Two of the four: - body temp >100.5 or 90bpm -RR>20 or PaCO2 12k or 10% immature bands

Sepsis Flashcards by Ilonna Kirkland

which is NOT a part of the one hour bundle?
- Draw Lactate levels
-Obtain blood cultures
-Administer antibiotics
-Medicate for pain

medicate for pain

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what is the 1 hour bundle?

-drawing lactate and blood cultures
-administering broad spectrum
antibiotics
-administering IV fluids
-giving vasopressors if needed

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what lab is indicative of sepsis?
- decreased lactate
- increased lactate
-decreased potassium
-positive wound cultures

increased lactate

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what are the hallmarks of sepsis?

rising serum procalcitonin levels
increasing serum lactate levels
abnormal white blood cell count

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what does a rising serum procalcitonin level indicate?

inflammatory cytokine reponse

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what should the nurse report to a HCP?
-pain at the surgical site
-serous drainage from surgical site
-mild edema surrounding surgical site
-redness of surgical site

redness- indicates infection

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what is a priority action when adminisering antibiotics in a pt with sepsis?
-administer antibiotics within 2 hours
-obtain VS
-obtain informed consent
-ensure blood cultres were drawn

ensure blood cultures were drawn

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which of the following indicates organ dysfuntion?
-temperature 97.5 F
-Capillary refill less than 3 seconds
-O2 sat 95%
-urinary output 15mL/hr

urinary output 15mL/hr

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how many of the criteria are to be met to be considered SIRS?

2/4

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the nurse is caring for a pt with suspected sepsis. the nurse knows that the following criteria is included in SIRS (systemic inflammatory reponse syndrome) criteria:
HR<80bpm
Elevated lactic acid levels
increased capillary refill
hypoglycemia

elevated lactic acid levels

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which assessment findings would alert the nurse of the possibility of sepsis?
Inc HR, Inc, RR, and Inc BP
Inc HR, Inc RR, dec BP
dec HR, inc RR, dec BP
inc HR, inc RR, hypertensive crisis

increased HR and RR with a decreased BP

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a nurse educating clients on sepsis prevention includes teaching that the risk of sepsis is increased with:
adequate nutrition
undergoing surgery
being 25 years old
having a hx of headaches

undergoing surgery

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the nurse is caring for a client with sepsis. the nurse should question orders for
blood cultures
lactate levels
central venous pressure monitoring
administration of a vasodilator

administration of a vasodilator

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when caring for a client with sepsis, the nurse knows that the following should be performed first:
give a broad spectrum abx
give a narrow spectrum abx
obtain blood cultures
obtain a type and cross match for blood products

obtain blood cultures

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at what stage of the sepsis spectrum may a client look better?
sepsis
severe sepsis
septic shock
organ failure

severe sepsis

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when caring for a client with sepsis, the nurse knows that the pathophysiology of sepsis includes
vasoconstriction
hyoxia
decrease in pro-inflammatory cytokines
decreased utilization of clotting factors

hypoxia

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the nurse caring for a client with sepsis knows that an elevated lactic acid level indicates
cellular hypoxia
infection
increased bleeding risk
decreased kidney function

cellular hypoxia

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the nurse caring for a pt with sepsis knows that a gram-negative bacteria is most likely cause. gram-negative bacteria does NOT include:
psudomonas auruginosa
escherichia coli
klebisiella
staphylococcus

staphylococcus

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the nurse is caring for a client who has sepsis and is hypotensive. the nurse should give the following of amount of fluids intravenously
30mL/kg
35mL/kg
40mL/kg
45mL/kg

30mL/kg

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What is the sepsis spectrum?

SIRS, sepsis, septic shock, mods, death

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What is SIRS?

Systemic inflammatory response syndrome

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How is SIRS Dx?

Two of the four:
- body temp >100.5 or <96.8
-HR>90bpm
-RR>20 or PaCO2<32 mmHg
-leukocyte count >12k or <4k or >10% immature bands

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What is sepsis

SIRS and confirmed infection, no longer localized->infection spreads system wide

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What are s/s of septic shock?

Warm:compensated, low systemic vascular resistance,increased/ normal CO, warm extremities, reduction in cap refill
Cold: decompensated, increased vascular resistance, decreased CO, cold extremities, blood shunted to core, hypotension, decreased O2 sat, rapid RR, decreased output, LOC changes

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What stage of sepsis has the highest rate/risk of death than sepsis alone?

Septic shock

What stage of sepsis may the patient “look better”?

