Sepsis Chapter 14

Question 1

What is sepsis?

Answer 1

life threatening organ dysfunction caused by a deregulated host response to infection

Question 2

Is sepsis gram negative or positive?

Answer 2

Gram positive

Question 3

Sepsis patho

Answer 3

Excessive release of proinflammatory cytokines that cause:

• Vasodilation = drop in BP
• Decreased vasomotor
• Increased capillary permeability

Question 4

When does sepsis occur?

Answer 4

Local blood vessels dilate, increasing circulation to involved area, which allows for influx of immune cells, causing local redness, warmth, and edema. Sepsis occurs when inflammatory response is no longer localized

Question 5

Early signs of sepsis

Answer 5

• Tachycardia
• Bounding pulses
• Fever
• Normal BP
• Tachypnea

Question 6

Late signs of sepsis

Answer 6

• Cool, pale skin
• Weak thready pulses
• Tachycardia
• Hypotension
• ALOC
• Decreased RR
• Decreased urine output

Question 7

Medical Management of sepsis

Answer 7

PREVENTATION!

• Hand washing
• Aseptic technique for procedures

Question 8

Bundle of Care: Hour 1

Answer 8

Bundle = Activities that need to be completed within 1 hour after identifying sepsis

Question 9

Labs what should be drawn during Bundle of Care

Answer 9

• **Immediately = serum lactate and two sets of blood cultures
• CBC
• coagulation studies
• LFT
• ABGs
• D0miner

Question 10

Bundle of care and ABX

Answer 10

• Administered within 1 hour upon arrival

- Cultures should be done before antibiotics are administered

Question 11

Bundle of care fluid resuscitation

Answer 11

Fluid with crystalloid solution = N.S or LR

Question 12

What to use if fluid resuscitation does not successfully restore BP?

Answer 12

Initiation of vasopressors to keep MAP >65 mm Hg

Question 13

What to give if pt is not responsive to fluid or vasopressor therapy? and what is it caused by?

Answer 13

Give low dose corticosteroid therapy due to Adrenal insufficiency

Question 14

Ongoing monitoring during bundle of care

Answer 14

Ongoing monitoring = VS, perfusion, mental status, cultures again to check on tx, all lab work to check WBCs, lactic acid level coming down, hemodynamic monitoring, titrating drips, fluid levels, neuro checks

Question 15

Complications of sepsis and how to treat each?

Answer 15

-DIC (vasodilating)
TX: crystalloids, blood, FFP, and PLTs

-MODS
TX: control infection, increase O2, restore/maintain intravascular volume

Question 16

Nursing diagnosis for sepsis

Answer 16

Altered tissue perfusion r/t inadequate cardiac output

Question 17

Nursing assessment: Neurological status

Answer 17

Decreased level of consciousness occurs as a result of decreased cardiac output and hyperventilation causing a decrease in cerebral blood flow.

Question 18

Nursing assessment: VS

Answer 18

• Hypotension is present because of vasodilation, producing relative hypovolemia and decreased venous return.
• Tachycardia will be present as one of the compensatory mechanisms.
• Initially, the patient will be febrile as an adaptive response. In later stages, the patient will be hypothermic, potentially signaling the body’s inability to continue the adaptive response.

Question 19

Nursing assessment: Hemodynamic readings

Answer 19

• Initially, cardiac output is increased; however, as sepsis progresses, cardiac output decreases as a result of continued decreases in filling pressures, such as CVP and pulmonary artery occlusion pressures.
• Initially, systemic vascular resistance is decreased as a result of widespread vasodilation. Later, it may increase due to compensation and vasopressor therapy.

Question 20

Nursing assessment: Urine output

Answer 20

Decreased urine output occurs as a result of decreased cardiac output and the initiation of compensatory mechanisms.

Question 21

Nursing assessment: skin color and temp

Answer 21

Initially, the patient’s skin is flushed and warm because of increased cardiac output. Later, the skin becomes cold and clammy, signaling the progression of shock. Tissue necrosis in the extremities may indicate the enhanced coagulation of DIC

Question 22

Nursing assessment: Bleeding

Answer 22

Excessive bleeding from wounds and puncture sites may be present because of consumption of clotting factors in DIC.

Question 23

Lab test: ABGs

Answer 23

Initial ABGs may reflect a respiratory alkalosis due to hyperventilation. Hypercapnia and hypoxia are present as respiratory failure worsens. Later stages of shock reveal a metabolic acidosis due to anaerobic metabolism.

Question 24

Lab test: Venous O2 sat

Answer 24

Decreased SvO2 and ScvO2 are typically indicators of inadequate oxygen delivery. In later sepsis, values may be elevated because of maldistribution of blood flow and are not indicative of recovery.

Question 25

Lab test: Metabolic profile

Answer 25

Renal failure and liver failure, as evidenced by increased BUN and creatinine levels and liver function test results, may become evident as a result of decreased organ perfusion

Question 26

Lab test: lactate/base deficit

Answer 26

Increased lactate level and negative base deficit are evidence of poor perfusion at the cellular level. Normalizing levels are an endpoint demonstrating adequate resuscitation. Sustained abnormal levels are indicators of increased risk of mortality

Question 27

Lab test: clotting studies

Answer 27

Decreased levels of fibrinogen, increased fibrin degradation products, increased D-dimer levels (an indicator of clot breakdown), decreased platelets, prolonged prothrombin and activated partial thromboplastin times, and decreased antithrombin III levels indicate the progression to DIC.

Question 28

Nursing Actions

Answer 28

Meticulous hand washing and aseptic technique with all procedures Hand washing and aseptic techniques are basic interventions to help prevent and control infection. • Administer oxygen as ordered. Maximizing oxygenation is essential. • Anticipate and prepare for intubation. Intubation and mechanical ventilation may be required to improve oxygenation or if respiratory failure ensues. • Obtain lactate level. Lactate levels are an indicator of adequacy of perfusion; increased levels signal the presence of anaerobic metabolism. • Obtain two blood cultures from two different sites, obtain urine, sputum, and wound cultures. Cultures are obtained to identify the offending organism. • Administer antibiotics as ordered after cultures are obtained. Antibiotics are the first-line treatment in an attempt to control the infection. • Administer fluid replacement as ordered. Aggressive fluid replacement is the initial treatment to restore filling volumes and blood pressure in septic shock. • Administer vasoactive drips such as norepinephrine as ordered. Vasoactive drips may be necessary to restore vascular tone if fluid replacement therapy is not effective at increasing blood pressure and cardiac output. • Provide mouth care every 4 hours and when needed. Oral care is effective at reducing the occurrence of ventilator-associated pneumonia. • Supportive care: nutrition, turning, DVT prophylaxis, range of motion exercises, mobilize as tolerated. These actions provide a supportive healing environment while active treatment of the underlying problem is provided.

Question 29

Sepsis pt teaching

Answer 29

* Instruct the patient and family on the cause of sepsis and the importance of meticulous hand washing. Patient and family understanding of factors important in preventing, minimizing, and controlling infection are essential in the treatment. * Allow family member visitation during hospital treatment. Family visitation can help decrease a patient’s and family’s anxiety.

Question 30

Evaluating care outcomes

Answer 30

Satisfactory blood pressure Satisfactory cardiac output Tissue perfusion