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Sepsis and Septic Shock Emergency Nursing Care Plan

Definition of Sepsis

Sepsis is a systemic response to bacteremia. At the time of bacteremia caused changes in the circulation, leading to decreased tissue perfusion and Septic Shock occurs. Approximately 40% of patients with sepsis caused by gram-positive microorganisms and 60% due to gram-negative microorganisms. The most common organisms causing sepsis are Staphylococcus aureus and Pseudomonas sp.

Signs and Symptoms of Sepsis

Patients with sepsis and septic shock is an acute illness. Assessment and treatment is needed. Patients can die from sepsis. Common symptoms are:

  • fever
  • sweat
  • headache
  • muscle aches

Find out the source of primary infection. Consider the source of infection the following:
  • urinary infection
  • respiratory tract infections
  • dermatitis
  • meningitis
  • endocarditis
  • intra-abdominal infections
  • osteomyelitis
  • pelvic inflammatory disease
  • sexually transmitted diseases

Nursing Assessment - Sepsis and Septic Shock Emergency Nursing Care Plan

Always use the ABCDE approach.

Airway
  • Make sure the airway clearance
  • Give the tool a respirator if necessary (nasopharyngeal)
  • If a decline in respiratory function immediately contact the anesthesiologist and the patient may be brought immediately to the ICU

Breathing
  • Assess the amount of breathing, more than 24 times / minute is a significant symptom
  • Assess oxygen saturation
  • Check arterial blood gases to assess the oxygenation status and the possibility of acidosis
  • Give 100% oxygen via non re-breath mask
  • Chest auscultation, to determine the presence of chest infection
  • Photo thoracic radiograph

Circulation
  • Assess heart rate, more than 100 times / minute is a significant sign
  • Monitoring blood pressure
  • Check the capillary refill time
  • Attach infusion using a large canul
  • Replace catheter
  • Perform a complete blood
  • Record the temperature
  • Prepare the urine and sputum examination

Disability
  • Confused is one of the first signs of sepsis patients, whereas previously there were no problems (healthy and good).
  • Assess level of consciousness

Exposure
  • If the source of infection is unknown, look for the existence of injuries, cuts and the injection site and the source of other infections.

Sign of the threat to life

Severe sepsis defined as sepsis that caused the failure of organ functions. If it is causing a threat to the life of the patient should be taken to the ICU, while the indications are as follows:
  • decline in kidney function
  • decline in cardiac function
  • hypoksia
  • acidosis
  • clotting disorders
  • acute respiratory distress syndrome (ARDS)


Sepsis and Septic Shock Emergency Nursing Care Plan

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