Focus on SIRS and MODS (Relates to Chapter 67, “Nursing Management: Shock and Multiple Organ...

Focus on SIRS and MODS

(Relates to Chapter 67, “Nursing Management: Shock and Multiple Organ Dysfunction Syndrome,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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SIRS

Systemic inflammatory response syndrome (SIRS) is a systemic inflammatory response to a variety of insults.

Generalized inflammation in organs remote from the initial insult


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SIRS

Triggers Mechanical tissue trauma:

burns, crush injuries, surgical procedures

Abscess formation: intraabdominal, extremities

Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction


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SIRS

Triggers Microbial invasion: bacteria,

viruses, fungi Endotoxin release: gram-

negative bacteria Global perfusion deficits: post–

cardiac resuscitation, shock states

Regional perfusion deficits: distal perfusion deficits


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MODS

Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ systems. Homeostasis cannot be

maintained without intervention.

Results from SIRS


Relationship of Shock, SIRS, and MODS

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Fig. 67-1. Relationship of shock, systemic inflammatory response syndrome, andmultiple organ dysfunction syndrome. CNS, Central nervous system.

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SIRS and MODSPathophysiology Consequences of inflammatory

response Release of mediators Direct damage to the endothelium Hypermetabolism Vasodilation leading to decreased

SVR Increase in vascular permeability Activation of coagulation cascade


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SIRS and MODSPathophysiology Organ and metabolic

dysfunction Hypotension Decreased perfusion Formation of microemboli Redistribution or shunting of

blood


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SIRS and MODSPathophysiology Respiratory system

Alveolar edema Decrease in surfactant Increase in shunt V/Q mismatch End result: ARDS


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SIRS and MODSPathophysiology Cardiovascular system

Myocardial depression and massive vasodilation


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SIRS and MODSPathophysiology Neurologic system

Mental status changes due to hypoxemia, inflammatory mediators, or impaired perfusion

Often early sign of MODS


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SIRS and MODSPathophysiology Renal system

Acute renal failure Hypoperfusion Release of mediators Activation of renin-angiotensin- aldosterone system

Nephrotoxic drugs, especially antibiotics


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SIRS and MODSPathophysiology GI system

Motility decreased: abdominal distention and paralytic ileus

Decreased perfusion: risk for ulceration and GI bleeding

Potential for bacterial translocation


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SIRS and MODSPathophysiology Hypermetabolic state

Hyperglycemia-hypoglycemia Insulin resistance Catabolic state Liver dysfunction Lactic acidosis


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SIRS and MODSPathophysiology Hematologic system

DIC Electrolyte imbalances Metabolic acidosis


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SIRS and MODSCollaborative Care

Prognosis for MODS is poor. Goal: prevent the

progression of SIRS to MODS Vigilant assessment and

ongoing monitoring to detect early signs of deterioration or organ dysfunction are critical.


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Prevention and treatment of infection Aggressive infection control

strategies to decrease risk for nosocomial infection

Once an infection is suspected, institute interventions to control the source.


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Maintenance of tissue oxygenation Decreased O2 demand

Sedation Mechanical ventilation Paralysis Analgesia


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Nutritional and metabolic needs Goal of nutritional support:

preserve organ function Total energy expenditure is

often increased 1.5 to 2.0 times.


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Nutritional and metabolic needs Use of the enteral route is

preferred to parenteral nutrition.

Monitor plasma transferrin and prealbumin levels to assess hepatic protein synthesis.


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Support of failing organs ARDS: aggressive O2 therapy

and mechanical ventilation DIC: appropriate blood

products Renal failure: continuous

renal replacement therapy or dialysis


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A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which of the following orders implemented by the nurse has the highest priority?

1. Insert an indwelling urinary catheter. 2. Insert two large-bore intravenous catheters.3. Administer 0.9% normal saline at 100 mL/hr.4. Administer 100% oxygen by non-rebreather mask.

Audience Response Question


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A patient with a history of alcoholism is admitted to the intensive care unit (ICU) with hemorrhage from esophageal varices. Admission vital signs are blood pressure 84/58 mm Hg, pulse 105 beats/min, and respiratory rate 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding:

1. Pulmonary edema.2. Cardiac dysrhythmias.3. Absent bowel sounds.4. Decreasing blood pressure.

Audience Response Question


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Case Study

28-year-old woman is brought to the ED by her mother with confusion, fever, and “flu for past week.”

She has been vomiting for the past 2 days and has noted generalized edema.


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Case Study

The patient did not seek medical care before today.


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Case Study

Vital signs Blood pressure 88/54 Heart rate 112 Temperature 103.5°F Respiratory rate 24

Chest x-ray shows bilateral infiltrates.

WBC and lactic acid elevated


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Case Study

She is admitted to the ICU with a possible diagnosis of sepsis.

Urine output is amber and only 15 mL/2 hr.


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Discussion Questions

1.Nurse notes petechiae and jaundiced skin. What do these signs indicate?

2.What are some treatments that you would anticipate being done for her?


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Discussion Questions

3.How should she receive nutritional support? How would blood glucose be affected?

4.What can you do to prevent further infection?


Focus on SIRS and MODS (Relates to Chapter 67, “Nursing Management: Shock and Multiple Organ...

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