Nursing management in Sepsis & MODS - lpnh.go.th care nursing/NC sepsis... · 1 Nursing management...

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Nursing managementin Sepsis & MODS

Assoc. Prof. Chaweewan ThongchaiFaculty of Nursing

Chiang Mai University

SepsisThe final complications

of a critical illnessMR > 50%

Account for most death in non-coronary ICU

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Severe Sepsis: Comparison With Other Major Diseases

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Severe Sepsis: A Growing Healthcare Challenge

TodayToday

>>750750,,000 000 cases of severe cases of severe

sepsis/year sepsis/year in the USin the US**

FutureFuture

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400,000

600,000

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1,000,000

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1,400,000

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Year

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Severe Sepsis CasesUS Population

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Severe Sepsis: Severe Sepsis: Severe Sepsis: Severe Sepsis: A Significant Healthcare ChallengeA Significant Healthcare ChallengeA Significant Healthcare ChallengeA Significant Healthcare Challenge

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Sepsis: A Complex Disease

ACCP/SCCM conference consensus definitionsInfection : microbial phenomenon

inflammatory response to the presence of microorganisms

invasion of host tissue by organisms

Bacteremia : the presence of bacteria in the blood

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ACCP/SCCM conference consensus definitions

SIRS : 2 !"# > 2 conditions1. Temp > 38 �� !"� < 36 ��2. Heart rate > 90 /min 3. Respiratory rate >20 /min !"� PaCO2 < 32 mmHg

4. WBC > 12,000 cells/mm3 !"� < 4000 !"� > 10% bands

SIRS: More Than Just a Systemic SIRS: More Than Just a Systemic SIRS: More Than Just a Systemic SIRS: More Than Just a Systemic Inflammatory ResponseInflammatory ResponseInflammatory ResponseInflammatory Response

• SIRS: A clinical response arising from a nonspecific insult manifested by ≥2 of the following:– Temperature ≥38°C or ≤36°C

– HR ≥90 beats/min– Respirations ≥20/min

– WBC count ≥12,000/mL or ≤4,000/mL or >10% immature neutrophils

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Sepsis : The systemic response to infectionManifested by 2 or more of theSIRS criteria ( Infection & SIRS )

Sepsis: More Than Just InflammationSepsis: More Than Just InflammationSepsis: More Than Just InflammationSepsis: More Than Just Inflammation

• Sepsis:– Known or

suspected infection

– Two or more SIRS criteria

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Severe sepsis : Sepsis ( ISIRS ) !789ก;< organ dysfunctionhypotension, hypoperfusion lactic acidosis , oliguria acute alteration in mental status

Severe Sepsis: Acute Organ Dysfunction Severe Sepsis: Acute Organ Dysfunction Severe Sepsis: Acute Organ Dysfunction Severe Sepsis: Acute Organ Dysfunction and Disordered Hemostasisand Disordered Hemostasisand Disordered Hemostasisand Disordered Hemostasis

• Severe Sepsis: Sepsis with signs of organ dysfunction in ≥1 of the following systems: – Cardiovascular– Renal– Respiratory– Hepatic– Hemostasis– CNS– Unexplained

metabolic acidosis

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Severe Sepsis: A Complex and Unpredictable Clinical Syndrome

• High mortality rate (28%-50%)

• Heterogeneous patient population

• Unpredictable disease progression

• Unclear etiology and pathogenesis

Systemic Inflammation

Impaired Fibrinolysis

Coagulation


Septic shock/SIRS shock : Severe sepsis ( ISIRS )Decreased tissue perfusionLactic acidosis, oliguriaAcute alteration in mental status@A�BCA!;< inotope/vasopressor �DE7FGA8��HB979I hypotension F9AHJ9I hypoperfusion

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Hypotension : Systolic blood pressure < 90 mmHgReduction of > 40 mmHg frombaseline ( 56789:9;<=> ?@#"AB )


Multiple organ dysfunction syndrome( MODS ) :

9Iก�!KL��MKINOPCQกRPS��8;D8J !"� 9IT8�9GA9U G8S��8;D8JVMOEAQW8DUXID<YG;M HMKL�V AB97Z�9�!@T�Z9C[G ( homeostasis )

S��!7��ก�DBCA

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Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis

