Sepsis and Septic Shock: Nursing Care Management

Sepsis kills when it is missed early. You are the one at the bedside who catches the subtle turn (the new tachypnea, the rising lactate, the patient who just is not acting right) before the pressure drops. Recognize it fast, get cultures and antibiotics moving, resuscitate volume, and support perfusion until the source is controlled.

What Is Sepsis and Septic Shock?

Sepsis is one of the most common forms of circulatory shock, and incidence keeps climbing despite advances in care.

Sepsis is a systemic response to infection, shown by two or more SIRS (Systemic Inflammatory Response Syndrome) criteria from a documented or presumed infection. Septic shock is sepsis plus hypotension and hypoperfusion that persist despite adequate fluid volume replacement.

Pathophysiology

Microorganisms invade body tissue and trigger an immune response. That response activates biochemical cytokines and mediators of inflammation. Increased capillary permeability and vasodilation wreck the body's ability to deliver perfusion, oxygen, and nutrients to tissues and cells. Proinflammatory and anti-inflammatory cytokines released during the response activate the coagulation system, which forms clots whether or not there is bleeding. The imbalance between the inflammatory response and the clotting and fibrinolysis cascades drives the physiologic progression of sepsis.

Epidemiology

Sepsis affects a large and growing number of patients in the United States and worldwide. An estimated 750,000 people in the United States are affected each year, and projections put the rate as high as 1 million cases per year by 2010. Elderly patients carry the highest risk because of decreased physiologic reserve and an aging immune system. Gram-positive bacteria account for 50% of septic shock cases. In 20% to 30% of severe sepsis cases, the site of infection is never identified.

Causes

Several factors raise the risk for septic shock. Immunosuppression makes it easier for microorganisms to invade tissue. Extremes of age (the elderly and infants) carry weaker immune systems. Malnourishment lowers the body's defenses. Chronic illness leaves the immune system already taxed by existing pathogens. Invasive procedures introduce microorganisms directly into the body.

Clinical Manifestations

With oxygen and nutrient delivery interrupted, the heart compensates by pumping faster, so expect tachycardia. Vasodilation drives hypotension. The patient breathes faster to compensate for low oxygen and to blow off carbon dioxide. The inflammatory response fires in answer to the invading pathogens. Urine output drops as the body conserves water. Mentation changes as the patient becomes acidotic and mental status deteriorates. Lactate climbs because of maldistributed blood flow.

Prevention

Stop sepsis before it takes hold. Hold the line with strict infection control and effective aseptic technique. Run efficient programs to prevent central line infections, the most dangerous route into sepsis. Debride wounds early to clear necrotic tissue. Keep equipment, especially anything used for invasive procedures, clean and maintained so it does not harbor pathogens.

Complications

Untreated, sepsis progresses. Severe sepsis brings organ dysfunction, hypotension or hypoperfusion, lactic acidosis, oliguria, altered level of consciousness, coagulation disorders, and altered hepatic function. Multiple organ dysfunction syndrome is altered function of one or more organs in an acutely ill patient who needs intervention and organ support to maintain the homeostasis the body can no longer hold on its own.

Assessment and Diagnostic Findings

Catch the infection early before it progresses. Blood culture identifies the responsible organism. Liver function tests detect hepatic involvement. Hematologic studies check blood perfusion.

Medical Management

Treatment centers on identifying and eliminating the source of infection. Fluid replacement therapy corrects tissue hypoperfusion, so resuscitate aggressively. Aggressive nutritional supplementation matters because malnutrition further cripples resistance to infection.

Nursing Management

Keep the high mortality of sepsis, severe sepsis, and septic shock front of mind.

Nursing Assessment

Assess for a positive blood culture, current antibiotics, recent exam or chest x-ray, or a suspected infected wound. Watch for signs of acute organ dysfunction: hypotension, tachypnea, tachycardia, decreased urine output, clotting disorder, and hepatic abnormalities.

Diagnosis

• Risk for deficient fluid volume related to massive vasodilation.
• Risk for decreased cardiac output related to decreased preload.
• Impaired gas exchange related to interference with oxygen delivery.
• Risk for shock related to infection.

Planning and Goals

The patient will display hemodynamic stability, verbalize understanding of the disease process, and achieve timely wound healing.

Nursing Interventions

Run every invasive procedure with aseptic technique after careful hand hygiene. Collaborate with the team to pin down the site, source, and organisms behind the sepsis. Manage fever and monitor closely for shivering. Give prescribed IV fluids and medications, including antibiotics and vasoactive agents. Monitor for antibiotic toxicity along with BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels, and coagulation studies. Track hemodynamic status, fluid intake and output, and nutritional status.

Evaluation

The patient displayed hemodynamic stability, verbalized understanding of the disease process, and achieved timely wound healing.

Discharge and Home Care Guidelines

Teach the patient and family strategies to prevent further shock episodes by identifying the factors behind the initial episode. Teach the assessments needed to catch complications after discharge. Cover treatment modalities: emergency administration of medications, IV therapy, parenteral or enteral nutrition, skin care, exercise, and ambulation.

Documentation Guidelines

Document individual risk factors, assessment findings, laboratory and diagnostic results, the plan of care and teaching plan, the client's responses to treatment and teaching, and any modifications to the plan of care.