Sepsis
Risk factors
Diabetes, immunosuppression, invasive procedures, malnutrition, age older than 80, chemotherapy, and alcoholism
What is the EKG interpretation of a P wave?
Atrial Depolarization
ABG Interpretation
pH -> (acidic) 7.35-7.45 (basic)
PaCO2 -> (basic) 35-45 (acidic)
HCO3 -> (acidic) 22-28 (basic)
What would the nurse monitor in the suction chamber?
Verify that water, suction, and dial on dry suction are at prescribed level
Pulmonary contusion
dyspnea, chest pain, pt may present as stable as it takes time for fluid to build up
Stages of Sepsis
Initial: systemic inflammatory response syndrome, disseminated intravascular coagulation, multiple organ dysfunction syndrome
Leads to septic shock
EKG interpretation and duration of QRS complex
ventricular depolarization; <0.10 sec
Chest X-ray indication
assess lung pathology -> evaluate chest status and provide baseline comparison
What would the nurse monitor in the water seal?
Monitor bubbling - intermittent is expected but consistent bubbling indicates air leak
Pneumothorax
tachypnea, diminished LS, asymmetrical chest expansion, tracheal deviation, JVD
Labs to assess
Lactate >= 4mmol
WBC: decreased with an increased # of neutrophils
EKG interpretation of T-Wave
ventricular repolarization
What is a Thoracentesis
What would a nurse monitor in the drainage collection chamber?
Drainage should be less than 70 mL/hr and color of drainage should remain consistent.
Hemothorax
tachypnea, diminished LS, asymmetrical chest expansion, chest pain, tachycardia, hypotension
Treatment
Measure lactate -> obtain blood cultures -> broad spectrum antibiotics -> vasopressors
O2 therapy, blood replacement, and monitor blood glucose
PR Interval
0.12-0.20 sec
What is a pneumothorax? What are the different kinds?
Air in the pleural space that compresses the lung
Open: results from a hole in the chest wall
Closed: air leaks into the space from within the lung
Tension: opening in the chest wall that allows air to enter but nor exit
How much water should the water seal contain?
Early Stage Sepsis
increased RR r/t, decreased perfusion, hypotension, decreased urine output
Disseminated intravascular coagulation
Clotting factors deplete -> bleeding becomes uncontrolled
bleeding from venipuncture sites and mucous membranes
QT Interval
<0.44 sec
(small box is 0.04 sec)
What is a hemothorax?
Blood in the pleural space
What does the water seal do?
Traps air so it does not re-enter the chamber.
Late Stage Sepsis
decreased brain perfusion, tachycardia, elevated serum lactate, organ damage occurs