TachycardiaTachycardiaTachycardiaTachycardiaHypotensionHypotensionHypotensionHypotension↑↑↑↑ CVPCVPCVPCVP↑↑↑↑ PAOPPAOPPAOPPAOP

JaundiceJaundiceJaundiceJaundice↑↑↑↑ EnzymesEnzymesEnzymesEnzymes↓↓↓↓ AlbuminAlbuminAlbuminAlbumin↑↑↑↑ PTPTPTPT

Altered Altered Altered Altered ConsciousnessConsciousnessConsciousnessConsciousness

ConfusionConfusionConfusionConfusionPsychosisPsychosisPsychosisPsychosis

TachypneaTachypneaTachypneaTachypneaPaOPaOPaOPaO2222 <<<<70 70 70 70 mm Hgmm Hgmm Hgmm Hg

SaOSaOSaOSaO2222 <<<<90909090%%%%PaOPaOPaOPaO2222/FiO/FiO/FiO/FiO2222 ≤≤≤≤300300300300

OliguriaOliguriaOliguriaOliguriaAnuriaAnuriaAnuriaAnuria

↑↑↑↑ CreatinineCreatinineCreatinineCreatinine

↓↓↓↓ PlateletsPlateletsPlateletsPlatelets↑↑↑↑ PT/APTTPT/APTTPT/APTTPT/APTT↓↓↓↓ Protein CProtein CProtein CProtein C↑↑↑↑ DDDD----dimerdimerdimerdimer

Update knowledge Update knowledge Update knowledge Update knowledge related sepsisrelated sepsisrelated sepsisrelated sepsis

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Surviving Sepsis CampaignInternational guidelines for

management of severe sepsis & septic shock 2008

Dellinger et al, 2008

Quality of evidenceGrades of Recommendation, Assessment,

Development, and Evaluation (GRADE) System

Strength of recommendation (beneficial health outcomes, less burden on staff & patients, & cost saving)

• Grade I = Strong recommendation (RECOMMEND)• Grade II = Weak recommendation (SUGGEST)Quality of evidence• A = high (RCT)• B = moderate (downgraded RCT or upgraded

observational studies)• C = low (well-done observational studies)• D = very low (case series or expert opinion)

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Initial resuscitation (first 6 hrs)

• Begin resuscitation immediately in patient with hypotension or elevated serum lactate > 4 mmol/L (IC)

• Do not delay pending ICU admission (IC)

Resuscitation goals (IC) :• CVP 8 -12 mmHg• MAP > 65 mmHg • Urine output > 0.5 ml/kg/hr• Central venous (superior vena cava) oxygen saturation (ScvO2) > 70%

or mixed venous (SvO2) > 65 %

If venous oxygen saturation target is not achieved (IIC) :• Consider further fluid • Transfuse PRC if required to Hct > 30%• And/or start dobutamine infusion, maximum 20ug/kg/min

Infection issues

Diagnosis

Obtain appropriate cultures (IC) - 2 or more blood culture

- 1 or more blood culture should be percutaneous

- blood culture from vascular access device in place > 48 hrs

- culture at site as clinically indicated

ABO therapy• Begin IV ABO as early as possible (within 1 the first hour of

recognizing severe sepsis (ID) or septic shock (IB)

• Reassess antimicrobial regimen daily (IC)

• Combination therapy for Pseudo (IID)• Duration of therapy typically limited to 7 - 10 days (IID)

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Infection issues

Source identification & control• A specific anatomic site of infection should be

established as rapidly as possible (within first 6 hrs of presentation) (ID)

• Formally evaluate patient for focus of infection amenable to source control measures (abscess drainage, tissue debridement) (IC)

• Implement source control measures as soon as possible (IC)

• Remove IV access devices if potentially infected (IC)

Hemodynamic support

Fluid therapy• Fluid-resuscitate using crystalloids or colloids (IB)• Target a CVP of > 8 mmHg ( >12 mmHg if mechanically ventilated (ID)• Use a fluid challenge technic while associated with a hemodynamic

improvement (ID)• Give fluid challenge of 1,000 ml of crystalloids or 300 - 500 ml of colloids

over 30 mins (ID)

