Infections and Sepsis

Question 1

What are the 3 core or macro aspects of dealing with sepsis in a patient?

Answer 1

Recognise, resus, refer

Question 2

What assessments should be considered for a potential sepsis case?

Answer 2

~Physical assessment - A-G
~Focussed assessment (e.g. respiratory if symptoms present)
~Blood cultures
~UA/MSU cultures
~any other relevant cultures (e.g. would swab)
~ Chest X-ray

Question 3

What are the 6 main components of sepsis Resus?

Answer 3

1. Oxygen = maintain ^95% SpO2
2. Blood cultures
3. Check Serum lactate
4. IV fluids
5. Antibiotics
6. Monitoring and Assessment

Question 4

What are some risk factors for Sepsis?

Answer 4

1. Re-presentation within 48hrs
2. Recent surgury or wound
3. Indwelling medical device
4. Immunocompromised
5. Age > 65yrs
6. Fall

Question 5

What are some ‘subjective’ Signs and symptoms of Sepsis?

Answer 5

1. Fever or Rigors
2. Dysuria/frequency
3. Cough/speutum/ breathlessness (SOB)
4. Line accosiated infection
5. Abdo pain
6. altered LOC/ cognition

Question 6

How many risk factors/s&s’ and yellow/ red crieteria are needed to place a patient on the sepsis pathway?

Answer 6

1x risk factor and EITHER
2 x yellow criteria OR
1x Red criteria

Question 7

What are the red zone criteria?

Answer 7

Systolic BP (SBP) <90mmHg
Lactate > 4mmol
Base excess < -5.0 (related to PH? = indic. acidosis or the other one…)

Question 8

What are the yellow zone criteria?

Answer 8

RR <10 or >25
SpO2 <95%
HR <50 or >120
Altered LOC / new onset of confusion
Temp <35.5 or >38.5
Lactate >2mmol/L is significant

Question 9

What are the nursing considerations for A - airway, in a septic patient?

Answer 9

Assess and maintain airway

Question 10

What are the nursing considerations for B - Breathing in a septic patient?

Answer 10

assess and administer O2 PRN (aim SpO2 >95%)

Question 11

What are the nursing considerations for C - Circulation, in a septic patient?

Answer 11

Lactate, vascular access, Blood/culture collection, Fluid resus & antibiotics

Question 12

Within what time would ABx’s have to be administered to be considered the gold standard?

Answer 12

Within 1 hr of presentation/ diagnosis

Question 13

What is the minimum # of blood cultures needed to collect for a potential septic patient?

Answer 13

at least 2 sets

Question 14

What are the nursing considerations for D- disability, in a septic patient?

Answer 14

Assess LOC using AVPU

Question 15

What are the nursing considerations for E - exposure, in a septic patient?

Answer 15

Re-examine patient for other potential sources of infection to guide further investigations

Question 16

What are the nursing considerations for F - Fluid, in a septic patient?

Answer 16

Monitor/ document strict fluid input/output, and consider IDC if not already in situ

Question 17

What is the final step of the ‘Resus’ portion of the sepsis pathway?

Answer 17

Monitor and reassess

Question 18

After completing the sepsis pathway, what are some signs that indicate a patient is deteriorating further?

Answer 18

RR is in yellow or red zone
SBP <100mmHg
deceased LOC
Urine output <0.5mL/kg/hr
Serum lactate of 2mmol/L (or increasing)
if no improvement after fluid resus ?septic shock