SIRS/Sepsis

Question 1

inflammatory process

Answer 1

1. cell injury
2. chemical mediators
3. vasodilation
4. vascular permeability
5. immune system activation

Question 2

localized infection assessment findings

Answer 2

redness, heat, swelling, pain

Question 3

systemic infection assessment findings

Answer 3

elevated leukocyte, fever, malaise, anorexia

Question 4

systemic inflammatory response syndrome (SIRS)

Answer 4

not a disease process
a proinflammatory response precipitated by a nonspecific insult: mechanical, chemical, or ischemic

Question 5

SIRS criteria

Answer 5

temperature >38 or <36
heart rate > 90
respiratory rate >20 or PaCO2 < 32mmHg
WBC >12 or <4

Question 6

dysregulated response

Answer 6

uncontrolled release of proinflammatory mediators
insult: cell injury
early mediators: TNF, IL-1
late mediators: free radicals, prostaglandins

Question 7

SIRS response

Answer 7

vasodilation: delivers oxygen, glucose, increases transport of cells
microvascular permeability: nutrient transport, cell access to insult
cellular activation: phagocytosis, healing
coagulation: repair tissue

Question 8

sepsis criteria

Answer 8

microbial infection: bacteria, virus, fungi
AND
2 SIRS criteria:
temp >38 or <36
HR > 90
RR >20
WBC >12 or <4

Question 9

sepsis response

Answer 9

excessive vasodilation: decreased SVR, hypotension
increased microvascular permeability: 3rd spacing, decreased blood volume
cellular activation and increased mediators released: TNF alpha causing microvasculature constriction
coagulation: increased microthrombi with a procoagulant space

Question 10

sepsis continuum to shock

Answer 10

maldistribution of blood volume: regional tissue hypoxia, anerobic metabolism, lactic acidemia
shock is present when symptoms are unresolved by fluids and require vasopressors

Question 11

sepsis assessment findings

Answer 11

general: abnormal vitals, altered LOC
hemodynamic: SBP <90 or MAP <65
tissue perfusion: increased cap refill, skin mottling, lactate >2 mmol/L
inflammatory: WBC >12

Question 12

sepsis laboratory studies

Answer 12

lactic acid >2
procalcitonin

Question 13

coagulopathy tests

Answer 13

PT/INR increased: test of prothrombin
PTT decreased: tests all the clotting factors

Question 14

nurse driven protocols for surviving sepsis

Answer 14

early identification: 2 out of range vitals or SIRS criteria
suspected or known infection
hour 1 sepsis bundle initiation

Question 15

sepsis hour one bundle

Answer 15

1. measure lactate
2. obtain blood culture prior to administering antibiotics
3. administer broad spectrum abx
4. rapid administration of 30mL/kg of crystalloid for hypotension or lactate >4
5. apply vasopressors for hypotension after fluid challenge to maintain MAP >65

Question 16

sepsis vasoactive management

Answer 16

norepinephrine is first line ->
target MAP of 65 ->
use on invasive blood pressure monitoring ->
might need peripheral IV to not delay support -> add vasopressin -> add dopamine or switch to epinephrine

Question 17

sepsis nursing management

Answer 17

fluid resuscitation
timely abx administration
reassessment
vasoactive med management

Question 18

sepsis NANDAs

Answer 18

ineffective tissue perfusion
decreased cardiac output
fluid volume deficit
impaired gas exchange