Vasopressors • Maintain MAP > 65 mmHg (IC)Initial vasopressors of choice are

norepinephrine and dopamine (IC)• When BP is poorly responsive to norepinephrine and dopamine, use

epinephrine as the first alternative agent• Do not use low-dose dopamine for renal protection (IA)• Insert an arterial catheter as soon as practical in patients who need

vasopressor (IB)

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Hemodynamic support

Inatropic therapy• Use dobutamine in patients with myocardial

dysfunction as support by elevated cardiac filling pressures and low cardiac output (IC)

• Do not increase cardiac index to predetermined supranormal levels (IB)

Adjunctive therapy

Steroids • Consider IV hydrocortisone for adult septic shock when

hypotension response poorly to adequate fluid resuscitation & vasopressors (IIC)

• Hydrocortisone is preferred to dexamethasone (IIB)• Hydrocortisone dose should be < 300mg/day (IA)• Do not use corticosteroids to treat sepsis in the absence of

shock (ID)

Recombinant human activated protein C• Consider rhAPC in adult patient with sepsis-induced organ

dysfunction with clinical assessment of high risk of death (APACHE II > 25 or MOF) if there are no contraindication (IIB, IIC for PO patient)

• Adult patient with sepsis and low risk of death (APACHE II < 20 or one organ failure) should not receive rhAPC (IA)

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Supportive therapy

Blood product administration• Give PRC when Hb decrease to < 7.0 g/dl

(adult target = 7-9 g/dl) (IB)• Administer platelets when :

* counts are < 5,000/mm3 regardless of bleeding* counts are 5,000-30,000 mm3 and there is

significance bleeding risk* high platelet counts (> 50,000 mm3) are required for

surgery or invasive procedure• Do not use FFP to correct laboratory clotting abnormalities

unless there is bleeding or planned invasive procedures (IID)• Do not use antithrombin therapy (IB)

Supportive therapy

Mechanical ventilation of sepsis-induced ALI/ARDS

• Target tidal volume of 6ml/kg (predicted) BW in patient with ALI/ARDS (IB)

• Target an initial upper limit plateau pressure < 30 cmH2O (consider chest wall compliance) (IC)

• Allow Pa CO2 to increase above normal, if needed to minimize plateau pressure & tidal volume (IC)

• Set PEEP to avoid extensive lung collapse at end- expiration (IC)

• Consider using prone position for ARDS patient ( IIC)

• Head of Bed raised to 45o , unless contraindicated (IB), between 30o - 45o (IIC)

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Supportive therapy


• Non invasive ventilation may be considered in minority ALI/ARDS patients with mild to moderate hypoxemic respiratory failure ( hemodynamic stable, easily arousable, able to protect/clear airway, expected to recover rapidly (IIB)

• Do not use a pulmonary artery catheter for the routine monitoring of patient with ALI/ARDS (IA)

• Use a conservative fluid strategy for patient with established ALI who do not have evidence of tissue hypoperfusion (IC)

Supportive therapy


• Use a weaning protocol & an SBT regularly to evaluate the potential for discontinuing mechanical ventilation (IA)

- SBT options include a low level of PS with CPAP 5 cmH2O or a T piece

- Before T piece patient should be arousable, hemodynamically stable without vasopressors, no new potentially serious conditions, have low PEEP, require low FiO2

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Supportive therapy

Sedation, Analgesia & neuromuscular blockade in sepsis

• Use sedation protocols with a sedation goal for critically ill mechanically ventilated patients (IB)

• Use either intermittent bolus sedation or continuous infusion sedation to predetermined end points (sedation scales), with daily interruption/lightening to produce awakening, re-titrate if necessary (IB)

• Avoid neuromuscular block where possible (IB)

Supportive therapy

Glucose control• Use IV insulin to control hyperglycemia in patient

with severe sepsis following stabilization in ICU (IB)• Aim to keep blood glucose <150mg/dl

using a validated protocol for insulin dose adjustment (IIC)

• Provide a glucose calorie source and monitor BS values every 1-2 hrs (4 hrs when stable) in patient receiving IV insulin (IC)

• Interpret with caution low glucose levels obtained with point of care testing, as these technic may overestimate arterial blood and plasma glucose value (IB)

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Supportive therapy

Renal replacement• Intermittent hemodialysis & CVVH are considered

equivalent (IIB)• CVVH offers easier management in

hemodynamically unstable patients (IID)

