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58 Year Old Female Diagnosis: Hypotension w/ Code Sepsis, KEY, Admitting…

- - - - Open Wounds
      - Urinary Tract Infections
      - Respiratory Tract Infections
      - Infection of Indwelling medication devices.
        
        Central Lines
        
        Urinary Catheters
      - GI Obstruction/GI Tract Infections
    - - As the pathogen infects the bloodstream, cytokines are released in response to the infection which increase vascular permeability to allow for more white blood cells to respond to the infection.
        
        These compensatory mechanisms can cause adverse complications to an untreated blood infection; if the sepsis continues to go untreated, multiple organ failure and death can occur. It is important to recognize signs and symptoms of sepsis early.
        
        Signs & Symptoms of sepsis
        
        Hypotension
        
        A bolus of NS is typically given per protocol in a patient with code sepsis. This is to prevent fluid volume deficits and increase cardiac output and tissue perfusion. It will also correct hypotension.
        
        Fever
        
        Decreased Cardiac Output
        
        Hypotension leads to decreased cardiac output due to the widened vessels not being able to perfuse blood properly.
        
        due to decreased cardiac output, blood is shunted to vital organs to maintain survivability and extremities can become cool and pale.
        
        Tachypnea
        
        Tachycardia
        
        Cool and pale skin
        
        Elevated Lactic Acid
        
        Hyperglycemia
        
        Increased cortisol production
        
        Cortisol levels are highest in the morning, thus meaning that Pantoprazole will be most beneficial for the patient if taken in the morning.
- - - - Diagnostic Tests
        
        Blood Cultures were positive for infection.
        
        Lactic Acid drawn and shows elevation (3.0)
        
        Lactic Acid levels increase in sepsis due to decreased oxygenation of the tissues r/t low cardiac output and hypotension. This causes the body to use anaerobic metabolism to maintain organ functions; creating a byproduct of lactic acid.
        
        CT Scan negative for brain trauma or abnormalities.
        
        Patient had fainted and hit her head as the EMS team arrived. CT scan was needed to observe for any possible trauma or causation related to the syncope episode.
- - - - Increased cortisol levels occur due to stressors on the body; such as infection. When a patient is septic, increased glucose production puts the patient at risk for hyperglycemia.
  - - - This level indicates that the dose of vancomycin may need to be increased or a new level needs to be drawn to ensure accuracy and efficacy.
- - - - Vancomycin has more adverse effects that the nurse should be aware of.
        
        Redman Syndrome can occur if vancomycin is pushed or infused too fast. This syndrome causes hypotension, severe rash, and irritability.
        
        Vancomycin can be very toxic to the kidneys, monitor kidney function and ensure an output of at least 30mL/hour
  - - - PPIs limit gastric parietal cells' production of gastric acid to reduce patient's risk of forming gastric ulcers.
      - PPIs are best administered in the morning and before meals.
- - - - Septic Shock is one of the major cardiovascular concerns in a patient with sepsis. Frequent CV assessments are required to ensure that the patient is remaining stable and organs are being adequately perfused.
    - - Due to blood shunting away from the extremities in sepsis, pulses can become weak and thready.
  - - - Due to decreased perfusion to the lungs, patients in sepsis can progress into respiratory distress and can consistently have low O2 levels.
  - - - Abdominal hardness and rebound tenderness could be indicative of a GI perforation, bleed, or peritonitis.
- - - - Interventions
        
        administer ABX as prescribed per MD order.
        
        Monitor vital signs for drop in BP, elevations in temperature, tachypnea, tachycardia, and changes in mental status.
        
        Examine patient for possible sources of infection; such as, sore throat, burning upon urination, localized abdominal pain, open wounds, and invasive catheters or lines.
  - - - Interventions
        
        Monitor trends in BP, noting progressive hypotension and widening pulse pressure.
        
        Assess for respiratory rate, depth, and quality.
        
        Administer parenteral IV fluids per MD order to decrease risk of deficient fluid volume.
  - - - Interventions
        
        Supervise patient and assist (if needed) during ambulation.
        
        Keep room clean and free of clutter.
        
        Keep call light within reach and remind patient to use call light for assistance.
- - - - 36.4-36.6
    - - 58-64
    - - 135/84-156/77
    - - 15-16
    - - 94%-99% RA
- - - - Care