Reflective Analysis of Evidence-Based Care

Introduction

In healthcare, evidence-based care is important because it helps to provide most enhanced individualised care with minimum error to the patients, assist in lowering care cost and improve the expertise of the medical professional in delivery care (Crowe et al., 2020). Therefore, a reflection regarding evidence-based care is developed to examine the professional practise ability as a nurse. In nursing, reflection acts as self-evaluation as well as the examination of the efficiency of the care delivered that helps nurses to understand the changes to be made for future practice in them and in care to ensure better well-being and quality of care for the patients (Reljić et al., 2019). Thus, being a third-year student nurse, I determined to reflect on my care for a Sepsis patient to gather experiences in improving my professional practice ability, skills and knowledge. In reflecting regarding the care of the patient, the initial assessment, care planning made, interpreted care observation, medicine management, interdisciplinary care involvement and my leadership ability along with evaluation of care is to be reflected. For those involved in similar reflective practices or seeking guidance on healthcare dissertation help, understanding these aspects is crucial. According to Nursing and Midwifery Council’s (NMC) Code of Conduct, the confidentiality and privacy of the patient is to be maintained under all condition (NMC, 2018). Thus, the pseudonym Barry is used to indicate the patient who was informed of the action and written consent is taken from him to ensure ethical consideration.

Case Study

Barry is a 55-year-old individual who is admitted to the Accident and Emergency Unit due to reporting extreme pain and swelling on the cut of his thumb that occurred in the morning along with suddenly increased heartbeat, chills and shivers, confusion and shortness of breath. The cut occurred on his thumb while attaching an accessory to the mowers present in the yard service operated by him. Since the day was busy with more than 25 customers waiting for the service, he ignored the wound and was involved in working. After coming back home, he mentioned feeling extreme discomforted pain in his thumb with a throbbing sensation. The thumb is found to be swollen with yellowish pus present in the area and two read strikes going towards his forearm. His past health history mentions he has type-2 diabetes for the last 10 years which is controlled through regular medication and physician visits.

After admission to the hospital, the initial health analysis shows he has high fever of 39.2℃ with a pulse of 120 beats per minute, blood pressure of 100/68 mmHg and blood glucose of level of 145 mg/dl. Barry was accompanied to the hospital by his wife who mentioned he has taken his diabetic medication regularly as well as today and is not involved in drinking or smoking anymore. The primary symptoms of Barry mention he has developed sepsis which is required to be immediately managed to avoid the septic shock that at times is fatal for the individuals. Thus, in the presence of my mentor, I immediately intervened to perform effective health assessment of Barry to arrange and deliver immediate care to him.

Initial Assessment

On admission to the A&E unit, I was asked to take and deliver direct care to Barry in the presence of my mentor. In the condition, my initial response was to make own detailed health assessment of Barry to determine his extent of worsened state of health and identify appropriate actions to be taken for delivering him holistic care. The symptoms of sepsis include rapid breathing, breathlessness, shivering and chills, confusion and sweaty skin with presence of swollen and painful wound (Wattanapaiboon et al., 2020). Barry expressed all the mentioned symptoms of sepsis during admission to the hospital, thus health assessment considering the health issue is executed. In nursing, the ABCDE assessment framework is regarded as the most efficient systematic approach to be taken by the nurses for immediate assessment and treatment of any critically-injured or ill patient (resus.org.uk, 2021). The failure to make the assessment with appropriate use of framework leads the nurses to delay care which contributes towards worsening of patient’s health (Steele et al., 2017). The ABCDE assessment includes airway, breathing, circulation, disability and exposure examination of the patient (Smith and Bowden, 2017).

