Module 1 Flashcards
What does SIRS stand for?
systemic inflammatory response syndrome
What are the stages of sepsis?
SIRS, sepsis, late sepsis, warm shock, cold shock, MODS
Is SIRS only triggered by an infection?
NO; can also be triggered by inflammation
How many of the criteria must be met before SIRS can be confirmed?
2/4
What criteria are monitored with SIRS
body temp, heart rate, respiratory rate, leukocyte count
What must the body temp be to meet SIRS criteria?
> 100.5 or <96.8
What must the heart rate be to meet SIRS criteria?
> 90bpm
What must the leukocyte count be to meet SIRS criteria?
> 12,000 or <4,000 (or > 10% immature bands)
What must the respiratory rate be to meet SIRS criteria?
> 20 breaths/ min (or PaCO2 <32 mmHg)
what does PaCO2 measure?
partial pressure of carbon dioxide in the blood
Will older adults always meet SIRS criteria?
NO
What may be the first signs of SIRS/sepsis in the older adult?
AMS, confusion, agitation, irritability, incontinence
what are band cells?
young, immature white blood cells
What can band cells indicate?
mature WBC are becoming unavailable to fight off infection
What is classified as sepsis?
SIRS + a confirmed infection
In early sepsis, symptoms of our patient may include?
mild hypotension, low urine output, increased respiratory rate
mild hypotension, low urine output, and increased respiratory rate result in (hyper/hypodynamic state)? Will our cardiac output be decreased or increased?
hypodynamic states; decreased cardiac output
What are compensatory responses to impaired gas exchange and perfusion
reduced urine output and increased respiratory rate
Body temperature varies depending on the duration of sepsis meaning we can have
low, high, and normal temperatures
When sepsis first begins, our WBC will most likely be?
elevated
When white blood cells enter the bloodstream, they release cytokines that?
dilate blood vessels and damage blood vessels
When blood vessels dilate, we have decreased
systemic vascular resistance = decreased blood pressure
When the blood vessels become damaged by cytokines, their permeability increases or decreases
increases
When the blood vessels leak into the tissues, what can happen to perfusion and oxygenation?
Fluid buildup = decreased perfusion= decreased oxygenation
What is disseminated intravascular coagulation?
when micro-thrombi form to combat capillary leak and we have systemic clotting. When clotting factors and fibrinogen are used up, it leads to hemorrhage of the blood vessels.
What is the outcome of DIC?
decreased cardiac output, blood pressure, and pulse pressure, decreased platelet count
Micro- thrombi clotting will increase or decrease oxygen to the cells?
decrease –> extra fluid that has leaked + hyper clotting reduces perfusion and gas exchange. can lead to systemic hypoxia which drops O2SAT
When our cells are starved for oxygen, we begin what type of metabolism?
anaerobic
Anaerobic metabolism will cause an increase of this lab value
lactic acid
How does sepsis raise the blood glucose?
raised cortisol levels from stress will stimulate release of glucose from the liver
How will adrenal function be altered during sepsis?
stress of sepsis caused adrenal insufficiency. We have alterations in cortisol metabolism and tissue resistance to glucocorticoids
During the late stages of sepsis and into septic shock, is cardiac function hypo or hyperdynamic?
hyperdynamic
Why does the heart become hyper dynamic in late sepsis/early shock
capillary leaks stimulate the heart into increasing cardiac output
What symptoms can occur during the hyperdynamic state in late sepsis/ early shock?
rapid heart rate, elevated systolic BP, warm extremities, pink skin and MM (no cyanosis)
During late sepsis/ early shock, what may happen to the WBC count?
no longer be elevated/ getting low (bone marrow can no longer keep up)
What are other late signs of sepsis that need to be addressed?
low O2SAT, decreased or absent urine output, change in cognition
What is required for patients to be in septic shock
vasopressor to maintain a map of 65 mm Hg and have a serum lactate level greater than 2mmol/L despite IV fluids (low blood pressure)
what is the early stage of septic shock
warm shock (compensated stage)
What symptoms are seen in warm shock?
low systemic vascular resistance, normal / increased cardiac output, warm extremities, flash capillary refill
During warm shock, is the heart in a hypo or hyper dynamic state
hyper dynamic
In cold shock (decompensated stage) why does peripheral vascular resistance increase
to shunt blood away from nonvital to vital organs (when vascular resistance is higher, it requires less cardiac output which also decreases work on the dysfunctioning heart)
What symptoms are seen during cold shock
cool clammy skin, PVR trying to raise, decreased cardiac output, delayed capillary refill, organ dysfunction, poor clotting
During cold shock, is the heart in a hypo or hyperdnyamic state
hypodynamic
what is MODS
multi-organ dysfunction syndrome (last stage of sepsis)
What stage of shock includes MODS
cold shock
During MODS, we can see skin discoloration known as
cyanosis
What stage of sepsis has the highest death rate?
