Infection Cascade
Body's defense mechanisms against pathogens
What are:
Primary: Skin, mucous membranes at body openings, respiratory tract, GI tract, urinary tract, Neutrophils, inflammation enzymes such as histamine and fibrinogen, crying, etc.
Complications of Sepsis
What is:
> Multiple organ dysfunction, DIC, ARDS, Death
Normal ABG Range (pH, PaCO2, PaO2, HCO3, SaO2)
What is:
pH: 7.35 to 7.45, PaCO2: 35 to 45, PaO2: 80 to 100, HCO3: 80-100, SaO2: 95 to 100
Normal Serum Lactate
What is 0.5 - 2
The nurse is assessing an older adult client with acute respiratory distress syndrome (ARDS). Which assessment finding indicates an early sign of hypoxemia for this client? (Select all that apply.)
A. Agitation
B. Tachypnea
C. Confusion
D. Anxiety
E. Dyspnea
A,C,D
Anxiety, agitation, and confusion are assessment findings that older adult clients experience as early signs of hypoxemia. While dyspnea and tachypnea may indicate hypoxemia, these are not early symptoms the nurse will find during the assessment process.
Risk factors for infection/sepsis
What are:
> Elderly, newborns, immunocompromised, recent injury or surgery, chronic illnesses, catheters and tubing, central lines, ventilator support
Ways to prevent sepsis
What is:
> Primary: Aseptic technique, vaccines, public awareness, abx prophylaxis, discontinue lines when not needed, ween off ventilator, handwashing
> Secondary: Sepsis care bundle, foley care, respiratory care (q4 vent, q shift non vent), line care, scrub the hub, following isolation guidelines
> Tertiary: ICU care, rehab
Signs and Symptoms of ARDS
What are:
> Changes in respiratory rate, changes in respiratory pattern, changes in lung sounds, hypoxia (pallor, cyanosis, increased HR, restlessness, confusion), decreased O2, cyanosis, crackles in lungs
Verifying tube placement
What is:
> Checking end-tidal carbon dioxide levels, chest x-ray, assessing breath sounds bilaterally, looking for symmetrical chest movement,
The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply.)
A. Shortness of breath
B. Rapid breathing
C. Fluid imbalance
D. Chest x-ray clear of infiltrates
E. Arterial blood gases varying from normal limits
A, B, D
Rapid breathing and shortness of breath are two early symptoms of ARDS that manifest in the first day or two after the initial injury. On chest x-ray, no infiltrates will be noted in the early stages and lung sounds will be clear. Fluid imbalance and abnormal arterial blood gas levels will be noted later in the disease process.
Body's reaction to controlled localized infection. (SXS or lack there of at local site and systemically)
What is:
> At site you may experience redness, swelling, heat, pain
> Systemically you should not have a fever, regular HR, normal O2 saturation, normal UOP
Sepsis Bundel
What is:
> Measure serum lactate, draw blood, administer abx, administer fluids (30 ml/hr), vasopressors (If MAP does not stay above 65 after fluids)
Direct vs indirect causes of ARDS
What is:
Direct: Aspiration, chest trauma, pneumonia, pulmonary contusion, inhalation injury, pulmonary embolus
Indirect: Sepsis shock, pancreatitis, burns, TRALI (transfusion related acute lung injury), cardiopulmonary bypass, drug/alcohol overdose
Red man syndrome signs and symptoms and interventions
What is:
> Sxs: Flushing, erythema, pruitus, usually affects upper body, neck and face, myalgia, dyspnea, hypotension
> Interventions: Slow or stop infusion, administer antihistamine, restart infusion at a slower rate after symptoms resolve
The nurse would recognize which clinical manifestation as suggestive of sepsis?
a- Sudden diuresis unrelated to drug therapy
b- Hyperglycemia in the absence of diabetes
c-Respiratory rate of seven breaths per minute
d-Bradycardia with sudden increase in blood pressure
B- Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.
Signs and Symptoms of systemic infection
What are:
> Fever, Mild hypotension, Tachypnea, Low urine output
Types of Sepsis (Signs and symptoms, what they indicate, treatment)
What are:
> Early Hypodynamic: Short duration, manifestations are subtle, if treated at this point can be stopped. SXS: Mild hypotension, low UOP, decreased cardiac output, elevated WBC, increased RR, may or may not have fever
> Hyperdynamic: Patient may appear to be getting better symptom wise but labs will show patient is still septic, usally lasts 24 hours. SXS: Increased BP, Decreased or absent UOP, increased cardiac output and HR, low WBC, increased RR, potential fever, warm extremities, no cyanosis, low O2 sat, mat have mental status changes
> Severe Sepsis/ Late Hypodynamic: Body unable to compensate, decreased perfusion to organs causing organ damage. SXS: Clotting/bleeding, Decreased BP and CO, increased HR, arrhythmias, increased RR, decreased O2 sats, elevated liver enzymes, jaundice, increased serum lactate, decreased response to stimuli, pale dry skin, increased BS, thready, diminished pulses, cyanosis, cold extremities, decreased UOP, increased BUN and CRT, edema
Treatment Options for ARDS
What are:
Phase 1: Patient may be having dyspnea/ tachypnea so focus is on support and oxygen.