In sepsis, airway and breathing assessment is necessary because it leads to acute respiratory distress syndrome (ARDS). In ARDS, the inflammatory mediators injure the lungs resulting in impaired gaseous exchange leading to requirement of invasive mechanical ventilation. This is because it causes build-up of fluid in the alveoli of the lungs leading them unable to be filed with enough oxygen for support effective gaseous exchange in the bloodstream (Auriemma et al., 2020). The symptoms of ARDS are bluish colouration of fingernails, rapid heartbeat, chest pain and extreme breathlessness (Quan et al., 2020). In Barry’s case, his airway assessment mentioned no chest pain or presence of bluish colouration of the fingers. A chest X-ray is immediately carried out for Barry to diagnose ADRS in the airways. The chest X-ray shows no sign of fluid accumulation in the chest with his airways showing no obstruction indicating he has enhanced airways and lack of presence of ADRS.

The breathing assessment in case of Barry is performed as he reported shortness of breath during admission. The normal rate of breathing in individuals is 12-20 breaths/min and more than 25 breaths/min indicate illness and health warning sign for the patient (resus.org.uk, 2021). As argued by Van Lier et al. (2021), sepsis leads to stimulate medullary ventilatory centre by the inflammatory mediators like endorphins in the body. It leads to hypoperfusion which causes the respiratory rate to be increased for supporting metabolic acidosis leading the patient to feel shortness of breath. Thus, the breathing assessment of Barry is executed which indicated he has 28 breaths/min. It informs he is suffering from warning signs of breathing and immediate action is to be taken to resolve his condition. The oxygen saturation is measured for Barry because in sepsis condition the saturation level is reduced due to hindered blood flow, disturbances in the microcirculation and peripheral shunting of oxygen along with lactate academia in patients who are experiencing septic shock (Semler and Singer, 2019). The pulse oximeter is used to determine oxygen saturation in Barry which indicated 81% oxygen in the blood. The normal level is considered to be above 95% oxygen in the blood and saturation below 78% indicate septic shock (resus.org.uk, 2021). Thus, Barry is seen to have extremely low oxygen saturation and it is indicating he may be reaching septic shock.

The circulation assessment is made to determine the heart rate and blood pressure of patients (resus.org.uk, 2021). In sepsis patients, the blood pressure is lowered, and heartrate is increased because in this condition the immune system of the body becomes less effective and makes the blood vessels to be dilated. It causes the heart to beat faster in sending adequate oxygenated blood to the organs for supporting their enhanced functioning (Carlson and Fitzsimmons, 2019). Barry’s heart rate is 125 beats/min and his blood pressure is 100/68 mm Hg indicating both are beyond the normal rate that is 60-100 beats/min and 120/90 mm Hg (resus.org.uk, 2021). The disability assessment is made to determine the presence of hypoxia or sedation condition (Romanelli and Farrell, 2020). Barry expressed no disability and show14 score on APUV assessment indicating he is fully alert to the condition. Since diabetes acts as major risk for sepsis extension to septic shock, Barry’s blood glucose level is examined (Romanelli and Farrell, 2020).

During severe sepsis and septic shock, the blood glucose is raised due to hindered lactate level that is related with hyperglycaemia (Giannini et al., 2019). The normal glucose level in type-2 diabetes patients is within 130 mg/dl whereas Barry’s glucose level was 145 mg/dl indicating hyperglycaemia. The exposure assessment is made to determine presence of any other wound which may have contributed to the sepsis condition of the patient. The assessment mentioned no other active wound expect the thumb on Barry indicating the sepsis is developed due to infection from the cut of the thumb. The normal body temperature of human is 36.5℃ whereas Barry’s body temperature is 39.2℃ indicating he has high fever that may have developed due to infection in the body (Sundén-Cullberg et al., 2017). In case of Barry, severe sepsis is confirmed as his blood pressure and heart beat are suddenly lowered and raised along he expresses rapid breathing and high body temperature.

