Deteriorating patient & Sepsis Flashcards
What is sepsis?
Sepsis
= infection of the blood stream —> Body’s extreme response to infection
- Most preventable cause of death world wide —> SEPSIS KILLS
- Medical emergency —> early recognition & Resuscitation is essential
- nurses must know signs of deterioration
What are the risk factors of sepsis?
- Immunocompromised
- indwelling medical device
- recent surgery/ invasive procedure
- history of fevered
- fall not related to mechanism of injury
- age over 60 or under 1
Key signs of deterioration
Key Signs of deterioration:
1. RR
2. Decrease LOC (drop of 2 in GCS)
3. Tachycardia
4. Hypotension
5. Decrease urine output
6. Desaturation
key signs of inadequate perfusion
Key signs of inadequate perfusion
- tachycardia
- tachypnoea
- vasoconstriction
- confusion
- Changes in LOC
- hypotension
- Decreased urine output
indicators of sepsis
Indicators of sepsis
- abdomen —> pain or peritonitis
- Lung —> Cough, SOB
- Neuro —> Altered LOC, onset of confusion, neck stiffness, headache
- Skin —> wound, cellulitis
- Urine —> dysuria, frequency, Color
Treatment for sepsis?
BUFALO –> Sepsis 6
1. Blood cultures
2. Urine output and monitoring,
3. Fluids IV
4. Antibiotic
5. Lactate (bloods)
6. Oxygen
What is the nurses role in sepsis?
- Early identification
- appropriate charting
- documentation
- communication
What is involved in ABG interpretation?
Ph
CO2
HCO3
What is normal pH?
Normal pH = 7.35 - 7.45
Acidosis = below 7.35
Alkaloid = above 7.45
What is normal Co2?
Normal Co2 = 35-45
Acidotic = higher than 45
Alkalotic = above 26
What is normal HcO3?
Normal HCO3 = 22-26
Acidotic = below 22
Alkalotic = above 26
What is shock?
Shock = Failure of the circulatory system to maintain effective tissue perfusion resulting in cellular dysfunction & acute organ failure
— Inadequate perfusion (sepsis) —> multi organ dysfunction syndrome
