Sepsis Flashcards
What do you suspect is happening to Anne ?
Suspect Anne is septic
What factors led you to this conclusion ?
Day 5 postnatal - feeling unwell, shivery, severe abdominal pain.
Diarrhoea and vomiting.
Pyrexia - 39.5
Tachycardia
Hypertensive
Episiotomy that was suctured
What would your first step be?
Call for assistance
Enter room and introduce myself to Anne- ask how she is feeling.
Emergency buzzer - summon help.
Request urgent medical assistance as Anne has suspected sepsis.
Emergency trolley.
Emergency phone call - 2222
Request - obstetrician, anaesthetist, senior charge midwife, any other available staff. Inform microbiologist & bacteriologist.
What would you do next?
Once my help has arrived into room I would give an SBAR.
Situation - This is Anne, I suspect she has sepsis.
Background - SVD 5 days ago, episiotomy that was sutured.
Uneventful postnatal period.
Has attended triage today due to feeling unwell over the past 24 hours.
Assessment - Reported feeling shivery, severe abdominal pain, vomiting and diarrhoea.
Observations - tachycardic, hypertensive and pyrexia.
Recommendations - Initiate sepsis 6 protocol within 1 hour of diagnosis.
ABCDE & AVPU.
Cannulate & catheterise.
Continuous 5 minutely observations.
3 ins - oxygen, fluids, IV ABX.
3 outs - bloods, urine, cultures.
Airway
Going to use ABCDE approach - assess for any dangers to ann and myself or others.
Assess the situation and provide appropriate care and treatment.
checking for any signs of obstruction, must ensure she is maintaining her own airway.
If not : head tilt, chin lift - prevent tongue from obstructing airway.
Tongue sweep - check if anything is present in mouth.
Guedel airway - helps maintain airway. Measure from the jaw to the corner of the mouth, using as a tongue depressor then rotate 180 once reached the back of the mouth.
Breathing
Check breathing - look, listen, feel
Check for chest wall movement - rising and falling, symmetrical.
Listening for any wheezing or strider, obstruction?
Feeling for breathe against cheek.
Counting respiration rate : 12-20.
Saturations : >95
15/L min oxygen via facial trauma mask as per sepsis 6 protocol.
If not breathing - require 2 person bag-mask ventilation.
Circulation
Assess circulation - pulse, peripheral perfusion, blood pressure.
Pulse : rate rhythm and volume.
Peripheral perfusion : capillary refill time <2 seconds.
Blood pressure.
Commence MEWS chart - 5 minutely obs
Help visualise trend and detect deterioration or improving condition.
Circulation - cannulate
Gain venous access to obtain bloods, administer fluids and antibiotics.
2x wide bore cannulas grey (14-16)
Aseptic non touch technique.
Sterile dressing, date and time.
Flushed by someone IV trained.
Bloods -
FBC
GROUP AND SAVE
LFT
U+E
CRP
Serum Lactate
Blood Cultures
Circulation - Antibiotics
Now cannulated I would administer IV ABX as per sepsis 6 Protocol.
Broad spectrum IV ABX - unsure of sight of infection until blood cultures return.
E.g metronidazole - IV
Remember to have prescribed by doctor, ensure correct dose, route and patient prior to administering.
Run through by someone IV trained.
Circulation - Fluids
Next I would administer fluids as per sepsis 6 protocol.
Hartmans- 1000mls over 30 minutes
Gelofusion - 500mls over 30 minutes.
Check expiry date, ensure solution is not contaminated.
Document batch number and expiry date.
Run through by someone IV trained.
Circulation - catheterisation
I would then catheterise as it is import to monitor fluid output as part of sepsis 6 protocol.
I would commence a fluid balance chart, measuring and recording fluid input and output.
Size 12 indwelling foleys catheter with urometer attached. Using an aseptic non touch technique with consent.
Remeber :
Must be vigilant for fluid overload and pulmonary oedema.
Can also indicate renal function.
Accurate fluid monitoring and documentation is essential.
25ml/hr.
Circulation - investigation
Part of circulation would be to try identify the source of infection by investigating.
I would do this by carrying out the following culture and sensitivity investigations :
MSSU
High vaginal swab
Episiotomy wound swab
Throat swab
Stool sample
Send to labs.
Disability
Assess responsiveness using AVPU
A- alert, able to speak.
V- responsive to vocal stimuli.
P- responsiveness to painful stimuli.
U- unresponsive to all stimuli.
Ensuring someone remains with woman all throughout care and continues to assess responsiveness.
Exposure
Through examination is vital whilst maintaining and respecting privacy and dignity.
Temperature - thermometer. Can give 1g paracetamol as per weight.
Limb temperature - hot, cold, clammy ?
Colour - check for mottled skin, pallor, cyanosis.
Palpate fundus - any tenderness?
Perineal wound - any redness, swelling, discharge.
PV loss - colour, odour clots and amount.
Transfer
Using MOVE acronym once the women’s is stable for transfer we would prepare to transfer to isolation to prevent the spread of infection.
M- full set of observations prior to transfer, ensure stable for transfer. All equipment is safely transferred with woman such as IV fluids, infusions etc.
O- oxygen, if still required portable oxygen will be required for transfer.
V- venous access already as cannulas inserted.
E- expertise awaiting at HDU, department informed before arrival, barrier nursing, cared for by suitably qualified midwife.
