Septic shock nursing
What may be the first sign of sepsis in an elderly patient
Confusion
what are S&S of SIRS
Fever >100.4F or <96.8F Heart rate >90 bpm Respiratory rate >20 or PaCO2 <32 mm Hg WBC count >12,000 cells/mm3, <4000 cells/mm3, or >10% immature WBC (bands)
What other routes of infection
Foley, drain and debride wounds
What is the fluid resuscitation goal
CVP of 8-12 mmHg, MAP>65, urine output >0.5 mL/kg/h and ScVo2 >70%
What are some signs of hyper metabolism with sepsis
increased serum glucose and insulin resistance
more sepsis patho
inflammatory response activates coagulation system, body forms clots whether needs them or not
What are some signs of end organ damage
renal failure, pulmonary failure, hepatic failure
Does the patient have signs of acute organ dysfunction? What are some respiratory signs
respiratory rate >20 PaCO2 <32 • Is increasing oxygen or mechanical ventilator support needed?
In late septic shock/cold phase how does death occur
respiratory, cardiac and/or renal failure
How would signs of organ dysfunction be assessed
Oliguria <0.5 renal failure, LOC brain failure, coagulation disorders, liver altered or failure
What are some mental status changes
Subtle changes in mental status, such as confusion or agitation, may be present.
What are some labs seen
The lactate level is elevated because of the maldistribution of blood. Inflammatory markers such as white blood cell counts and C-reactive protein are also elevated
What do we do for the infection
obtain blood, sputum, urine, and wound cultures, administer broad spectrum antibiotics
What are other ways we id and treat possible routes of infection
remove IV lines and place in a different location, if it's a high risk pt. may use antibiotic coated central lines
When does dysregulation of the coagulation system seem to occur
severe sepsis
Why fluid therapy
to correct hypoperfusion from incompetent vasculature and inflammatory response, reestablishing perfusion is key in treating sepsis
What about blood
transfuse with packed RBC's if hemoglobin is <7g/dl
What happens to urinary & GI
urine @ normal levels or decreased, GI nausea, vomiting, diarrhea, or decreased bowel sounds
Does the patient have signs of acute organ dysfunction? What are some renal signs
urine output <0.5 mL/kg/hr
What is the pt is anxious
use IV sedation, avoid neuromuscular blockers when possible
What if fluids don't restore BP and cardiac output
use vasopressors
What are the cardiovascular signs of MODS
• Cardiovascular: hypotension and hypoperfusion
clinical signs and symptoms include those of sepsis as well as septic shock
• Lactic acidosis <4 • Oliguria or hypouresis • Altered level of consciousness • Thrombocytopenia and coagulation disorders • Altered hepatic function
What are the metabolic signs of MODS
• Metabolic: lactic acidemia, metabolic acidosis
What are the neurologic signs of MODS
• Neurologic: altered level of consciousness
Does pt. have S&S of infection
• Positive blood cultures • Currently receiving antibiotic or antifungal therapy • Examination or chest x-ray suggestive of pneumonia • Suspected infected wound, abdomen, urine, or other source of infection
What are the renal signs of MODS
• Renal: increased creatinine, decreased urine output
What are the respiratory signs of MODS
• Respiratory: hypoxemia, hypercarbia, adventitious breath sounds
Does the patient have signs of acute organ dysfunction? What are some cardiovascular signs
• systolic BP <90 or MAP <65 , or drop in SBP >40 mm from baseline • Is hypotension responsive to fluid resuscitation, or is vasopressor support needed? • Is the serum lactate >4 mmol/L?
What should we consider if adult pt. with sepsis induced organ dysfunction has high risk of death
recombinant human activated protein C, (rhAPC; drotrecogin alfa [Xigris])
What are the hematologic signs of MODS
• Hematologic: thrombocytopenia, coagulation abnormalities
What are the hepatic signs of MODS
• Hepatic: elevated liver function tests, hyperbilirubinemia
Early phase or warm phase
BP WDL or hypotensive but responsive to fluids. HR increases to tachycardia, hyperthermia, bounding pulses are evident.
