of sepsis screening tool and the sepsis six care bundle on every pod and to ensure every member of the team are aware where the file is located.

2. Demonstrate competence in assessing and managing the care of patient with a
Neuroendocrine disorder and / or deterioration of neuroendocrine function.
The learner was assigned to look after a 60 years old male neurological patient who developed hydrocephalus and had a lumbar drain inserted. The patient was a level three but very stable. This was an uncomfortable situation for the learner as her knowledge is very limited with neurological patient care especially with these type of drain. This reminded the learner of being a level of a novice (Benner, 2) in this situation, thus requiring the learner’s need to ask for her mentor help & guidance in the management of the patient particularly in the monitoring of patient with a lumbar drain. The realization of the learner’s weakness in this area led her to “reflect-in-action”. This is the capacity to learn and grow consistently by innovatively applying present and past encounters and thinking to new situations while they are happening (Schon, 1987). The learner also made time to read further on the pathophysiology of the nervous system and the care and management of particular patient.
The placement of a lumbar drain device (LDD) as stated by Sade et al (2006), Van aken et al (2004) and Vourc’h (1963), is an acceptable medical therapy for the treatment of postoperative or traumatic dural arteriovenous fistulas such as cerebrospinal fluid (CSF) leak, Pudenz (1989) and Thompson (2000) also added that LDD placement is to treat occurrence of shunt infections.

It is also placed for diagnostic evaluation of idiopathic normal pressure hydrocephalus according to Marmarou (2005). Hydrocephalus as defined by Sheppard & Wright (2006) is an abnormal increase in the volume of CSF within the brain. LDD placement is also used to reduce intracranial pressure (ICP) during craniotomy according to Grady et al (1999) and Samadani et al (2003) and as adjuvant therapy in the management of traumatically brain-injured patients added by Munch et al (2001). The knowledge gained from reading books and articles and the skills acquired and enhanced during the process of mentoring developed the confidence of the learner in looking after particular patient. To complete competency in this area and to advance knowledge and skills, it was suggested that learner have to increase exposure to particular patient group. This is experiential learning (learning by doing) recommended by Kolb (1984) where through repeated encounters thoughts are framed and modified. This support the advancement of the learner from ‘novice to expert’ (Benner, 1984) that occur as part of professional development.

To avoid the same occurrence in the future, the learner will feedback occurrence to PDN for a possible resolution to make learning more accessible and standardized based on national guidelines.