The nurse is responsible to apply knowledge and identify a possible complication including sepsis before it needlessly progresses. Do this and a life can be saved.
Unfortunately, the converse is also true. If the bedside nurse fails to recognize a complication until it is too late, the same patient could experience needless complications and could even die as a result (see last week’s blog and the implications of failure to rescue).
This is the incredible responsibility that every nurse must embrace once in practice. When four words that begin with “T” are recognized and three simple questions are answered by the nurse, this will provide practical guidance to RECOGNIZE and IDENTIFY sepsis EARLY before it needlessly progresses with potentially disastrous consequences.
The Four T’s
There are four words that begin with the letter “T” that will help any nurse recognize and identify sepsis EARLY before it progresses to septic shock and possible death:
- TREND relevant clinical data
- Temperature
- Tachycardia
- Tachypnea
It is not enough to simply remember these four T’s! The nurse must also UNDERSTAND the pathophysiology and the significance these symptoms represent.
Let’s explore each of these symptoms in additional depth:
1. TREND relevant clinical data
Identifying the MOST important clinical data and TRENDING it by comparing it to the most recent data is an essential component of clinical reasoning and thinking like a nurse in practice. Because students tend to see ALL clinical data as relevant, as a new nurse they will struggle to sort out the least from that data that is most important (Benner, 1984).
In order to “rescue” a patient with a change in status, the nurse must be able to recognize EARLY yet SUBTLE changes in a patient’s condition over time. In addition to trending VS and nursing assessment data, laboratory values and the response to nursing interventions must also be consistently compared and trended.
When it comes to sepsis, the following VS assessments are ALWAYS relevant and must be TRENDED from the most recent to the current to determine the DIRECTION that your patient is heading. Let’s go deeper and not just restate SIRS criteria, but be able to state the WHY or rationale for the significance of these positive SIRS criteria in the context of sepsis.
2. Temperature
WHY is the temperature elevated (>100.9) or can even be hypothermic (<96.8) and be clinically significant in sepsis? The body was designed to elevate its set point thermostat in order to do two things: increase the production of neutrophils that serve as “pacman” phagocytes within several hours of a bacterial invasion.
Secondly, to make the body a less susceptible host by making it more difficult for bacteria to thrive and multiply. Hypothermia is an abnormal response but expected with those with a weakened immune system most commonly seen with the very young (<2 months) and the elderly.
3. Tachycardia
WHY does the HR elevate from baseline in any volume depleted or shock state? When this formula is applied, the answer is obvious. To maintain cardiac output and perfusion to all cells, the HR will ELEVATE as the FIRST and EARLIEST compensatory response and maintain BP. This is WHY tachycardia (>90) without an obvious clinical indication (fever, pain, etc) is ALWAYS a clinical RED FLAG that must be recognized by the nurse.
Commit to DEEPLY understand this foundational pathophysiology formula to clinical practice: CO=SVxHR (see prior blog on cardiac output).
4. Tachypnea
When any shock state is understood, the significance of tachypnea or RR >20/minute becomes apparent. When a patient begins to slide into septic shock, perfusion and oxygenation to the cells is impaired. Just as tachycardia is a compensatory response to the problem of PERFUSION, tachypnea is a compensatory response to the problem of OXYGENATION.
The RR increases in order to increase oxygenation to the cells that are not being adequately perfused.
What about BP?
Does BP matter in sepsis progressing to septic shock?
Absolutely. But it is a LATE finding and if the nurse recognizes a problem only when the BP has dropped precipitously, it may be too late! Therefore recognize the significance of hypotension, but catch any shock state BEFORE it gets to this point is the point of SAFE nursing care.
Screening for Sepsis. As Simple as 1, 2, 3
Sepsis can be screened by the bedside nurse. Here is the essence of a hospital based screening tool that can empower the bedside nurse in any setting to identify sepsis and know when to initiate a rapid response team (RRT) activation if available in your facility.
Question #1: Does your patient have hypotension? (SBP <90 or MAP <65). If yes, go to question #3, if no, go to question #2.
Question #2: Does your patient have two or more of the following SIRS criteria:
- HR >90/minute
- RR >20/minute
- Temperature >100.9 F (38.3 C) or <96.8 F (36 C)
- WBC >12 or <4 or 10% bands
- Newly altered mental status
Question #3: Do you suspect that your patient may have a new or worsening infection? Only one of the following patient symptoms below is needed to confirm a “suspected infection”
- Generalized symptoms. Shaking, chills, new weakness, lethargy, headache or neck stiffness
- Respiratory symptoms. Cough, SOB, increasing O2 needs or decreasing O2 saturation
- Urinary symptoms. New pain w/urination, new onset of flank pain, Foley catheter in place >48 hours
- GI symptoms. New abdominal pain, diarrhea
- Skin/wound symptoms. New drainage, redness, or rash
- Bone/joint symptoms. Red, warm, or swollen joint
- Central IV or PICC in place >48 hours
Putting it all Together
If your patient has hypotension (#1) and any positive sign of suspected infection in #3, STOP and page a RRT or contact the primary care provider! This is a POSITIVE screen for sepsis.
If your patient had two or more SIRS criteria (#2), and any positive sign of suspected infection in #3, STOP! Sepsis has just been identified and it is time to page a RRT or notify the primary care provider!
Common Pitfalls in Practice
I work at a hospital with an excellent rapid response team! I asked my colleagues what are the most common errors in clinical judgment by nurses they experience in the context of sepsis that we can all learn from:
- Did not intentionally TREND vital signs. As a result, the nurse failed to recognize an EARLY change in status that included NEW tachycardia/tachypnea.
- Rigid thinking. Tachycardia/tachypnea that was not recognized.
- Looked at clinical data in isolation and did not cluster. When patient spikes a temperature for example, the nurse pages RRT, even though all other VS parameters are normal.
In Closing
Make it a priority to assess your soon to graduate nursing students ability to “rescue” by recognizing and identify sepsis through the use of my sepsis clinical reasoning case studies that can provide needed PRACTICE of clinical reasoning.
Nurse educators have a responsibility to not just prepare students for the NCLEX®, but applying content and clinical reasoning to the bedside.
Though resources such as the sepsis screening tool can be helpful to identify the presence of sepsis, this is not enough! The nurse must also be able to clinically reason by identifying the rationale of RELEVANT clinical data, current nursing PRIORITY, and capture the ESSENCE of the current scenario to put the entire clinical picture together.
When this level of nurse thinking is present, adverse complications are recognized early, patient outcomes are improved, and even lives can be saved. This is how every nurse can not only make a difference, but can be a superhero at the bedside!
What do you think?
How are you practically preparing your students to identify and recognize sepsis in clinical practice?
Comment below and let the conversation begin!
RELEVANT YouTubes to Check Out!
If you are a visual learner, I have a YouTube channel THINK Like a Nurse that has videos I have posted that supplement today’s topic:
References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
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