Sepsis

• What are risk factors for sepsis?

  • Healthcare associated infection 
  • Infection causing pneumonia or UTI 
  • Staph, e coli, and strep 
  • Client with poorly controlled co-morbid conditions or immunocompromised  
  • Older adult (age > 65)  
• What are the two screening tools used for sepsis?

  SIRS criteria and qSOFA score.
• What is the criteria for the qSOFA screening tool?

  • RR >/= 22 per min; should be closely monitored  
  • Altered mental status (GCS </= 13); drowsier, harden to awaken, getting confused  
  • SBP </= 100 mmHg  
• What is the criteria for SIRS screening tool?

  • Temp > 38C (101.4F), OR < 36 C (98.6) 
  • HR > 90 bpm 
  • Resp > 20 bpm or PaCO2 < 32 mmhg  
  • WBC > 12000, or < 4000  
• How many positive criteria between the two screening tools is needed to warrant further assessment for sepsis?

  If any 2 are positive, further assessment should be done to diagnose sepsis  
• What are assessment findings of sepsis?

  • Hypotension needing fluids to keep MAP >/= 65 
  • CRT < 4 seconds; CO increases, Tachycardic to increase CO 
  • Skin warm, flushed d/t vasodilation  
  • Early signs of organ dysfunction = Altered mental status, decrease in urine output 
  • Hyperglycemia
• What are the assessment findings for septic shock?

  • Hypotension needing PRESSORS to keep MAP >/= 65  
  • Lactate >/= 2  
  • CRT > 4 seconds; CO DEcreased  
  • Skin cool & mottled [= poor perfusion] 
  • Signs of organ failure = oliguric, anuric, hypoxic, unresponsive etc. 
  • DIC and/or MODS may develop 
• What are some orders for the early treatment of sepsis?

  • Call RRT for sepsis ~ aimed to increase perfusion  
  • For suspected sepsis: 
  • Measure lactate level 
  • Search for source of infection 
  • For hypotension: 
  • NS 30ml/kg for hypotension within the first 3H 
  • Monitor lung sounds closely ---> at risk for ARDS 
  • Fluid administration must be balanced w/ risk for fluid overload  
• What are some orders for septic shock?

  • Vasopressors if non-responsive to fluids  
  • If hypotension persists past initial fluid resuscitation  
  • Levophed 1st choice  
• Antibiotics = treats source and timin is r/t pt dx of infection, sepsis and shock  

  • In states of shock = should be given within 1 hr 
  • Goal: obtain blood cultures within 45 min 
  • If blood cultures too difficult to obtain ---> do NOT delay abx > 45 min  
  • If not showing shock but sepsis is possible... 
  • Look at likelihood and aim to give within 3 hours  
• What fluids and medications are given to support cardiovascular function in sepsis?

  • NS 30ml/kg for hypotension within the first 3 hours  
  • Vasopressors: Norepinephrine 
• Vasopressors: Norepinephrine 

  • A: stimulates alpha receptors in blood vessels, causing constriction. Mild beta1 stimulant = increases contractility of heart  
  • S: tachy arrhythmias, decreased urine output (d/t dec renal perfusion), tissue necrosis at IV site  
• Norepinephrine Nursing care: 

  • Second nurse check required ~ titration 
  • Assure dehydration is corrected before initiating  
  • MUST have adequate hydration for ANY vasopressor = w/o proper volume, squeezing veins is useless b/c nothing will perfuse  
  • Monitor VS, rhythm, urine output frequently  
  • Monitor IV site: antidote = phentolamine 
  • Need good IV site; central line required  
  • Can be started peripherally then to central  
• How does the nurse maintain oxygenation in a patient experiencing sepsis?

  • Maintain oxygenation: PaO2 > 60, Hgb > 7 
  • Respiratory Support: oxygenation on lowest FiO2 = HFNC preferred over bipap  
  • Keeping Hgb > 7 – 9 = decreases oxygenation demands  
• How does the nurse improve perfusion for a septic patient?

  • Norepinephrine, dobutamine, steroids for client unresponsive to fluids or vasopressors  
  • Increase CO for oxygen transport and for perfusion by... 
  • Adding dobutamine to increase BP by increasing contractility and increase CO if pressors alone insufficient  
  • If hypotensive after fluid resuscitation and not responding to inotropes (dobutamine) consider... hydrocortisone 200mg/day  
• How does the nurse Support Failing organs in a septic patient?

  • Renal replacement therapy 
  • Protect GI tract 
  • Stress ulcer prophylaxis 
  • Nutrition 
  • Supports immune system 
  • Protects gut 
  • Reduce risk of translocation 
  • Start within 48H and advance to goal over 7 days  
  • Maintain FBS < 180 
• How does the nurse manage arterial pressure with a septic patient?

  Things to monitor: 

  • Hand circulation: hand ischemia 
  • Monitor hand warmth, color, movement, CRT  
  • s/s of infection 
  • Bleeding ~ hemorrhage, arterial spasm, possibly arterial dissection and air embolism  
  • IABP 
  • Waveform ~ is it consistent? Are you getting consistent valuable data?  
• What measures should be implemented to reduce a client's risk of sepsis?

  Prevention & Early Detection

  • Handwashing 
  • Aseptic technique 
  • Oral care 
  • Avoid invasive procedures 
  • Discontinue un-needed invasive devices 
  • Maintain nutrition  
  • Client education: vaccinations (flu/pneumovax); chronic disease management  
  • Early detection = Sepsis screening q4h in the at-risk client  
• What are Assessment findings for DIC?

  • Signs of bleeding: bloody body fluids, bruising, petechiae, oozing orifices  
  • Signs of clot formation: cyanosis of digit tips, and ears; organ failure  
• How do you diagnose DIC?

  • Dx: suggestive but not diagnostic 
  • Increased D-dimer [indicates fibrinolysis], FDP [clot breakdown], APTT, PT  
  • Decreased platelets, fibrinogen [reflects clotting factors]  
• What is the medical treatment for DIC?

  • Medical Tx to reverse clotting and bleeding  
  • Treat sepsis 
  • FFP for INR > 1.5 ~ contains fibrinogen and clotting factors = controls bleeding  
  • Cryoprecipitate, platelets for < 50K  
• What nursing care is required for a patient with DIC?

  • Risk for hemorrhage --> No meds that affect bleeding; avoid invasive procedures; gentle oral hygiene prolonged pressure to puncture sites  
  • Bleeding precautions 
  • Monitor VS, perfusion status  
  • Protect from injury  
  • Ineffective tissue perfusion 
  • Assess organ function  
  • Monitor BUN & creat, urine output; O2, monitor LOC, LFTs 
• What are the assessment findings found in MODS (Multi Organ Dysfunction Syndrome)?

  • Lungs: tachypnea, hypoxemia, hypercarbia, PF ration < 300  
  • Heart: hypotension/tachycardia unresponsive to fluids, edema, delayed CRT 
  • Kidneys: oliguria progressing to anuria  
  • Liver/GI: bleeding, jaundice, ileus 
  • CNS: delirium 
• What nursing care if given to a patient experiencing MODS?

  • Sepsis management 
  • Advance Directives Discussion 
  • No specific Tx ~ mainly about restoring perfusion; prognosis is poor ---> end of life discussion needed