Planned Care

The initial planning of care is done for Barry by consideration of the Sepsis Six Bundle mentioned by the UK Sepsis Trust in 2011 (sepsistrust.org, 2018). This is because the bundle allows effective actions to be taken to avoid the spread of sepsis and protect Barry from septic shock which is serious health condition. The Sepsis Six is delivered to Barry within one hour of diagnosis of sepsis in him as instructed to avoid septic shock (sepsistrust.org, 2018). According to Sepsis Six, the initial set of planned care is titrating the oxygen in the bloodstream to a saturation level of 94% within one hour in the patient (sepsistrust.org, 2018). In reaching the oxygen saturation target, the plan of care is providing oxygen therapy to Barry. This is because oxygen therapy helps in increasing the oxygen level in the bloodstream that support enhanced oxygen-rich blood to be present and assist in overcoming shortness of breath (sepsistrust.org, 2018). The NICE guidelines inform a 0.5-1 fraction of inspired oxygen (FiO) is to be provided to the sepsis patients through the non-breather oxygen mask top enhanced their oxygens saturation and breathing efficiency (NICE, 2016). The mentioned measures are followed for Barry’s oxygen saturation to be made normal.

The Sepsis Six informs that source control of sepsis is to be made through blood culture so that infection rate can be reduced (Burke et al., 2019). In source control for sepsis patients, the surgical and non-surgical health professionals as a multi-disciplinary team are to be involved. This is because they through discussion determine if surgical removal of the infectious source or percutaneous removal or draining the infectious fluids for controlling the spread of infection is needed and best treatment for the patient (Murray et al., 2019). Thus, the surgical and non-surgical health professionals are involved in care for Barry where they planned to percutaneously remove the surface of the wound to release the pus and infectious fluid for infection source control. Thereafter, they planned to disinfect the area and bandage the wound to avoid further infectious. The third step of Sepsis Six is administration of intravenous antibiotics. The blood culture is further performed to determine the infectious agents responsible in causing sepsis for Barry. This is important to determine the antibiotics to be provided in killing the agents to control sepsis (Lin, 2021). In Barry’s blood culture, Staphylococcus aureus is the main causative agent identified in the individual.

The intravenous antibiotics delivery is the third step of Sepsis Six bundle which is performed to ensure antibiotics directly reach the blood and to the source of infection to destroy the causative agents of sepsis (Napolitano, 2018). According to Chiappelli et al. (2022), oxacillin or nafcillin at 2g IV q4h is required to be provided to sepsis patients in controlling infection. This is because the medication helps in treating infection that are caused by bacterial agent as seen in Barry. The fourth step of Sepsis Six indicates measuring the serum lactate level of the blood. This is because the level of serum lactate indicates the severity of sepsis and assist in monitoring whether the medicines are working to lower infection rate so that lower impaired tissue oxygenation is seen (Evans, 2018). A serum lactate level of 2 mmol/L is targeted to be achieved for Barry within one-hour of diagnosis of sepsis which is currently 2.7 mmol/L. This is because increased level of serum lactate indicates worsening of the infection and intense hypoperfusion indicating damaged to organs due to reduced blood flow towards them (Ryoo et al., 2018).

In Sepsis Six, the fifth stage is administration of intravenous fluid resuscitation to the individuals suffering from sepsis. This is important because fluid administration assist in restoring cardiovascular stability in patients by restoring the blood volume, controlling bleeding and supporting regaining of perfusion of tissues along with organ function so that the heart rate and blood pressure is normalised. It also helps in reducing chances of septic shock among individuals (Marik et al., 2017). According to NICE, 30ml/kg of crystalloid fluid is to be administered to sepsis patients from the point of diagnosis of the disease for 30-60 minutes (NICE, 2016). Thus, the similar action is planned to be followed in delivering care to Barry to help his circulation parameters to be stabilised and avoid risk of septic shock. The last step of Sepsis Six is to be ensure normal urine output for the sepsis patient. This is essential so that renal function can be assured to be performing effectively and waste from the body along with medication residues are ensures to eb effectively released for assuring good health condition of the patient (Brown and Semler, 2019). The urine output of 30 ml/hr is planned to be gathered from Barry to ensure his enhanced health condition and protection from sepsis (resus.org.uk, 2021).

