1. Evaluate patients at risk for developing sepsis. Who is at risk?
a. Diabetics, cancer patients, immunocompromised, malnourished
... [Show More] (alcoholics),
elderly, very young, those who have has an invasive procedure
2. SIRS criteria (at least 2 of the following)
a. Abnormal WBC count >12,000 or <4,000
b. Normal WBC count with >10% bands
c. Heart rate >90 bpm
d. RR >20
e. Temperature >101 or <96.8
f. Also watch for decreased urine output and changes in mental status
3. Stages of sepsis.
a. Early (SIRS)
i. Changes can be subtle
ii. Mild hypotension
iii. Decrease urine output
iv. Increased respiration rate and white blood cells
v. Inappropriate clotting (DIC)
vi. Hypodynamic (weak)
b. Severe
i. Improved BP and cardiac output
ii. Elevated heart rate
iii. Skin- pink and warm
iv. Mental status or behavioral changes
c. Septic shock (MODS)
i. Decreased blood pressure, cardiac output, and oxygen saturation
ii. Increased heart rate and respiration rate
iii. Decreased urine output
iv. Temperature either too high or too low
v. Skin is cyanotic, pallor, clammy or mottled.
4. Assessment of patients with infection and sepsis.
a. Decreased BP, 02, urine, and CO
b. Increased HR and RR
c. Increased or decreased temperature
d. Inflammation
e. Inappropriate clotting
f. Erythema, pain, fever, skin changes
g. Elevated WBC or lactate levels
5. Signs and symptoms of infection and sepsis.
a. Fever
b. Fatigue.
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Updated 1/2020
c. Inflammation
d. Erythema
e. Pain
f. Increased RR, HR, WBC and lactate levels
g. Decreased CO, BP, 02, and urine
h. Mental status changes
6. Patient education to prevent sepsis and infection.
a. Good wound care, know signs and symptoms of infection and sepsis, good
nutrition, exercise and rest.
7. Labs to assess for infection and sepsis.
a. Lactate, CBC (lactate), WBC, ABG, chest x-ray, urine output
8. Signs, symptoms, assessment findings of patients with sepsis.
a. Increased or decreased temperature
b. Decreased urine, BP, CO and 02
c. Increased HR, RR
d. WBC >12,000 or <4,000
e. Mental changes
f. High lactate (>4).
g. Decreased perfusion to fingers and toes
h. Inappropriate clotting (DIC).
i. Hemodynamic (weak)
9. Sepsis guidelines for treatment.
a. First 3 hours:
i. Blood cultures, lactic acid level (hallmark for sepsis), administer broad
spectrum antibiotics, fluid challenge
b. Within 6 hours
i. Vasopressors given for hypotension resistant to fluid resuscitation
(maintain MAP greater than or equal to 60 mmHg), re-measure lactate
levels
10. Nursing interventions for sepsis and prioritization of interventions. When do you call
provider?
a. Administer oxygen, raise HOB, TCDB, call provider for further orders
11. Discharge teaching for a patient at risk for sepsis.
a. Learn signs and symptoms of infection and sepsis, nutrition, exercise/rest, wound
care, good hygiene
Respiratory
1. Identify assessment findings of the respiratory patient (ie, normal/abnormal lung sounds,
history).
a. Decreased oxygen, diminished or adventitious lung sounds, abnormal heart rate
and blood pressure, mental changes, history of smoking, COPD, skin assessment
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2. Know respiratory assessment methods/diagnostics.
a. Listen to heart and lung sounds, bronchoscopy, PFT, chest x-ray, CT scan, 02 sat.,
skin assessment
3. Know patient prep, patient education, indications, nursing implications and postprocedure
care for the following:
a. Thoracentesis: needle aspiration of air or fluid from pleural space to provide
therapeutic relief or obtain specimen. Done at bedside. Local anesthesia and pain
medication. Sterile procedure. Need an additional nurse. 1000 mL limit at one
time to prevent re-expansion pulmonary edema (swift change in pressure that
draws fluid into the lung itself) [Show Less]