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:
Find out the source of primary infection. Consider the source of infection the following:
Nursing Assessment - Sepsis and Septic Shock Emergency Nursing Care Plan
Always use the ABCDE approach.
Airway
Breathing
Circulation
Disability
Exposure
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:
Sepsis and Septic Shock Emergency Nursing Care Plan
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
- se.ually 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
