Sepsis Nursing CMS – Flashcards
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What is the leading cause of death in non-coronary ICU
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Sepsis
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In septic shock, what % of ppl will die from it?
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50%
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Why is sepsis on the rise?
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Aging population, overuse of antibiotics, survival of immunocompromised
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Do ppl usually contract sepsis in ICU?
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No, at home or med-surge
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What is the physiological response to any injury? Microbial, mechanical, or thermal
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Inflammation
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Inflammation vs Infection
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protective defense mech vs result of the invasion of cells/tissue by living organisms
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What is the progression from injury to death by sepsis?
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1. Systemic inflammatory response syndrome (SIRS) 2. Sepsis----catch it now or else!... 3. Severe sepsis 4. Septic shock & Multiple organ dysfunction syndrome (MODS)
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What causes SIRS?
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A systemic inflammatory response a VARIETY of injuries/conditions: pancreatitis, trauma,
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Is SIRS organ or system specific?
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No, it can be caused by almost any type of injury
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Critieria for SIRS...Must have 2 to Dx
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Temp FEBRILE of >38C (100.4F) or HYPOTHERMIC 90 bpm Resp Rate >20/min or PaCO2 12,000/mm or 10% bands
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What type of breathing might be seen in SIRS?
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Kussmaul's/ hyperventilation
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What ABG would the hyperventilating SIRS pt manifest?
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Respiratory alkalosis
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Do you have to have SIRS to have sepsis or can sepsis stand alone?
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someone with sepsis always has SIRS
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The clinical signs of SIRS + an infection=
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sepsis
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In sepsis, do we need proof of infection to diagnose?
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No, infection can be presumed.
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Is sepsis present in specific systems or organs?
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No , sepsis is systemic, affecting entire body.
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What are the hallmark (differentiating) labs of sepsis?
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increased serum lactate and increased bands (neutrophils)
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Three sepsis 'marker' organs/systems?
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Renal, pulmonary and neuro
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What 3 'dysfuncional problems assoc w/ Severe Sepsis?
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Organ dysfunction, hypotension, and/or hypoperfusion
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What are the manifestations of hypoperfusion?
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Tachycardia, oliguia and acute alteration in cognition/affect
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What part of vitals are we very concerned about in Severe Sepis
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MAP <65 or systolic BP <90mm/Hg
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How can we help w/crap MAP (<65) in severely septic pt?
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Give fluids
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What does giving fluids do for a pt w/severe sepsis?
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Raises BP, increases vascular volume
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What type of shock is septic shock?
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distributive, fluids lying stagnant out in peripherals and places
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What called when severely septic pt is unresponsive to fluids?
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They have moved into septic shock
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Is there hypotension in severe sepsis?
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Yes, SBP <90 or MAP < 65
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Septic Shock: Despite fluid replacements, what is renal output?
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<30 mL/hour
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Septic Shock: ABG status?
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Lactic acidosis, metabolic acidosis
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Septic Shock: Neuro status?
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Acute alteration in mental...if concious
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What happens when fluid replacement given to septic shock?
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Nuttin. Refractory.
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What does the HCP order after fluids failed to raise BP?
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Vasopressors or inotropes
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Why would inotropes be given to septic shock?
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Support BP after vasopressors tried AND to boost a sluggish heart. Encourage strong contractions which increase C/O
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What is MODS: Multiple Organ Dysfunction?
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2 or more organ dysfunction in an acutely ill pt where homeostasis cannot be maintained w/out intervention...BAD!
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MODS: How is BP/perfusion in MODS?
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Shite. SystolicPB <90 or reduction of 40mmHg Systolic off baseline OR MAP <65 in absence of no other cause for hyPOtension
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Sepsis RISK factors: Age and nutrition?
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The very young and very old are at higher risk 65yr Malnourished (anorexic/bulimic) ppl have fewer physio resources.
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What kind of common ICU invasive tubes can lead to sepsis?
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Endotracheal tubes and Central Veinous caths (central lines) PICC lines
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What particular vent-assoc illness often leads to sepsis?
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Ventilator Associated Pneumonia
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What immunodeficiencies can put one at risk for sepsis?
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chemotherapy, alcoholism, HIV
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How are stroke pt's particularly vulnerable to sepsis?
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Aspiration and subsequent pneumonia/pulmonary infection
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What chronic illnesses put person at risk 4 sepsis?
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Diabetes (surprise! bacteria love sugar) and chronic (or acute) renal failure
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Do surgeries and/or invasive procedures put pt at risk 4 sepsis?
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Uh, yeah.
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What happens if you culture AFTER starting antibiotics?
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You will have skewed results.
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What is the highest PRIORITY action for a sepsis pt?
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Start antibiotics
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What is the FIRST thing to do for a septic pt?
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Culture blood and whatever else BEFORE starting antibiotics
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What do you culture from a septic patient?
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Everything, blood, sputum, urine, any wounds
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What will the CBC of a septic pt reveal?
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WBC elevated w/shift to left. Elevated immature granulocytes (bands, baby neutros) Platelets decreased.
