The guidelines identify that patients who present with sepsis should be evaluated for the presence of a focus infection that can benefit from source control - for example, removing a potentially infected device or debridement of an infectious source.11 Cultures should also be obtained to promote identification of the source of sepsis and the specific pathogen to target with antibiotic therapy.
Prompt initiation of antibiotic therapy is indicated for the treatment of severe sepsis, and the new guidelines highlight that this should be accomplished within the first hour of recognition.11 The timely administration of antibiotics to older adults with suspected or confirmed sepsis is crucial. Table 3 outlines additional treatment recommendations.
The role of the nurse in the identification and treatment of sepsis in the elderly is important, as early recognition can help to promote best outcomes for patients.15 Nurses can assess patients for the clinical signs of sepsis by frequently monitoring vital signs, including urinary output, skin color, and perfusion and reporting signs of organ system dysfunction.14 Carrying out the treatment plan of care including prompt administration of antibiotic therapy, fluid resuscitation, lung protective ventilation strategies and other treatment measures are additional areas of nursing care importance.
Of all the Surviving Sepsis guidelines, the only grade A recommendations (supported by at least two large, randomized clinical trials with confident results) are ensuring measures such as head of bed positioning and oral care for patients receiving mechanical ventilation to prevent the development of ventilator associated pneumonia and prophylaxis measures against deep vein thrombosis and stress ulcer can help to prevent complications in the elderly patient with severe sepsis.15
Previous research has demonstrated the benefit of nurses in promoting compliance with clinical practice guidelines for complex conditions such as deep vein thrombosis, pulmonary embolus and bleeding stress ulcers.16,17 The nurse's role in the promotion of evidence-based care therefore has significant implications for promoting implementation of the Surviving Sepsis guidelines in clinical practice.
Although listed as one of the last recommendations of the new guidelines, consideration for limitation of support is one that holds much potential for nurses in addressing appropriate care in the ICU. The benefit of prolonged aggressive treatment for critically ill patients with sepsis requires attention, particularly for older adults.
Nurses can play a significant role in discussing realistic treatment strategies with families of critically ill older adults. Research about the role of the acute care nurse has shown that discussing care with family members is a frequently performed role component.16
Strategies for improving communication and providing information to families, such as family conferences with active participation and computer-based programs in the family waiting room, can help enhance decision making about end-of-life issues.17,18
Recent research has demonstrated the beneficial impact of family communications on end-of-life decision-making in the ICU.19
Because sepsis is a critical illness, addressing the expected outcomes of care and discussing realistic treatment goals are areas in which nurses can have significant impact.
The Surviving Sepsis guidelines provide new strategies for the management of sepsis, but the challenge of converting evidence-based guidelines into actual practice remains. Keeping up to date with the literature on sepsis, including new research findings, is essential for nurses.
Nurses play an important role in monitoring older patients at risk for sepsis, promoting early detection and instituting treatment measures. Nurses also are in a unique position to champion the use of the Surviving Sepsis guidelines and to promote the best possible outcomes for older patients with sepsis.
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Ruth M. Kleinpell is a professor at Rush University College of Nursing in Chicago and a certified acute care nurse practitioner.