Interpretation of Results

The continuous monitoring and evaluation of clinical observation of sepsis patient for the first one hour is vital as during the initial phase increase risk of life is raised in sepsis patients out of probability of facing septic shock in which the organs initiate to dysfunction (McIntyre et al., 2018). Thus, observation for Barry was carried out every 15 minutes for the initial one hour of Sepsis Six implementation. After one hour, an hourly observation of the vitals such blood sugar, blood pressure, heart rate, breathing rate, body temperature and wound leading to sepsis are done for the patient in next 6 hours. This is because it is the guidance mentioned by the UK Sepsis Trust to be followed after the one-hour Sepsis Six bundle for patients (sepsis.org, 2021).

The study by Choi et al., (2018) mentions that hyperoxia in sepsis patients causes damage to the lungs due to increased presence of supplement oxygen to be breathed. Thus, the oxygen saturation of the blood in Barry is continuously observed for the initial one-hour. At the end of Sepsis Six bundle implementation, Barry showed 94% oxygen saturation in the pulse oximeter which indicates he has reached the determined oxygen saturation target and the supplement oxygen is to be removed. Further, hourly observation of oxygen saturation of Barry is executed to determine he no longer develops breathing trouble after removal of the supplement oxygen. According to Skube et al. (2018), low blood pressure is related with potential risk of recurring septic shock in patients. As per Napolitano (2018), the systolic blood pressure is to be above 90mmHg and mean arterial pressure is to be above 70 mmHg after persistent fluid resuscitation to ensure the patient safe from septic shock and indicate recovering from sepsis. The post-Sepsis Six bundle session of Barry indicated he has average blood pressure of 110/80 mmHg after one-hour therapy which indicate he is recovering from the condition and gradually developing stable blood pressure.

The serum lactate level is seen to rapidly normalise in the initial phase of the therapy for sepsis (first 6 hours). It is key indicator in sepsis as lactate in the blood is raised during sepsis because of stimulation of the endogenous epinephrine of beta-2 receptors that participate in dilation of blood vessels in infection state causing increased low blood pressure (Chan et al., 2020). After one-hour of Sepsis Six bundle, Barry’s blood lactate level is reduced to 2 mmol/L indicating it reached the safe levels as targeted. The body temperature of Barry after one-hour of intervention indicated 37.8℃ indicating the temperature is gradually lowering of normal. This also informs that the infection spread within the body is gradually lowering to make the individual overcome fever. However, Barry still mentions of chills even after one-hour and so blankets are provided to him to ensure him remain comfortable.

The wound on the thumb of Barry is checked and it indicate no further swelling or deposition of pus to be removed indicate the source control for the infection is effectively executed. The intravenous fluid resuscitation is to be stopped for Barry when he reaches absolute central venous pressure (CVP) more than 8-12 mmHg (Choi et al., 2018). The urine output in case of Barry indicates he expelled urine at the rate of 28 ml/hr in the initial hour which was raised to 30ml/hr in the next 3 hours. Thus, effective urine output is further monitored for Barry in the next three hours to ensure it remain normalised. The overall observation of Barry after one-hour mentioned reduction of exacerbated symptoms from the time of admission which indicates he is responding effectively to the care support provided.

Medication Management

The complete history of medication used by the patients in to be determined for understanding the way an individual’s health is controlled through them (Kim et al., 2019). The oxacillin is administered intravenously for 10 days to control sepsis for Barry.

The oxacillin is administered intravenously through injection and antibacterial drug that is within the class of medication known as Penicillin. It is used for killing bacteria such as Staphylococcus sp. in patients with infection or sepsis (Duarte et al., 2019). The caution towards the use of oxacillin is that it is to be administered effectively through monitoring in individuals who represent allergies or has asthma. This is because in such condition the use of penicillin drugs leads to overgrowth of unsusceptible organisms which creates health adversity in individuals (Aku et al., 2018). The mode of action of oxacillin is bonding with the penicillin-binding proteins on the bacterial cell wall to block the peptidoglycan production which is the key compound for formation of the cell wall. The inhibition of the peptidoglycan production leads to hindered cell wall growth leading to expose the inner material of the cell to be gradually destroyed to be released outside the body (Santella et al., 2020). The side-effects of oxacillin include pain at the site of injection, vomiting, nausea, headache and others (Mukhopadhyay et al., 2019). This information is to be provided to Barry by the nurse to ensure he is aware of the side effects and cope with the condition.