Bicarbonate Therapy• Do not use bicarbonate therapy for the purpose of

improving hemodynamics or reducing vasopressor requirements when treating hypoperfusion-induced lactic acidemia with pH > 7.15 (IB)

Supportive therapy

Deep vein thrombosis prophylaxis• Use either low-dose UFH or LMWH, unless contraindicated (IA) • When heparin is contraindicated, use a mechanical prophylactic device

(compression stockings, intermittent compression device) (IA)• Use a combination of pharmacologic & mechanical therapy

for patients who are at risk for DVT (IIC)

Stress ulcer prophylaxis• Provide stress ulcer prophylaxis using H2 blocker (eg. Ranidine) (IA)

or proton pump inhibitors (eg. Omeparzole) (IB). Benefits of prevention of upper GI bleed must be weighed against the potential for development of VAP

Consideration for limitation of support• Discuss advance care planning with patients and families.

Discuss likely outcomes and set realistic expectations (ID)

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Early – Goal Directed Therapy (EGDT)

EFGHIJ786G!KLก=!NกG8O P G• CVP = 8-12 mmHg• MAP > 65 mmHg• Urine > 0.5 ml/kg/hr• ScvO2 > 70%

Q=7PB 6 SKAJ59T

Rivers et al, 2001

EARLY GOALEARLY GOALEARLY GOALEARLY GOALEARLY GOALEARLY GOALEARLY GOALEARLY GOAL--------DIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPYDIRECTED THERAPY

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ขอคดิสําคญัทีไ่ดจาก ขอคดิสําคญัทีไ่ดจาก ขอคดิสําคญัทีไ่ดจาก ขอคดิสําคญัทีไ่ดจาก EGDTEGDTEGDTEGDT

• Early resuscitation Early resuscitation Early resuscitation Early resuscitation เปนกญุแจดอกสาํคญัสาํหรบัการรอดชวีติเปนกญุแจดอกสาํคญัสาํหรบัการรอดชวีติเปนกญุแจดอกสาํคญัสาํหรบัการรอดชวีติเปนกญุแจดอกสาํคญัสาํหรบัการรอดชวีติ• การใหสารน้าํทีพ่อเพยืงและการดแูลรกัษาทีร่วดเรว็ในชวงเริม่ตน การใหสารน้าํทีพ่อเพยืงและการดแูลรกัษาทีร่วดเรว็ในชวงเริม่ตน การใหสารน้าํทีพ่อเพยืงและการดแูลรกัษาทีร่วดเรว็ในชวงเริม่ตน การใหสารน้าํทีพ่อเพยืงและการดแูลรกัษาทีร่วดเรว็ในชวงเริม่ตน

((((6666 ชัว่โมงแรกชัว่โมงแรกชัว่โมงแรกชัว่โมงแรก))))• 6666 ชั่วโมงแรก เปนชวงทีเ่ซลลและเนือ้เยือ่ยงัไดรบับาดเจบ็ไมมากนกั ชั่วโมงแรก เปนชวงทีเ่ซลลและเนือ้เยือ่ยงัไดรบับาดเจบ็ไมมากนกั ชั่วโมงแรก เปนชวงทีเ่ซลลและเนือ้เยือ่ยงัไดรบับาดเจบ็ไมมากนกั ชั่วโมงแรก เปนชวงทีเ่ซลลและเนือ้เยือ่ยงัไดรบับาดเจบ็ไมมากนกั

สามารถกลบัคนืสภาพปกตไิด ถาไดรบัการรกัษาอยางทนัทวงทีสามารถกลบัคนืสภาพปกตไิด ถาไดรบัการรกัษาอยางทนัทวงทีสามารถกลบัคนืสภาพปกตไิด ถาไดรบัการรกัษาอยางทนัทวงทีสามารถกลบัคนืสภาพปกตไิด ถาไดรบัการรกัษาอยางทนัทวงที• ชวยลดความรนุแรงของภาวะ ชวยลดความรนุแรงของภาวะ ชวยลดความรนุแรงของภาวะ ชวยลดความรนุแรงของภาวะ global tissue hypoxia global tissue hypoxia global tissue hypoxia global tissue hypoxia