MODS
During MODS, what other symptoms will we see?
evident organ failure, poor clotting, uncontrollable bleeding, severe hypovolemic shock
Who is at risk for sepsis
immunocompromised (HIV, AIDS, Chemo, transplant, cancer), invasive procedures, malnutrition, diabetes, older adults, open wounds, central lines
Which screening is used in a non-ICU setting
qSOFA
What does qSOFA stand for?
quick sequential organ failure assessment
What does the qSOFA assessment evaluate
hypotension (systolic <100), AMS, tachypnea > 22 breaths/min
A qSOFA score of ____ suggests a greater risk of poor outcomes
2
What assessment tool is used in ICU settings
SOFA
A high SOFA score indicates
greater risk of organ failure, poor outcomes, and death
What is an ideal SOFA score
1 or less
During sepsis, platelets and clotting factors will first be _______. Eventually, they begin to ______.
increased ; decrease
What is procalcitonin, a lab commonly looked at in septic patients
biomarker released in response to bacterial infections
Hemoglobin and hematocrit are labs monitored during sepsis; however,
they typically do not change until late sepsis
Blood cultures need to be taken before
administration of antibiotics
Arterial blood gases can be drawn to help determine
how much oxygen remains in the blood
what is the 1 hr bundle for management of sepsis
steps that must be completed within 1 hour of recognizing sepsis may be present
What is contained in the 1 Hour Bundle?
- measure lactate level
- obtain blood cultures before
- administering broad spectrum antibiotics
- begin rapid administration of 30mL/kg of crystalloid for hypotension or lactate 4mmol/L
- apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP of 65mmHg
What two labs track inflammation
CRP and ESR
What does a vasopressor do?
decrease dilation of blood vessel in order to raise systemic vascular resistance
The nurse is caring for a client with septic shock. Which assessment data alerts the nurse to severe tissue hypoxia?
PaCO2: 58 mm Hg
Lactate: 81 mg/dL (9.0 mmol/L)
Partial thromboplastin time: 64 seconds
Potassium: 2.8 mEq/L (2.8 mmol/L
Lactate
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first?
Administer the antibiotic.
Ensure that blood cultures were drawn
Insert an intravenous line.
Take the client’s vital sign
ensure that blood cultures were drawn
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated
Localized erythema and edema
Low-grade fever and mild hypotension
Low oxygen saturation rate and decreased cognition
Reduced urinary output and increased respiratory rate
low - grade fever and mild hypotension
If we have a client that weighs 50kg, how much fluid would they require
1500 mL
If our blood pressure does not raise after administering fluids, this is classified as
shock
The nurse is caring for a client with suspected sepsis. The nurse knows that the following may indicate sepsis:
a. HR less than 80 BPM
b. Elevated lactic acid levels
c. increased capillary refill
d. hypoglycemia
elevated lactic acid levels
which assessment findings would alert the nurse of possible sepsis?
a. increased HR, increased RR, decreased BP
b. decreased HR, increased RR, decreased BP
c. increased HR, increased RR, hypertensive crisis
d. Increased HR, increased RR, increased BP
A
A nurse educating clients on sepsis prevention includes teaching that the risk of sepsis is increased with?
a. adequate nutriiton
b. undergoing surgery
c. being 25 years old
d. having a history of headaches
B
The nurse is caring fora client with sepsis. The nurse should question orders for?
a. lactate levels
b. administration of vasodilator
c. Central venous pressure monitoring
d. blood cultures
B
when caring for a client with sepsis, the nurse knows that the following should be performed first?
a. give a broad spectrum antibiotic
b. obtain blood cultures
c. give narrow spectrum antibiotic
d. obtain blood type
b
At what stage of the sepsis spectrum may a client look better?
a. septic shock
b. organ failure
c. severe sepsis
d. sepsis
C (heart is in hyper dynamic state)
When caring for a client with sepsis, the nurse knows that the pathophysiology of sepsis includes?
a. decrease in pro-inflammatory cytokines
b. decreased utilization of clotting factors
c. hypoxia
d. vasoconstriction
c
the nurse is caring for a client with sepsis knows that elevated lactic acid levels indicate?
a. decreased kidney funciton
b. increased bleeding risk
c. infection
d. cellular hypoxia
d
the nurse caring for a client with sepsis knows that gram - bacteria is the most likely cause. Gram - bacteria does not include?
a. E-coli
b. pseudomonas aeruginosa
c. klebseilla
d. staphylococcus
d
The nurse caring fora client who has sepsis is hypotensive. The nurse should give the following amount of fluids intravenously?
