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Sepsis is essentially an overactive/uncontrolled immune response to an infection. The immune system kicks into overdrive, for whatever reason, and cannot be calmed down. It’s like someone turned the dial all the way up on the immune system and ripped the dial off the dashboard. As the healthcare team, we are trying to turn the immune response down as best we can… but it is VERY challenging. This is a very complex issue that affects many body systems, with an overall mortality rate anywhere from 27-36% (and higher in patients in intensive care settings). The challenge is that it can present with very subtle symptoms and progress quickly to septic shock. Time is of the essence in sepsis recognition and treatment.
Essentially, the cause of septic shock is the original infection. Examples include pneumonia, urinary tract infection, infection in the bloodstream (bacteremia), etc. It doesn’t have to be a bacterial infection, it can be a virus or a fungus as well.
Lessening the immune response, prevention of cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build-up, maximizing cardiac output, and resolution of the condition.
Septic Shock Nursing Care Plan
- Difficulty breathing
- Reports of s/s infection (burning with urination, frequent cough, green mucus, etc.)
- ↑ temp (over 101° F)
- ↓ temp (below 96.8° F)
- HR over 90 bpm
- RR over 20 bpm
- Respiratory distress
- ↓ urinary output
- ↓ platelet count
- Hyperglycemia (no hx diabetes)
- Altered LOC
- Mental status changes
- ↑ WBC, bands
- ↓ SVO2
- ↑ lactic acid
- ↑ creatinine
Nursing Interventions and Rationales
- Prompt lab draws
- CBC – WBC count
- Lactate – ↓ O2 to tissues
- BMP – kidney function
- ABG – shows acidosis
- Blood Cultures
- Appropriate administration of IV antibiotics
- Drawing the labs, then starting antibiotics as ordered is the nurse’s responsibility.
- The goal is to initiate broad-spectrum antibiotics within 1 hour of recognition of sepsis.
- Optimize fluid-volume status
Patients suffering from sepsis usually require massive fluid resuscitation. This helps to increase their preload and therefore their cardiac output.
- 30 mL/kg in the first 6 hours
- 100 kg man = 3 L fluid
- Assess, monitor, and optimize cardiac output
- Signs of perfusion
- Lactic Acid
Cardiac output is compromised in septic shock. The nurse must communicate with the MD about this and how to treat it, as some may need more fluid, or vasopressors, or both.
- Non-invasive cardiac output monitoring (NICOM) or central venous pressure monitoring (CVP) are options.
- MAP should be monitored with an arterial line when administering vasopressors
- Lactic acid levels are elevated with decreased tissue perfusion – following lactic acid levels helps to determine if therapy is being successful.
- Assess, monitor, and support oxygen status
- Lung sounds
- Prevent infection
- Assess, monitor, and manage body temp
- Communicate with and educate patient and loved one