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