a. 40mL/kg
b. 45 ml/kg
c. 30 ML/kg
d. 35 mL/kg
c
what is not apart of the sepsis 1-hour bundle?
a. lactate levels
b. obtain blood culture
c. administer antibiotics
d. medicate for pain
d
What lab is indicative of sepsis?
a. decreased lactate
b. positive wound cultures
c. increased lactate
d. decreased potassium
c
What caused procalcitonin levels to be high during sepsis?
responding to inflammatory cytokines
What assessment finding requires the nurse to notify the provider?
a. redness around surgical incision
b. serous drainage from a surgical incision
c. pain at a surgical incision
d. mild edema ata surgical site
a
What is a priority action when administering antibiotics in a patient with sepsis?
a. administer ABX within 2 hours
b. obtain Vs
c. ensure blood culture was drawn
d. obtain informed consent
c
Which of the following indicates organ dysfunction?
a. temp 97.5
b. o2 95
c. capillary refill less than 3 seconds
d. urinary output 15mL/h
d
During sepsis, procalcitonin levels will?
rise
During sepsis, lactic acid levels will?
rise
During sepsis, the white blood cell count will?
be elevated –> become normal or low
During sepsis, platelets and fibrinogens levels will?
be elevated –> become low from DIC
CRP and ESR, used to track inflammation, will be?
very elevated in the beginning
Indicators for improved tissue perfusion?
arterial blood gases within normal range (pH, Pao2, PaCo2), maintenance of urine out 0.5ml/kg/hr, maintenance of MAP >65, absence of MODS, extremities warm
Treatment of sepsis after the 1 hr bundle
- drug therapy 2. source control 3. temperature 4. address adrenal insufficiency 5. blood glucose 6. bicarbonate therapy 7. clotting 8. blood replacement 9. oxygen therapy
What does source control mean when related to sepsis?
finding the route of the source ; ex: abscess drainage, removal of infected device (such as Foley catheter), and debridement of infected tissue
What medications are given for adrenal insufficiency
corticosteroids such as IV hydrocortisone and oral fludrocortisone
How do we manage hyperglycemia and sepsis
insulin therapy , should maintain between 140-180 (remember that if blood glucose is less than 110 it can increase mortality)
What do we administer to help combat metabolic acidosis?
bicarbonate therapy
What are expected outcomes of sepsis treatment?
maintain normal aerobic metabolism and increased blood pressure
Discharge teaching for a patient at risk for sepsis?
importance of vaccines, wound care, self care strategies, how to obtain temperature, notify provider if signs of infection appear, importance of taking antibiotic as prescribed
What are examples of self-care strategies should we include in our discharge teaching?
good hygiene, handwashing, balanced diet, rest, exercise, skin care, mouth care
The nurse is caring for a client with sepsis. Which client assessment date would reflect an early sign of progression to shock?
heart rate 118beats/min
cool, mottled extremities
MAP changes from 62 to 80
dilated pupils
heart rate 118 bpm (client is progressing to warm shock and the high heart rate is compensating)
the nurse is teaching a client’s family about septic shock. Which of the following teachings will the nurse include. Select all that apply
a. the blood cultures will tell us for sure if your loved one has septic shock
b. the clients change in behavior and lethargy may be associated with septic shock
c.antibiotics will be started within the hour to treat the sepsis
d.an insulin drip has been started to keep the clients glucose as low as possible
e.septic shock is easily treated with multiple antibiotics
b. the clients behavior
c.antibiotics started within an hour
rationale:
a: blood cultures are not always definitive or bacteria may not be present
b. late sepsis (which progresses into shock) can show AMS
c. abx are included in the 1 hour bundle
d. we want the clients glucose between 140-180
e. shock is not easily treated when it is this late
The nurse is caring for a client with septic shock. Which assessment findings indicate improvement in organ perfusion?
a. MAP change from 85 to 60 mmhm
b. change in heart rate from 98 to 76 bpm
c. urine output remains 15 ml
d. capillary refill changed from >3 s to 2 s
d
What are non-modifiable risk factors for CVD?
age, sex, ethnic origin, family history of CVD
do males or females have a higher risk of CVD
males
Our clients with coronary artery disease and valvular disease have an increased or decreased risk of heart disease
increased
Clients with diabetes have an increased or decreased risk of heart disease
increased
What are modifiable risk factors our patients at risk of CVD can change?
lifestyle habits such as smoking, physical inactivity, obesity, psychological variables
Cigarettes increase or decrease risk of CVD
increase ; specifically CAD and PVD
What are pack years?
number of packs per day multiplied by years patient has smoked
Sedentary lifestyles will increase or decrease risk of CVD
increase
What are the exercise recommendations for adults in the US to not have a sedentary lifestyle. Doing these can decrease risk of CVD
150 minutes moderate exercise, 70 minutes vigorous exercise ; 2 weight lifting days/week
Does obesity increase or decrease risk of CVD
increase
What does a BMI of 25-30 or greater indicate ?