The tetracycline is one of the bacteriostatic antibiotics which antagonises the bactericidal impact of penicillin and concurrent use of the medication with oxacillin is to be avoided as otherwise is would hinder its ability to act in minimising infection. Moreover, it would impact to cause blockage of the renal tubular secretion of pencilling leading to deposition of the medication within the body (Patel et al., 2020). The oxacillin is absorbed in the blood directly and is distributed to the area of infection where they are present. The 45-50% of oxacillin dose is metabolised by liver to inactive as well as active metabolites to be excreted primarily as urine through glomerular filtrate and tubular secretion (Colaço et al., 2021).

Interdisciplinary Care

In Barry’s case, the multi-disciplinary team is involved to deliver him care from the initial stage of sepsis. The team involved surgical health professionals, nurses, pharmacist and others. The multi-disciplinary team helps to facilitate effective collaboration between different professionals and allow sharing of expert ideas as well as skills to deliver quality care to the patient (Sloan et al., 2019). In case of Barry, each of the member of multi-disciplinary team involved in delivering care performed different roles for his’s care. The Roper-Logan-Tierney model is used in determining the independence and needs of further intervention in the ongoing support for sepsis to Barry. This is because the model helps in analysis of the key everyday activities of life (ALs) of the individuals in deciding care for them to offer them holistic support (Holland and Jenkins, 2019). The key ALs in the model are maintaining safe environment, communication, breathing, washing and dressing, elimination, breathing, temperature control, working and playing, mobilisation, sleeping, sexuality and death and dying (Williams, 2017). The analysis through the model mentioned that Barry express effective mobilisation, breathing, sleeping, eating and drinking, elimination and communication ability. However, he expressed issues with washing and dressing, working and maintaining safe environment.

The case history of Barry explains that he was independent in each of the activities of living before the sepsis but currently express issues with performing few of the actions. He explains his hindered ability to work and play is due to feeling of increased fatigue and perception of pain in the wounds of his thumb. It is evident as the wound is currently active and require time to heal to allow the individual to work again. The dietician was involved in determining the diet chart for Barry. This is because they have enhanced expertise to understand the nature of food required by sepsis patients to regain their strength which is lowered by the metabolic impact of infection in the body (Derouin et al., 2021). Barry is unsure of the way he developed sepsis from a simple cut on the thumb in such severe manner. Thus, the health professional and nurses are involved to educate him regarding the way bacteria develops and present in surface and way they can be removed. Moreover, effective precautions are informed to Barry to avoid further incidence of sepsis while experiencing any cut such as way to clean wounds, taking medication and others (Filbin et al., 2018). The Barry expressed issues with washing and dressing due to the wound on the hand. He expressed feeling pain due to which he avoids moving the hand. The nurse assists him in washing and dressing during the care at hospital and instructed his wife to provide care after discharge at home.

Leadership ability and Care evaluation

In the third-year of adult nursing, as a nursing student my course required me to mange and lead care in the clinical environment. I consider myself to be successful in the process as I led proper care for Barry while accessing assistance from my mentor.

In nursing, effective communication ability is one of the key aspects in care because it helps nurses to identify the needs of care from the patients and assist them in making themselves known to the patient to make them believe and trust the nurse to easily accept care. Moreover, effective communication by the nurses leads them to deliver information about care to patients to gather informed decisions and ensure greater control of care by avoiding misjudgements (Pool et al., 2018). In the care delivery of Barry, I feel that I have been successful in establishing effective communication and developed trusting therapeutic relationship with him as in all context of care he never expressed doubt or avoided compliance in care. I also feel communication was one of the strengths in the care episode because I was interacting freely with the patient as well as my mentor to decide proper care in all condition. However, I expressed issues with written communication to some extent as in some cases reaffirmation of information written by me regarding Barry in health records is required.