และ บรรเทากระบวนการอกัเสบของรางกายลงไดอยางมาก และ บรรเทากระบวนการอกัเสบของรางกายลงไดอยางมาก และ บรรเทากระบวนการอกัเสบของรางกายลงไดอยางมาก และ บรรเทากระบวนการอกัเสบของรางกายลงไดอยางมาก ((((ลดระดบั ลดระดบั ลดระดบั ลดระดบั biomarkers biomarkers biomarkers biomarkers ---- interleukininterleukininterleukininterleukin----1111, , , , ----8888, D, D, D, D----dimer, TNFdimer, TNFdimer, TNFdimer, TNF----alpha)alpha)alpha)alpha)

• ม ีม ีม ีม ีacute lung injury & ARDSacute lung injury & ARDSacute lung injury & ARDSacute lung injury & ARDS เกดิขึน้นอยลงกวาเดมิ เกดิขึน้นอยลงกวาเดมิ เกดิขึน้นอยลงกวาเดมิ เกดิขึน้นอยลงกวาเดมิ ทาํใหมกีารใสทอชวยหายใจและใชเครือ่งชวยหายใจนอยลงทาํใหมกีารใสทอชวยหายใจและใชเครือ่งชวยหายใจนอยลงทาํใหมกีารใสทอชวยหายใจและใชเครือ่งชวยหายใจนอยลงทาํใหมกีารใสทอชวยหายใจและใชเครือ่งชวยหายใจนอยลงกวาเดมิกวาเดมิกวาเดมิกวาเดมิ

• การทีภ่าวะ การทีภ่าวะ การทีภ่าวะ การทีภ่าวะ global tissue hypoxia global tissue hypoxia global tissue hypoxia global tissue hypoxia และกระบวนการอกัเสบของและกระบวนการอกัเสบของและกระบวนการอกัเสบของและกระบวนการอกัเสบของรางกายลดลง ทาํใหโอกาสเกดิ รางกายลดลง ทาํใหโอกาสเกดิ รางกายลดลง ทาํใหโอกาสเกดิ รางกายลดลง ทาํใหโอกาสเกดิ organ dysfunction organ dysfunction organ dysfunction organ dysfunction ลดลง การลดลง การลดลง การลดลง การเสยีชวีิตใน เสยีชวีิตใน เสยีชวีิตใน เสยีชวีิตใน sepsis sepsis sepsis sepsis จงึลดลงจงึลดลงจงึลดลงจงึลดลง

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การ การ การ การ monitor monitor monitor monitor ในผูปวย ในผูปวย ในผูปวย ในผูปวย sepsissepsissepsissepsis

• MAP & CVP MAP & CVP MAP & CVP MAP & CVP เพยีง เพยีง เพยีง เพยีง 2 2 2 2 อยางอาจไมพอเพยีงอยางอาจไมพอเพยีงอยางอาจไมพอเพยีงอยางอาจไมพอเพยีง• ถงึ ถงึ ถงึ ถงึ Systolic BP Systolic BP Systolic BP Systolic BP >>>> 90 90 90 90 mmHg, CVPmmHg, CVPmmHg, CVPmmHg, CVP >>>> 8 8 8 8 mmHgmmHgmmHgmmHg

แตยงัพบวาม ีแตยงัพบวาม ีแตยงัพบวาม ีแตยงัพบวาม ีglobal tissue hypoxia ~global tissue hypoxia ~global tissue hypoxia ~global tissue hypoxia ~ 40404040%%%%• ScvOScvOScvOScvO2 2 2 2 เปนตวัแทนทีด่ขีอง เปนตวัแทนทีด่ขีอง เปนตวัแทนทีด่ขีอง เปนตวัแทนทีด่ขีอง tissue oxygenationtissue oxygenationtissue oxygenationtissue oxygenation• การประเมนิในผูปวย การประเมนิในผูปวย การประเมนิในผูปวย การประเมนิในผูปวย sepsis sepsis sepsis sepsis ควรใช ควรใช ควรใช ควรใช hemodynamic hemodynamic hemodynamic hemodynamic

data data data data ควบคูกบั ควบคูกบั ควบคูกบั ควบคูกบั tissue oxygenationtissue oxygenationtissue oxygenationtissue oxygenation