Sepsis/early septic shock… pooling of blood and capillary leak stimulates increased CO, HR, SBP—> warm extremities and little to no cyanosis… WBC lower bc marrow can’t keep up

What does septic shock require?

Vasopressor therapy to maintain at least 65mmHg AND have a serum lactate level of greater than 2mmol/L despite fluid resuscitation

What complications may occur during septic shock?

MODS and ARDS

What is MODS

2 or more organs that need medical intervention for homeostasis

What is ARDS

Acute respiratory distress syndrome; caused by free radicals of oxygen that damage lung cells

What is the inflammation process?

WBC->Cytokines->trigger local inflammation(constrict small veins and dilate arterioles in are to inc perfusion)-> increased WBCs->kill bacteria->inflammation ceases when infection is gone.

What is septic shock?

Subset of sepsis where there are circulatory, cellular, and metabolic abnormalities that increase the risk of death over sepsis alone

How do you check the progress of infection?

Look for a down-trend in ESR (normal= <20-23mm/hr) and CRP (normal= >1mg/dL); this tracks inflammation

What is the fluid dosing for treating septic shock?

30mL/kg

What two components make up septic shock?

Sepsis and hypotension

Criteria for SIRS

Body temp, HR, RR, WBC count

What must the body temp be to meet SIRS criteria?

Above 100.5 or below 96.8

What must the HR be to meet SIRS criteria?

Above 90 (tachycardia)

What must the RR be to meet SIRS criteria?

Above 30bpm or PaCo2 <32mmHg

What must the WBC count be to meet SIRS criteria?

Above 12,000 or below 4,000 or greater than 10% immature bands

Where is the invading organism usually at?

Tissues rather than the blood, WBC must get into tissues=vasodilation=dec vascular resistance, capillary leak=edema=harder to oxygenate cells

If you are not able to clear the infection locally, what develops?

Early sepsis Mild hypotension Inc RR Mild low urinary output Fever varies Microthrombi forming Hyperdynamic cardiac function(blood pools so skin=warm to touch)

Late sepsis

DIC and hypoxia Anaerobic metabolism- metabolic acidosis Increased stress on body=inc cortisol=hyperglycemia The more severe the response = the higher the glucose Rapid RR Decreased/absent urinary output LOC changes WBC elevated or normal (exceeding available WBC)

Septic shock components

Organ dysfunction Require vasopressor to maintain MAP of at least 65 and serum lactate greater than 2

Warm shock

Compensated stage of shock Systemic vascular resistance low Normal/inc CO Warm extremities Cap refill normal

Cold shock

Decompensated stage Peripheral vascular resistance inc Shunt blood to non vital organs Cold extremities Low CO Delayed cap refill Organ dysfunction and organ failure Uncontrolled bleeding may occur

MODS signs

Low BP, CO Tachycardia Cool,clammy, mottling skin Cyanosis Hypotensive despite fluids Poor clotting uncontrolled bleeding

Who are at risk for sepsis

Immunocompromised, open wounds, central lines, malnutrition, older than 80, DM, invasive procedures, hepatitis, transplants, cancer, alcoholism, HIV/AIDS

what is the qSOFA

Quick sequential organ failure assessment

What does the qSOFA look at

SBP less than 100 RR > 22 Change in LOC Scores 2 or 3=needs an in depth screening

What is the SOFA

Sequential organ failure assessment

Where is the SOFA used

ICU

qSOFA used in

Non ICU settings

What does the SOFA look at?

Resp effort PLT count Liver function (bilirubin) Hypotension Neurological GCS Renal (creatinine) Scored 1-4 The higher the score, the higher the pt is at risk for organ failure/poor outcome/death

Ideal SOFA score

1 or less

Sepsis labs

WBC(inc) PLT/clotting factors(low) Lactate(inc) Procalcitonin(inc, bacterial infection) BUN/Creatinine Hemoglobin and Hematocrit(changes in late sepsis) Blood cultures ABGs

One hour bundle

1. Measure lactate level 2. Obtain blood cultures before abx admin 3. Admin board spectrum abx 4. Begin rapid admin of 30mL/kg crystalloid for hypotension or lactate > or equal to 4 mmol/L 5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP of 65 mm Hg or greater

ABG values

PH 7.35-7.45 PaCO2 45-35 (resp) HCO3 22-26 (metabolic)

HCO3 is associated with… in ABGs

Metabolic

PaCO2 is associated with… in ABGs

Respiratory

Sepsis Flashcards

(61 cards)