I expressed effective team working ability as I never involved in any conflict or dispute while arranging multi-disciplinary care for Barry. However, I personally feel, and my mentor mentioned to improve my multi-tasking ability. This is because while caring for Barry’s needs I was found unable to delivery timely care to other patients in the ward as I was too much inclined on his care support. Moreover, while taking decision regarding care for Barry, in some context I expressed lack of confidence and depended too much on my mentor’s view to deliver support. Thus, my mentor mentioned to improve my confidence in care which she mentioned is to be achieved with increase practical practice in nursing field and engaging in evidence-based care.

Conclusion

The above discussion mentioned that effective care provision was created by me for Barry with immediate effect. I have shown effective communication ability and decision-making ability to delivery care as well as enhanced team working ability to work with multidisciplinary team in delivering support to patients. However, I need to improve my written communication, multi-tasking and time management ability. Therefore, I plan forward to develop strategies to act on improving the weak ability to become a better nurse.

Dig deeper into Reflections in Healthcare with our selection of articles.

References

Aku, F.Y., Akweongo, P., Nyarko, K., Sackey, S., Wurapa, F., Afari, E.A., Ameme, D.K. and Kenu, E., 2018. Bacteriological profile and antibiotic susceptibility pattern of common isolates of neonatal sepsis, Ho Municipality, Ghana-2016. Maternal health, neonatology and perinatology, 4(1), pp.1-8.

Auriemma, C.L., Zhuo, H., Delucchi, K., Deiss, T., Liu, T., Jauregui, A., Ke, S., Vessel, K., Lippi, M., Seeley, E. and Kangelaris, K.N., 2020. Acute respiratory distress syndrome-attributable mortality in critically ill patients with sepsis. Intensive care medicine, p.1.

Burke, J., Wood, S., Hermon, A. and Szakmany, T., 2019. Improving outcome of sepsis on the ward: introducing the ‘Sepsis Six’bundle. Nursing in critical care, 24(1), pp.33-39.

Carlson, B. and Fitzsimmons, L., 2019. Shock, sepsis, and multiple organ dysfunction syndrome. Priorities in Critical Care Nursing-E-Book, 474.

Chan, J.Z.W., Tan, J.H., Lather, K.S., Ng, A.J.Y., Ong, Z., Zou, X., Chua, M.T. and Kuan, W.S., 2020. Beta-blockers' effect on Levels of Lactate in patients with suspected sepsis–The BeLLa study. The American journal of emergency medicine, 38(12), pp.2574-2579.

Chiappelli, A.L., Trienski, T.L., Snawerdt, J., McKibben, L.B., Rivosecchi, R.M. and Horn, E.T., 2022. Antimicrobial therapy in infective endocarditis. Infective Endocarditis, pp.117-139.

Choi, M., Tamrakar, P., Schuck, P.F., Proctor, J.L., Moore, A., Asbury, K., Fiskum, G., Coksaygan, T. and Cross, A.S., 2018. Effect of hypobaria and hyperoxia during sepsis on survival and energy metabolism. Journal of Trauma and Acute Care Surgery, 85(1S), pp.S68-S76.

Choi, S.J., Ha, E.J., Jhang, W.K. and Park, S.J., 2018. Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients. BMC pediatrics, 18(1), pp.1-6.

Colaço, H.G., Barros, A., Neves-Costa, A., Seixas, E., Pedroso, D., Velho, T., Willmann, K.L., Faisca, P., Grabmann, G., Yi, H.S. and Shong, M., 2021. Tetracycline antibiotics induce host-dependent disease tolerance to infection. Immunity, 54(1), pp.53-67.