Oxygen transport & utilization

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Tissue perfusion monitoring

Macrocirculation monitoring or upstream markers

- Blood pressure

- PaO2- Cardiac output- Hemoglobin- CVP/PCWP

Tissue perfusion monitoring

Microcirculation monitoring or downstream markers

• Global circulation - venous oxygen saturation- serum lactate- base excess

• Regional circulation- gastric tonometry- sublingual capnography (PslCO2)

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Venous oxygen saturation

Mixed venous oxygen saturation (SvO2)• Pulmonary arterial catheter

Central venous oxygen saturation (ScvO2)• Central vein catheter (SVC)

Hก?U SvO2 > ScvO2 ~ 5 %(!7��ก�DZ78M<M extract oxygen BCACIก87�!7��ก�DZ78MG7��)

• Septic Uก\]^S�� Sepsis campaign V_A SvO2 > 65%, ScvO2 > 70%

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Central venous & mixed venous oxygen saturation

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Trzeciak and Rivers Critical Care 2005

Fluid challenge test

• Crystalloid 250 ml VM_78�Z;cMd !"� 20ml/kg/ in 30 min• CVP V_AZER! 2 - 5 response • PCWP V_AZER! 3 – 7 response• CVP ZE�SecMก87�UCP9 5 mmHg (PCWP ZE�SecMก87�UCP9 7 mmHg)

FZC�87�B97S�CMcL�

• CVP B97ZE�SecM !"�ZE�SecMB97@e� 2 mmHg (PCWP ZE�SecMMA�Dก87� 3 mmHg) FZC�87�R�<ZM��ก�!V AMcL�

• CVP ZE�SecM�DE7!J 87�� 2 - 5 mmHg (PCWP ZE�SecM�DE7!J 87�� 3 - 7 mmHg) V A!�M�KIKIN 10 @A�!�FGA8Y<87� CVP ZE�SecMH�ก baseline FR7B97UกPM 2 mmHg (PCWP ZE�SecMH�ก baseline UCP9B97UกPM 3 mmHg) FZC�87�R�<ZM��R7�ก�!V AMcL�

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Fluid challenge test

VW=BJBH!U9=X<=!BYW=Z;AP G[U6V=ก[:= CVP • CVP < 6 mmHg (PCWP < 12mmHg)

V AZ�!McL� 10 ml/kg• CVP 6 -10 mmHg (PCWP 12 -16 mmHg)

V AZ�!McL� 5 ml/kg• CVP > 10 mmHg (PCWP > 16 mmHg)

V AZ�!McL� 3 ml/kg

Successful fluid challenge test

(Vincent, 2006)

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Nursing management in sepsis & MODS

AssessmentVital signs : Fever, hypothermia

Tachycardia, tachypneaHypotension

Hemodynamic parameters:HR, arrhythmias, high COLow SVR

Nursing management in sepsis & MODs

AssessmentVentilator parameters :

RR, lung soundsSaO2 , ABG

Renal parameters :Urine per hour, Cr, BUN

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Nursing management in sepsis & MODsAssessmentCoagulation parameters :

PT, PTT, INR, fibrinogen level, plateletsMonitor for bruising & bleeding

Metabolic parameters :Nutritional support, blood sugarIntact gut barrier


AssessmentMental status parameters : Restlessness, confusion, deliriumMinimize extensive use of sedatives

GI parameters : Nausea, vomitting, abdominal distensionChanges bowel sounds, high RV(>200)

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AssessmentHepatic parameters : Hyperbilirubinemia,

Elevated liver enzymesNeurological parameters :

Restlessness, confusion, change GCSOthers : Skin color, temperature

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Provide comprehensive sepsis treatment

IV fluids, inotropes, vasopressorsOxygenation, ventilation, dialysis,CRRT, ABO, activated protein CMonitoring, report patient response


Promote patient & family comfort care

Promote patient’ s comfortRelief pain & sedationTurning & skin carePatient & family teachingAddress needs of families

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Sepsis preventionEnforce infection control measuresHandwashingUniversal precautionsMeasures to prevent nosocomial infections :oral care, positioning, turning, skin care,invasive catheter care, wound care


Sepsis prevention

Identifying patient at risk for sepsisPrioritizing culturesPan cultures for febrile episodesClinical assessment

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