Phase 2: Patient will have progressive hypoxemia despite high levels of oxygenation so focus is aimed at maintaining oxygen transport, preventing complications, supporting failing lungs
Phase 3: Patient has pulmonary fibrosis with progression and has permanent damage do focus is preventing sepsis, pneumonia, MODS and patient will be placed on a ventilator (with PEEP)
Other: Nutrition therapy, relaxation diversion and guided imagery, energy conserving measures, proning positioning
Types of ABX used to treat sepsis
What are:
> Ampicillin, amoxicillin, piperacillin, cephalosporins (AE: Rash and GI Upset), vancomycin (Red Man Syndrome), gentamycin (use for severe infections d/t ototoxicity and nephrotoxic) , tobramycin (use for severe infections d/t ototoxicity and nephrotoxic), macrolides "mycin" (Monitor for dysrhythmias) , fluroquinolines "floxacin" (Do not use in pregnancy, breastfeeding or children)
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?
a.) The patient is restless and anxious.
b.) The patient has a heart rate of 134.
c.) The patient has hypotonic bowel sounds.
d.) The patient has a temperature of 94.1° F.
d.) The patient has a temperature of 94.1° F.
Rationale:
Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.
The normal cascade of an infection. Starts with organism invading-
What is:
> Organism Invades > Local inflammation response aims to trap and eliminate the organism, preventing spreading > WBCs collect at spot and release cytokines which causes vasoconstriction and dilation of arterioles > Increased perfusion to local area > Leaky capillaries causing edema
QSOFA vs SOFA vs MEWS (When they are used, what do they include)
> QSOFA: Quick assessment of patient to determine if further testing is needed, score of 2 or more is indicating more testing/poor outcome. Includes: Hypotension, altered mental status (GCS under 15), Tachypnea (RR above 22)
> SOFA: Mortality predicter, score of 2 or more is indicating increased risk of organ damage or death, includes respirations, platelets, bilirubin, MAP, GCS, Creatinine and UOP
> MEWS: Used to help determine patient placement, includes RR, HR, BP, GCS, temperature, UOP
Phases of ARDS
What are:
Exudative Phase: Occurs 24 to 48 hours after injury and lasts for about a week, releases inflammatory mediators and fluid moves from capillaries into the interstitial space causing edema, this edema affects gas exchange at the capillary level and hypoxemia occurs. Tachypnea and increased work of breathing usually results in respiratory fatigue and failure - ventilated.
Fibroproliferative Phase: Usually days 7 to 21. Most patients recover quickly but despite this many patients still experience dyspnea, tachypnea, and hypoxemia. Recovery: Edema is drained, alveolar-capillary barrier is repaired, patients feel better and may recover. Further damage from the release of inflammatory mediators, pulmonary hypotension, fibrotic changes, refractory hypoxemia, ventilated with PEEP, MODS
Resolution-Fibrotic Phase: After 14 to 21 days, patients require long term support, there is fibrosis, patient may die or have chronic disease.
Sepsis Progression Criteria (SIRS > Sepsis > Severe Sepsis >Septic Shock > MODS)
What is:
> SIRS: 2 or more of the following: Temp greater than 100.4 or less than 96.8, HR above 90, RR above 20, PaCO2 less than 32, WBC greater than 12,000 or lower than 4,00 or greater than 10% band cells
> Sepsis: 2 SIRS criteria and known or suspected infection
> Severe Sepsis: Sepsis plus end organ damage
> Septic Shock: Severe sepsis plus unresponsive (refractory) hypotension (we have already tried fluids)
> MODS: Organ failure and death
The patient is an 82-year-old woman who has been a resident in an extended-care facility for the past year because of poor mobility and self-care problems. Today she is brought to the emergency department because she does not recognize her son and does not know where she is. She completed drug therapy for a urinary tract infection 1 week ago. Her skin is thin, and she has many bruises. In addition, she has a healing wound on her left shin, which her son tells you occurred 3 days ago when she scraped the area trying to get out of bed alone. The skin immediately surrounding the wound appears normal; however, about 3 inches to the right of the wound the skin is red, firm, and warm to the touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min; R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is applied until the neurologist can evaluate her, and an IV with normal saline is started at 100 mL/hr. Her son is concerned because she was given her oral antidiabetic drug this morning (5 hours ago) but has not eaten breakfast or lunch. When you check her blood glucose level, it is 131 mg/dL. When you assess her 15 minutes later, her oxygen saturation is 90%.
1. What risk factors does this patient have for sepsis?
2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)?
3. What assessment should you perform immediately?
4. What would be the most likely source of infection?
5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?
1. What risk factors does this patient have for sepsis?
Risk factors include older age, diabetes mellitus, poor mobility and self-care problems, a known urinary tract infection within the past 30 days, and an open skin area on a lower extremity.
2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)?
Manifestations include elevated temperature, a heart rate of more than 90 beats/min, a respiratory rate greater than 20 breaths/min, a blood glucose level above 120 mg/dL, a recent known infection, decreasing oxygen saturation, and confusion.
3. What assessment should you perform immediately?
Assess the color of her skin and mucous membranes, capillary refill, and capnography. Obtain an order for a serum lactate level and a complete blood count with differential. Also obtain an order to insert a Foley catheter for accurate urine output assessment.
4. What would be the most likely source of infection?
The two most likely sources of infection are the leg wound (even though the red area is adjacent to the scrape, it is an indication of cellulitis) and the urinary tract.
5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?
Absolutely; this patient meets multiple criteria for sepsis with SIRS and she is older. Her condition could worsen rapidly to severe sepsis and multiple organ dysfunction syndrome (MODS). She needs immediate intervention to save her life.