Risk factors for septic shock
Immunosuppression, hospitalization, malnourishment Extremes of age (1 yr and 65 yr), infants w/infectious process, Chronic illness, Invasive procedures, hospitalization
Severe sepsis
S&S of sepsis associated with organ dysfunction, hypotension, or hypoperfusion;
What are some early interventions
aggressive fluid resuscitation of 20 mL/kg/h of crystalloid or colloid equivalent
Given this information what labs should I monitor
antibiotic agents blood levels, BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels and coagulation studies
What is septic shock caused by
caused by bacteria in blood widespread infection
Does the patient have signs of acute organ dysfunction? What are some CNS signs
changes in LOC, range from agitation to coma
What if the pt. still doesn't respond to fluid or vasopressor therapy
consider IV steroid therapy
Does the patient have signs of acute organ dysfunction? What are some metabolic signs
insulin resistance, metabolic acidosis, or serum lactate >4mmol/L
How do we prevent problems r/t hematologic effects
interventions & meds to prevent DVT and stress ulcer prophylaxis like pantoprozole/protonix
How do we correct metabolic effects
keep serum glucose <150
Does the patient have signs of acute organ dysfunction? What are some hematologic signs
lab analysis S&S of coagulopathies
What about nutritional therapy
supplementation should be started in first 24 hours after ICU admission, continuous insulin IV can control hyperglycemia
hypotension
systolic <90, or drop of > = to 40 from baseline, systolic is top number, when heart contracts
multiple organ dysfunction syndrome or MODS
the presence of altered function of one or more organs in an acutely ill patient requiring intervention and support of organs
What problems can decreased perfusion cause with medications
they're normally cleared by liver and kidneys and levels may become toxic
What should the nurse monitor for this and other types of shock
hemodynamic status, I&O, nutritional status, daily weights, closely monitor serum albumin, pre albumin levels to determine pt. protein requirements
What are sepsis goals
id and treat patients in early sepsis, within 6 hours to optimize patient outcome
Progression of sepsis causes
less tissue perfusion, acidotic, compensatory mechanisms fail, pt shows signs of organ dysfunction, bp doesn't respond to fluid and vasoactive agents, signs of end organ damage are evident
What should nurse be cognizant of
look for patients at risk such as extensive trauma, burns, diabetes. Don't present typical symptoms
What about fever
may not be treated until dangerous >104 or unless patient is uncomfortable
How do we support the respiratory system
mechanical vent if needed
sepsis
must have 2 or more SIRS criteria as a consequence of documented or presumed infection
Does the patient have signs of acute organ dysfunction? What are some hepatic signs
elevated liver function tests, hyperbilirubinmemia
how do we provide nourishment
enteral are preferred to parenteral
septic shock
Shock associated with sepsis, S&S of sepsis + hypotension and hypo perfusion despite adequate fluid resuscitation
How might the nurse reduce hyperthermia
acetaminophen or apply hypothermia blanket but watch for shivering bc it increases O2 consumption
What pts. is drotrecogin alpha or Xigris contraindicated in
active internal bleeding, recent hemorrhagic stroke, intracranial surgery or head injury
How does drotrecogin alpha or Xigris work
acts as an antithrombotic, anti-inflammatory & profibrinolytic agent, thus restoring balance to coagulation dysfunction
When do we admin drotrecogin alpha or Xigris
as early as possible, SE are bleeding, can be reduced by stopping medication
How do we handle invasive procedures
aseptic technique, strict handwashing, monitor all lines for infection, watch for pressure ulcers and infection
sepsis patho
bacteria cause immune response that leads to poor tissue perfusion, increased capillary permeability leads to fluid leaking from capillaries, & vasodilation interrupt bodies ability to adequately perfuse, oxygenate & distribute nutrients
What does the progression from sepsis to septic shock look like
bp drops, skin is cool, pale and mottled. Temp is normal or below. HR & RR remain rapid. Urine production ceases, multiple organ dysfunction progressing to death occurs.
how do we ID sepsis early
does pt. meet criteria for SIRS,
