9/15/2017. Joyce Turner RN Director of Clinical Program Development

Transcription

1 Joyce Turner RN Director of Clinical Program Development A toxic response to an infection that spirals out of control attacking the body s own organs and tissues. The infection can be bacterial, viral or fungal. 1

2 Produced by American Association of Colleges of Nurses 7 min. video y6q&list=plv6y1ajsydzfehey6o6okbuh3vagn iyqa&index=10 1. Does the patient have a suspected or documented infection? (Signs of Suspected Infection: Fever, Chills, Cough, Dyspnea, Change in Sputum Character, Cellulitis, Wound Drainage, Flank Pain, Dysuria, Weakness) 2. Is the resident on antibiotic therapy? 3. Does the resident have at least one of the above answered yes? 4. Is the resident a diabetic? 2

3 Perform a blood glucose check only if one symptom is present (Question 1-5) Do Not perform a blood glucose check in no symptoms are present, or 2 or more symptoms are present (Question 1-5) 6. Blood Glucose > than 140 in non-diabetics Does the patient have 2 or more symptoms checked? If yes the patient has screened positive for Sepsis. 3

4 1. Review the advance directive and options 2. Complete the e-interact Change in Condition Evaluation 3. Notify the physician i of findings, utilizing i the information from the Sepsis Screen and e-interact Change of Condition Evaluation 4. Educate the patient / family on possible diagnosis Provide the following recommendations / request to the physician 1. Labs: CBC with differential BMP Lactate level Urinalysis and culture Consider CXR if patient has adventitious breath sounds Blood cultures for two different sites, all sent ASAP 4

5 3. Comfort Care: Pain Management Antipyretics for fever Keep family informed 4. Nursing Care: Vital signs every four (4) hours Intake/output monitoring i Reposition frequently Encourage fluids Adjust care plan 82 year old white female: 51.6 kg, resides in SNF long-term History: CAD, A-Fib, COPD, Dementia, Depression, Non-diabetic Chief Complaint: Chills, Rib pain, Chest congestion, SOB and Cough Awake A&O x 2, Generalized discomfort, patient stating I just don t feel good. 5

6 1. Does the resident have a suspected or documented infection? (Signs of Suspected Infection: Fever, Chills, Cough, Dyspnea, Change In Sputum Character, Cellulitis, Wound Drainage, Flank Pain, Dysuria, Weakness) 2. Is the resident on antibiotic therapy? 3. Does the resident have at least one of the above answered yes? 4. Is the resident a diabetic? Temperature: Respiratory Rate: 24 Heart Rate: 97 WBC: Unknown 5. Does the resident have any of the following symptoms (SIRS)? (Check all that apply.) a. Temperature greater than or equal to b. Temperature less than or equal to 96.8 c. Respiratory Rate greater than 20 breaths/min d. Heart Rate greater than 90 BPM e. WBC greater than 12,000 or less than 4,000 or greater than 10% bands (Lab must be within the last 24 hours.) f. Blood Glucose greater than 140 PERFORM BLOOD GLUCOSE CHECK ONLY IF ONE SYMPTOM IS PRESENT (Question 5 a-e). DO NOT PERFORM A BLOOD GLUCOSE CHECK IF NO SYMPTOMS ARE PRESENT, OR 2 OR MORE SYMPTOMS ARE PRESENT (Question 5 a-e). 6. Does the resident have two or more symptoms checked? (Question 5 a-f) 6

7 SaO2: 88% B/P: 88/62 Increased Confusion current labs available II. Organ Dysfunction 7. Does the resident exhibit any of the following conditions? (Check all that apply.) 1. Respiratory: SAO2 less than 90% or increase in O2 required 2. Cardiovascular: SBP less than 90 mmhg or 40 mmhg less than baseline 3. Renal: Urine Output less than 0.5 ml/kg over last 8 hours 4. CNS: Mental status changes 5. Lab (last 24 hours): Platelets less than 100, Lab (last 24 hours): INR greater than Lab (last 24 hours): Bilirubin greater than or equal to 4 mg/dl Situation Background Assessment Recommendation Request SBAR TOOL Tell Physician that the resident has screened positive for severe sepsis Describe positive SIRS Inform the physician if patient is currently being treated for a known infection or if you suspect an infection and which organ system is showing dysfunction Share VS, SaO2 and any additional vital information 7

8 Faces of Sepsis Video - 4 minutes SyDZFEHEY6o6okbUH3vAGniyQa&index=10 Sepsis SIRS Multiple Organ Dysfunction Syndrome 7.5 minutes Link to Sepsis Alliance Tri-fold educational brochure Question & Answers Comments 8