NUR 540 Module 7 Final Project Milestone Two Example

Milestone Two: Decisions, Technology and Treatment in the First Six Hours of Sepsis in a 79-Year-Old

[Student Name]

Southern New Hampshire University

NUR 540: Advanced Pathophysiology Across the Life Span

Final Project Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Decisions, Technology and Treatment in the First Six Hours of Sepsis in a 79-Year-Old

Milestone One explained how a 79-year-old's pneumonia became sepsis through a dysregulated host response that dilated and damaged blood vessels, activated clotting and starved cells of usable energy. This milestone follows the same patient through the first six hours of care. Its decisions are arranged under the four phases Tanner (2006) found in expert nurses' judgment, noticing, interpreting, responding and reflecting, then describes the technology that informed them and the rationale for each treatment. It argues that every early decision in sepsis is a response to a specific mechanism, and that current guidelines are best understood as a list of those mechanisms and the interventions that interrupt them.

Noticing and Interpreting

The triage nurse noticed a pattern rather than a single number: confusion in an older adult, a respiratory rate of 26, a systolic pressure below 90 and a fever that was only modest. The hospital's electronic sepsis alert fired on the same data. Current guidance recommends against using the quick SOFA score alone as a screening tool, because it misses many patients with sepsis, and supports screening with broader tools such as early warning scores (Evans et al., 2021). The nurse's recognition that confusion in this patient was new, not baseline, was the most important interpretive step; a neighbor's report that the patient had been fully independent two days earlier made the change unmistakable.

Interpretation continued with the first results. A lactate of 3.4 mmol/L indicated cellular stress and hypoperfusion; a creatinine of 2.1 mg/dL against a baseline of 1.3 indicated acute kidney injury; platelets of 118,000/mm³ suggested early consumption. Together with the organ dysfunction score calculated in Milestone One, these confirmed sepsis and raised the question of shock.

Technology in Diagnosis and Monitoring

Table 1 lists the main technologies used and what each contributed.

Table 1

Technologies Used in the First Six Hours and Their Contribution

Note. Composite case.

Responding: Antibiotics and Source

The mechanism of sepsis begins with a pathogen, so removing the pathogen comes first. When shock is possible or sepsis is probable in an adult, the Surviving Sepsis Campaign recommends starting antimicrobials without delay, with a one-hour goal counted from recognition, after blood cultures are drawn if that causes no substantial delay (Evans et al., 2021). Two sets of blood cultures were drawn, and ceftriaxone with azithromycin was infused 45 minutes after arrival. That combination follows the guideline for severe community-acquired pneumonia treated in hospital, a beta-lactam plus a macrolide, which covers pneumococcus and atypical organisms (Metlay et al., 2019). The dose of each drug was checked against the patient's reduced kidney function. The source, a lobar pneumonia, needed no drainage.

Responding: Fluids and Vasopressors

The second target is the circulation. Vasodilation and capillary leak had lowered effective volume and vascular tone. For sepsis-induced hypoperfusion, the guideline suggests at least 30 mL/kg of intravenous crystalloid within the first three hours and prefers balanced crystalloids to saline (Evans et al., 2021). At 68 kg, the patient received about 2 liters of lactated Ringer's solution over two and a half hours. Because of the patient's age and kidney disease, the team reassessed after each liter using the passive leg raise, lung sounds and oxygen needs rather than giving the full volume blindly. After the second liter, a passive leg raise no longer increased stroke volume, showing that more fluid would add to capillary leak and lung water without improving output.

The mean arterial pressure remained at 60 mm Hg. Norepinephrine, the recommended first-line vasopressor, was started through a well-placed peripheral line rather than waiting for central access, as the guideline allows, and titrated to a mean of 65 (Evans et al., 2021). Norepinephrine counters the vasodilation of sepsis mainly through alpha-1 receptor vasoconstriction, with modest beta-1 support of the heart. With a vasopressor needed and a repeat lactate of 3.9 mmol/L after fluids, the patient now met the Sepsis-3 criteria for septic shock (Singer et al., 2016).

Responding: Oxygen, Steroids and Supportive Care

Oxygen was escalated to high-flow nasal cannula, targeting a saturation in the low to mid 90s, to treat the shunt caused by consolidated lung. By the fourth hour, norepinephrine had reached 0.25 mcg/kg/min, and hydrocortisone 200 mg per day was added, as suggested for adults with septic shock and an ongoing vasopressor requirement (Evans et al., 2021); corticosteroids may restore vascular responsiveness to catecholamines and temper the inflammatory response. Supportive care addressed the other failing organs: urine output was measured hourly through a catheter, nephrotoxic drugs were avoided and the patient was repositioned and reoriented frequently to limit delirium, which the sepsis itself had already started.

Age, Goals and Reflection

Age shaped the plan beyond drug doses. Older adults are more likely to die of sepsis and more likely to leave hospital needing skilled care (Martin et al., 2006), so within the first hours the attending physician and nurse spoke with the patient's niece, the health care proxy, about the patient's wishes. The patient had previously said that intensive treatment was acceptable if recovery to independent living was possible, which supported full treatment, including vasopressors in the intensive care unit.

Reflection, the final phase of the judgment model (Tanner, 2006), came at the six-hour review. Lactate had fallen to 2.2 mmol/L, the mean pressure held at 67 on a lower norepinephrine dose and the patient was more alert. The team noted that the most valuable decision had been the triage nurse's early recognition of new confusion, and that the least certain had been the volume of fluid, which dynamic measures helped limit.

Conclusion

In the first six hours, each decision answered a mechanism described in Milestone One: antibiotics for the pathogen, fluids and norepinephrine for vasodilation and leak, oxygen for the shunt, hydrocortisone for refractory vascular tone and close monitoring for failing kidneys and brain. Technology turned those mechanisms into numbers that could be tracked, and age and kidney disease shaped how much fluid and which doses were safe. The final project will bring the mechanism, decisions and outcomes together in one complete case study.

References

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., . . . Levy, M. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. https://doi.org/10.1097/CCM.0000000000005337

Martin, G. S., Mannino, D. M., & Moss, M. (2006). The effect of age on the development and outcome of adult sepsis. Critical Care Medicine, 34(1), 15-21. https://doi.org/10.1097/01.ccm.0000194535.82812.ba

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J.-L., & Angus, D. C. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 315(8), 801-810. https://doi.org/10.1001/jama.2016.0287

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04