25-30overweight ; 31 or greater is obesity
A BMI of greater than 30 is associated with?
HTN, hyperlipidemia, diabetes –> increaseed risk for CVD
What psychological factors can increase chances of CVD?
high stress, depression, frequent hostility/angriness
What past medical history should the nurse recognize as risks for CVD
DM, renal disease, high BP, heart disease, pulmonary diseases, anemia, bleeding disorders, thrombophlebitis
A normal sinus rhythm will have a heart rate between
60-100
Sinus bradycardia will show a heart rate less than?
60
Sinus tachycardia will show a heart rate greater than
100
the nurse is conducting an admission assessment on a female client. which o the following assessment data would the nurse identify s a risk factor for cardiovascular disease
a. vmi of 28
b. bp of 120/68 mm HG
c. triglycerides 128
d. exposure to second hand smoke
e. moderate exercise for 20-30 min weekly
a, d, e
the nurse is caring for a client with hypovolemia, which assessment data would the nurse anticipate?
a hyperkinetic pulse
b. auscultation of a bruit
c.orthostatic hypotension
d. increased pulse pressure
c
The nurse is caring for a client scheduled for a cardiac catheterization, which statement made by the client on the way to the procedure would require immediate action by the nurse
a. I don’t know what Ill do if they find a blockage in my heat
b. my allergies are bothering me, so I took some Benadryl last night
c. I was nervous last night but I still remembered to take my warfarin
d. I am hungry
c
the nurse is teaching course on blood pressure management. which of the following statements would the nurse include?
a. blood pressure is a measure of the force that exits against the vessel walls
b. cardiac output has little effect on overall blood pressure
c. the kidneys have a role in the regulation of blood pressure in the body
d. If the peripheral vascular resistance increases, blood pressure decreases
e. respiratory rate is most affected by increased blood pressure
a, c
the nurse is caring for an older adult client who reports dizziness upon standing. How should the nurse explain this to the client
a. activity intolerance is normal as you age
b. this may be associated with age related EKG changes
c. when you move too quickly your aging heart cannot keep up
d. baroreceptor function that helps regulate BP can decline with a ge
d
The client with HF has reported a 7.6 lb weight gain over the past week. the nurse suspects the primary HCP to do this intervention?
a. dietary consult
b. sodium restriction
c. daily weight monitoring
d. restricted activity
c
the nurse is conducting a health history on a client experiencing dyspnea on exertion and heart failure (HF). which assessment data will the nurse anticipate
a. fatigue
b. swelling of one leg
c. slow heart rate
d. brown discoloration of lower extremities
a
Which client has the highest risk for cardiovascular disease?
a. man who smokes and whose father died at 49 to MI
b. woman with abdominal obesity who exercises three times per week
c. woman with diabetes who HDL is 75 mg/dL
d. man who is sedentary and reports four episodes of strep throat
a
Which nursing assessment statement reflects appropriate cardiac physical assessment technique?
a. I wil auscultate the aortic valve in the second intercostal space at the right sternal border
b. I will assess for orthostatic hypotension by moving the client from a standing to reclining positin
c. I will palpate the apical pulse over the 3rd intercostal space MCL
a
A client has been admitted to the ER with chest pain radiating down the left arm. which elevated lab value is most indicative of MI?
a. c reactive protein
b. homocysteine level
c. creatinine kinase
d. troponin
d
the nurse is teaching a class on risk factors for cardiovascular disease. which risk factors will the nurse include? select all that apply
a. fiber rich diet
b. elevated c - reactive protein levels
c. low blood pressure
d. elevated HDL
e. smoking history
b , e
(c- reactive protein is suggestive of inflammation, which is a risk factor for atherosclerosis and cardiac disease)
the client asks about MODIFIABLE risk factors for heart disease. Which nursing response is appropriate?
a. cigarette smoking is one of the most significant modifiable risk factors
b. your personal health over the past 10 years is a modifiable risk
c. diabetes is a modifiable risk factor
d. overall mass index is non modifiable
e. increasing exercise is a method to modify your risk
a ,e
What type of rhythm is this?
normal sinus
What type of rhythm is this?
sinus bradycardia
What type of rhythm is this?
sinus tachycardia
How to determine heart rate on a rhythm strip?
- determine we have three tick-marks at the top (or 30 large boxes)
- count how many QRS complexes in 6 seconds and multiple by 10
30 large boxes, or 3 tick marks is equivalent to how many seconds
6
How many seconds is one small box
.04
How many seconds is one large box
.20 s
What does the P wave represent ?
atrial depolarizatioin
What does the QRS interval represent
ventricular depolarizaton