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Sepsis: Why are platelets decreased in serum?
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Platelets are out 'microcoaulating' where they shouldn't be. They had an irregular response to infection/injury and are being used up.
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What will serum lactate levels look like? & what kind of cellular metabolism is that indicative of?
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Increased as ? How much anaerobic metabolism pt has.
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What will elevated serum lactate levels do to bodY?
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Eventually create a metabolic acidosis.
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Why is pt in anaerobic metabolism?
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Cells starved for O2 as microcoagulation cuts them off from vascular perfusion.
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What does procalcitonin do for the septic body?
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It neutralized H2O2 at a cellular level.
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What will be on our coagulation profile?
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PT/INR & PTT. D-Dimer and activated protein C.
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Sepsis: What will PT/INR & PTT look like?
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All elevated, all clotting factors out and now a bleeding risk.
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What is activated protein C?
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Heck if I know, but it's elevated in sepsis.
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Severe Sepsis and normal inflammation response
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Severe sepsis is an exaggeration of the responses to the infectious process.
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Severe sepsis activates 2 systems and impairs 1...which?
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Activates inflammatory process ; coagulation. Impairs fibrinolysis.
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Where do endotoxins come from?
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The by product of invading bacteria
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Patho Severe Sepsis: What happens w/clotting cascade?
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Excessive, unnecessary clotting in the microcirculation ; cellular dysfunction interfere w/blood flow ; DECREASE cell O2
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Severe sepsis patho: What will that look like in the peripheral extremities?
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Mottling, perhaps pale and cool to touch.
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Severe Sepsis patho: What happens after underoxygenated cells stunned and die?
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The tissue/organs they make up begin to necros/fail.
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Where is the endothelium?
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The single-layer cells that line the inside 'lumen' of blood vessels.
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Is there endothelium in stents?
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Not at first, but it grows in there.
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What has to be adhered to because of lack of endothelial cells in stents?
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coumadin, heparin, enoxaparin, ASA
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How do endothelial cells relate to clotting?
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They resist it, they are slippery.
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How do single-layer endothelial cells resist clotting? 3 ways
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1. endothelial protein C receptors 2. generate ; secrete antithrombotic substances 3. secret vasodilating substances including NO3
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What happens when endothelial cells/lining get injured?
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Produce substances that encourage localized clotting
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Where do the endothelial clots form and why is that problematic?
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They form in the local microvasculature and further damage endothelium.
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What happens if endothelial damage is extensive?
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Cells are damaged and microvessels are porous and leaky
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What happens with leaky vessels ; why problematic?
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fluid leaks into interstitial spaces causing edema ; worsening hypovolemia
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What happens when damaged endothelial cells secrete too much NO3 cuz of damage?
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Vasoregulation is impaired and vessels stay dilated...
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What can be a temporary effect of this unregulated vasodilation? Then what?
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Temporary Excellent perfusion, then as vasodilation fails to self-regulate...boom! HYPOperfusion
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What is refractory hypotension?
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When efforts to raise BP (fluids) fail to achieve desired effect.
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As sepsis progresses, what can severe vasodilation, refractory hypotension ; impaired microcirculation lead to?
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MODS ; death
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Severe/Septic shock: S/S Labs? WBC, bands, platelets, glucose?
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WBC ;20,000/mm OR 10% Platelets: DECREASED due to over distribution/dysfunctional use Glucose: INCREASED due to stress response, metabolic demand
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Severe/Septic shock: Renal?
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Decreased urine output, shows up early! NO perfusion, no pee pee
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Severe/septic shock: Vitals?
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Temp: febrile (38C, 100.4F or higher) or hypothermic (36C or 96.8F or lower) Pulse: ;90 Bpm: tachycardia (decreased volume, infectious process, cytokines, adrenal trigger) RR: ;20/min or PaCO2 ;32
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What is hyperglycemia doing to effect S/S in severe sepsis or septic shock?
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Helps coagulate in microvasculature, gunks up caps and feeds bacteria
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Severe/septic shock: What is assessment of extremities probably going to reveal?
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Mottled, cool, pale skin. (Decreased perfusion), petechiae or purpura (dyfunctional clotting), poor cap refill.
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Severe/septic shock: Why pt tachypnic?
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Trying to blow off excess CO2 metabolic acidosis, hyperventilating, won't work
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Severe/septic shock: Neuro status?
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Whacked, altered LOC and probably not oriented.
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Severe/septic shock: How will pt feel?
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Like hell, probably major chills, extreme lethargy, 'out of it'
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Septic shock is what kind of shock?
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distributive: vessels inappropriately dilated for too long, 3rd spacing due to damaged caps (endothelial injury) leaking fluid into tissue
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classic signs of a systemic infection:
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Tachypnea, Tachycardia, HIGH WBC count (left shift?), FEVER
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The severity of the septic reaction should also produce other warning signs, such as:
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Hot, flushed skin Newly altered mental status Hypotension Widened pulse pressure (Pulse pressure is the difference between the systolic and the diastolic blood pressure values.) Elevated blood lactate level Thrombocytopenia
