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At 7:55 am, the RRT nurse was on the floor and obtained report from Betty. At this time, A.R. stated that she didn’t know what was wrong, but she did not feel well. Betty hung the normal saline bolus and drew the blood out of A.R.’s central line. The RRT nurse continued to assess A.R. Per protocol, the RRT nurse began to administer Dopamine. A.R.’s blood pressure was down to 70/30 and was becoming hard to auscultate. After the blood pressure did not improve with fluids or Dopamine, Levophed was initiated. The cardiac monitor showed sinus tachycardia at 135 bpm. A.R. began to vomit again and become confused. Betty leaves the RRT nurse to tend to A.R. while she pages the surgeon again. While coming back from the nurses’ station, Betty sees A.R’s mom and husband in the hallway. Betty tells them that A.R.’s condition has changed and that she has an intensive care (ICU) nurse helping to get her stabilized. A.R.’s mom and husband become extremely upset and Betty asks another nurse to help the RRT nurse while she speaks with the family. At 8:30 am the surgeon arrives and transfers the patient to the ICU. At this time, A.R. is maxed out on Dopamine and Levophed. Her blood pressure is 65/30, heart rate 145, respiratory rate 31, oxygen saturation 90% on 100% nonrebreather, temperature 101.9 F. The CBC came back and showed a WBC of 21. Two days prior the WBC was 8. Her potassium was 5.6. The surgeon ordered several antibiotics and spoke with the family about taking her back to surgery to drain her abdominal wound. He also felt that the source of infection could be from her central line catheter. At 8:45 am the patient arrived in ICU. Betty gave report to the ICU nurse and then went to speak with the family in the waiting room. Betty apologized for not calling them and they said they understood. A.R.’s mom stated that she appreciated Betty doing everything she could to try to stabilize her daughter. At 9:30 am, Betty realized she forgot to send some of A.R.’s medications down to the ICU. When Betty brought the medications to ICU she saw that A.R.’s room was empty and she assumed they took her to surgery. Betty saw the ICU nurse and told her she had medications for A.R. The ICU nurse told Betty that won’t be necessary because A.R. had passed away. She went into ventricular tachycardia upon arrival to the operating room (OR). When the OR staff transferred her to the OR table, she went into ventricular fibrillation and they were not able to resuscitate her. Septic patients can change very quickly and it’s important to recognize the signs and symptoms as soon as possible. Early recognition leads to better outcomes and reduces the mortality rate. The next section discusses the case study and how the Synergy Model and the treatment plan could have improved the outcome of this patient. Application of Evidence-based Practice and Synergy Model In the above case study, early recognition of sepsis was not apparent. This patient was in septic shock before interventions started to take place. Vital signs were assessed and some pertinent lab data were obtained. Once treatment began, it was appropriate. The RRT nurse started with fluid resuscitation and then added vassopressors. By starting Dopamine first, she followed evidence-based practice guidelines established in Surviving Sepsis Campaign (Kaplow & Hardin, 2007). According to the Synergy Model, A.R. was in the middle of the continuum for resiliency at the beginning of the illness. She mounted a moderate response, had some degree of compensation, and had moderate reserves. This quickly changed and by the morning she was minimally resilient. A.R. had moderate vulnerability because she was somewhat susceptible and somewhat protected. She was moderately stable because she was able to maintain a steady state for a period of time; however, by the morning she was minimally stable. A.R. was moderately complex because she had an entanglement of two or more systems and her family was moderately involved. A.R. had many resources such as her own knowledge base, her family, and work friends. She exhibited full participation in her care and decision making; however, by morning she was not able to make decisions for herself. A.R. demonstrated moderate predictability. She was doing well, but then became ill. She was an abdominal surgical patient and that’s one of the groups that are at risk for sepsis complications (Kaplow & Hardin, 2007). A.R. was in the middle of the continuum and then quickly changed to critical by morning. She needed a nurse that was strong in clinical judgment, advocacy, systems thinking, and collaboration. Nikki and Betty were both strong in clinical judgment. Nikki realized something was wrong and notified the surgeon. Betty realized the situation was deteriorating and called the surgeon and RRT nurse. Both Nikki and Betty were strong in advocacy because they advocated the patient’s needs to the surgeon and RRT nurse. Both nurses were strong in caring practices because they not only met the current needs of the patient; they both looked at future needs and problems. Nikki and Betty were in the middle of the continuum with collaboration. Nikki collaborated with the surgeon about A.R.’s plan of care. She also showed openness by discussing her actions and concerns with Betty at the change of shift. Betty showed collaboration by working with the surgeon and the RRT nurse (Kaplow & Hardin, 2007).
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