Crowe, C., Collie, C., Johnson, C. and Wiltsey Stirman, S., 2020. An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system. American Psychologist, 75(8), p.1116.

Derouin, E., Picard, G. and Kerever, S., 2021. Dieticians’ practices in intensive care: A national survey. Clinical Nutrition ESPEN, 45, pp.245-251.

Duarte, F.C., Danelli, T., Tavares, E.R., Morguette, A.E.B., Kerbauy, G., Grion, C.M.C., Yamauchi, L.M., Perugini, M.R.E. and Yamada-Ogatta, S.F., 2019. Fatal sepsis caused by mecA-positive oxacillin-susceptible Staphylococcus aureus: first report in a tertiary hospital of southern Brazil. Journal of Infection and Chemotherapy, 25(4), pp.293-297.

Evans, T., 2018. Diagnosis and management of sepsis. Clinical Medicine, 18(2), p.146.

Filbin, M.R., Thorsen, J.E., Lynch, J., Gillingham, T.D., Pasakarnis, C.L., Capp, R., Shapiro, N.I., Mooncai, T., Hou, P.C., Heldt, T. and Reisner, A.T., 2018. Challenges and opportunities for emergency department sepsis screening at triage. Scientific reports, 8(1), pp.1-10.

Giannini, H.M., Ginestra, J.C., Chivers, C., Draugelis, M., Hanish, A., Schweickert, W.D., Fuchs, B.D., Meadows, L., Lynch, M., Donnelly, P.J. and Pavan, K., 2019. A machine learning algorithm to predict severe sepsis and septic shock: development, implementation, and impact on clinical practice. Critical care medicine, 47(11), pp.1485-1492.

Holland, K. and Jenkins, J. eds., 2019. Applying the Roper-Logan-Tierney Model in Practice-E-Book. Elsevier Health Sciences.

Kim, J., Kim, Y.A., Hwangbo, B., Kim, M.J., Cho, H., Hwangbo, Y. and Lee, E.S., 2019. Effect of antihypertensive medications on sepsis-related outcomes: a population-based cohort study. Critical care medicine, 47(5), pp.e386-e393.

Lin, Y., 2021. Effectiveness of the sepsis six bundle in the management of acute adult sepsis in the UK. Emergency Nurse, 29(3).pp.45-78.

Marik, P.E., Linde-Zwirble, W.T., Bittner, E.A., Sahatjian, J. and Hansell, D., 2017. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive care medicine, 43(5), pp.625-632.

McIntyre, L.A., Stewart, D.J., Mei, S.H., Courtman, D., Watpool, I., Granton, J., Marshall, J., Dos Santos, C., Walley, K.R., Winston, B.W. and Schlosser, K., 2018. Cellular

immunotherapy for septic shock. A phase I clinical trial. American journal of respiratory and critical care medicine, 197(3), pp.337-347.

Mukhopadhyay, S., Sengupta, S. and Puopolo, K.M., 2019. Challenges and opportunities for antibiotic stewardship among preterm infants. Archives of Disease in Childhood-Fetal and Neonatal Edition, 104(3), pp.F327-F332.

Murray, L., Halpin, J., Casserly, B., O'Connell, N.H. and Scanlon, T., 2019. A pyo-hydropneumothorax with sepsis, secondary to Gardnerella vaginalis infection in a post-partum female. Respiratory medicine case reports, 26, pp.189-192.

Napolitano, L.M., 2018. Sepsis 2018: definitions and guideline changes. Surgical infections, 19(2), pp.117-125.

Napolitano, L.M., 2018. Sepsis 2018: definitions and guideline changes. Surgical infections, 19(2), pp.117-125.

NICE 2016, Sepsis: management and treatment, Available at: https://www.nice.org.uk/guidance/ng51 [Accessed on: 20 December 2021] NMC 2018, The Code, Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed on: 20 December 2021]

Patel, A., Khande, H., Periasamy, H. and Mokale, S., 2020. Immunomodulatory effect of doxycycline ameliorates systemic and pulmonary inflammation in a murine polymicrobial sepsis model. Inflammation, pp.1-9.

