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Sepsis Exam

Terms in this set (54)

presence of sepsis with hypotension despite adequate fluid resuscitation along with the presence of inadequate tissue perfusion. body's response to infection is exaggerated, resulting in increase in inflammation and coagulation, and a decrease in fibrinolysis. three major pathophysiologic effects: vasodilation, maldistribution of blood flow, and myocardial depression. pts often have hypotension, respiratory failure, alteration in neurologic status, acute kidney injury with decreased urine output, and GI dysfunction. pts require large amounts of fluid replacement. goal is to achieve a targeted response based on CVP, ScvO2, cardiac ultrasound, a focused physical assessment, fluid responsiveness, or other measures. Use of a fluid challenge technique (crystalloids if associated with hemodynamic improvement [increased MAP and/or other measures]) is recommended. Vasopressor drug therapy may be added for mean arterial pressure (MAP) that does not respond to initial fluid resuscitation. Vasopressin may be added to patients refractory to vasopressor therapy. IV corticosteroids are only recommended for patients who cannot maintain an adequate BP w/ vasopressor therapy, despite fluid resuscitation. ABX are an important component of therapy for pts. They should be started after cultures are obtained and within the first hr of severe sepsis or septic shock. get early medical attention w/ evidence of infection, complete entire course of ABX. risk factors: endotoxins causing massive vasodilation. most common cause is gram negative bacteria. monitor cultures, pt, inr, aptt.
The initial assessment focuses on assessing responsiveness and ABCs, oxygentation. Then focuses on tissue perfusion and includes eval of trends in SV, peripheral pulses, LOC, cap refill, skin (e.g., temp, color, moisture), and urine output. goals include evidence of adequate tissue perfusion, restoration of normal BP, return/recovery of organ function, and avoidance of complications from prolonged states of hypoperfusion. RN role involves monitoring pts ongoing physical and emotional status, identifying trends to detect changes in the patient's condition, planning and implementing nursing interventions and therapy, evaluating the patient's response to therapy, providing emotional support to the patient and caregiver, and collaborating with other members of the health team to coordinate care. pt in shock requires frequent assessment of heart rate/rhythm, BP, CVP, SvO2, and pulmonary artery (PA) pressures or arterial pressure wave-form analysis for cardiac output (APCO); neurologic status; respiratory status, urine output, and temperature; capillary refill; skin for temperature, pallor, flushing, cyanosis, diaphoresis, or piloerection; and bowel sounds and abdominal distention, as well as prevention of health care-associated infections. Rehabilitation of the necessitates correction of the precipitating cause, prevention or early treatment of complications, and education focused on disease management and/or prevention of recurrence based on initial cause of shock. report urine output if <20 mL/hr. high flow O2 such as 100% nonrebreather face mask. if pt has COPD insert nasal cannula 2L/min and increase O2 flow as needed. Intubation and emergency resuscitation. Patent IV access. for hypotension, place pt flat w/ legs elevated to increase venous return.