Pool, R., Gomez, H. and Kellum, J.A., 2018. Mechanisms of organ dysfunction in sepsis. Critical care clinics, 34(1), pp.63-80.

Quan, C., Li, C., Ma, H., Li, Y. and Zhang, H., 2020. Immunopathogenesis of coronavirus-induced acute respiratory distress syndrome (ARDS): potential infection-associated hemophagocytic lymphohistiocytosis. Clinical microbiology reviews, 34(1), pp.e00074-20.

Reljić, N.M., Pajnkihar, M. and Fekonja, Z., 2019. Self-reflection during first clinical practice: The experiences of nursing students. Nurse education today, 72, pp.61-66.

resus.org.uk 2021, ABCDE assessment framework, Available at: https://www.resus.org.uk/library/abcde-approach [Accessed on: 20 December 2021]

Romanelli, D. and Farrell, M.W., 2020. AVPU score. In StatPearls [Internet]. StatPearls Publishing.

Ryoo, S.M., Lee, J., Lee, Y.S., Lee, J.H., Lim, K.S., Huh, J.W., Hong, S.B., Lim, C.M., Koh, Y. and Kim, W.Y., 2018. Lactate level versus lactate clearance for predicting mortality in patients with septic shock defined by sepsis-3. Critical care medicine, 46(6), pp.e489-e495.

Santella, B., Folliero, V., Pirofalo, G.M., Serretiello, E., Zannella, C., Moccia, G., Santoro, E., Sanna, G., Motta, O., De Caro, F. and Pagliano, P., 2020. Sepsis—A Retrospective Cohort Study of Bloodstream Infections. Antibiotics, 9(12), p.851.

Semler, M.W. and Singer, M., 2019. Deconstructing hyperlactatemia in sepsis using central venous oxygen saturation and base deficit. American journal of respiratory and critical care medicine, 200(5), pp.526-527.

sepsistrust.org 2018, The Sepsis Manual, Available at: https://sepsistrust.org/wp-content/uploads/2018/06/Sepsis_Manual_2017_web_download.pdf [Accessed on: 20 December 2021]

Skube, S.J., Katz, S.A., Chipman, J.G. and Tignanelli, C.J., 2018. Acute kidney injury and sepsis. Surgical infections, 19(2), pp.216-224.

Sloan, W.A., Kemmerly, S., Jain, S., Shreves, A. and Dauterive, K., 2019, October. 787. Improving ED Sepsis Care. In Open Forum Infectious Diseases.6. pp.34-56.

Smith, D. and Bowden, T., 2017. Using the ABCDE approach to assess the deteriorating patient. Nursing Standard (2014+), 32(14), p.51.

Steele, A., Greenwood, M. and Desai, H., 2017. ABCDE assessment and the out-of-hospital cardiac arrest. Dental Update, 44(10), pp.1003-1009.

Sundén-Cullberg, J., Rylance, R., Svefors, J., Norrby-Teglund, A., Björk, J. and Inghammar, M., 2017. Fever in the emergency department predicts survival of patients with severe sepsis and septic shock admitted to the ICU. Critical care medicine, 45(4), pp.591-599.

Van Lier, D., Kox, M. and Pickkers, P., 2021. Promotion of vascular integrity in sepsis through modulation of bioactive adrenomedullin and dipeptidyl peptidase 3. Journal of Internal Medicine, 289(6), pp.792-806.

Wattanapaiboon, K., Banditlerdruk, S. and Vattanavanit, V., 2020. Presenting Symptoms in Sepsis: Is the Mnemonic “SEPSIS” Useful?. Infection and Drug Resistance, 13, p.2199.

Williams, B.C., 2017. The Roper-Logan-Tierney model of nursing. Nursing2020 Critical Care, 12(1), pp.17-20.