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Case 2: Charles Wong - Sepsis - Coggle Diagram
Case 2: Charles Wong - Sepsis
Describe what is meant by the term “anterior resection”. Mr Wong has been seen by the stomal therapist pre-operatively. What is meant by pre-op education and stoma siting?
Stoma nurse
Pre-operative information giving/counselling
Siting of the stoma
Stoma appliance and accessory information
Post-operative management
Discharge planning
Manage stoma complications
Self-help groups - national and local
Liaising with the multi-disciplinary team involved in the care of the stoma patient
Pre-op education
Overview of GIT function
Reasons for the surgery
Impact of the ostomy
Questions about life with the ostomy
Caring for the ostomy
Potential changes in sexual function
Components of Haemodynamic monitoring
Transducer
Converts physiological events into electrical signals (eg. pressure, temperature)
Monitor
Display readings (waveforms, pressure values)
Catheter tubing and flush system
Keep catheter patent
Flush solution (check heparin)
Pressure bag
Outline the benefits of this and describe your nursing management of him with regard to the arterial line.
Allows repeated ABG samples to be obtained from the patient conveniently.
Monitor arterial line for kinking, immobilizing the arm,
clean aseptically, zero it everyday
, check
manual BP to ensure it is calibrated correctly
, ensure flushed and
patent
.
Avoid complications and infections
complications
– ischaemia
– Air embolism: major complication
– Cerebral air embolism (retrograde flow associated with flushing)
– Haemorrhage: Keep connections tight
– Thrombosis/ embolism
– Skin necrosis
– Infection ( 3 way taps source)
infections
– Use aseptic techniques during insertion
– Remove catheter as soon as possible
– Use non-vented caps on all stopcocks
– Change line components as per policy
– Minimise system entry
Identify the dicrotic notch on the below strip. What does this represent? Why is it important to identify the presence of this notch whilst monitoring him?
Stroke volume (area under ejection phase, upstroke to dicrotic notch is proportional to SV)
Systemic vascular resistance ( a low dicrotic notch suggests rapid aortic runoff)
Review Mr Wong’s notes and identify his early signs of sepsis. Describe the likely physiological compensatory mechanisms involved in sepsis.
Signs and symptoms suggestive of Sepsis (7 signs= I T R H C B O)
Infection
confirmed or suspected plus:
Temperature> 38.3C
or < 36C (normal temperature does not exclude sepsis)
Respiratory rate > 20 / minute
Heart rate > 90/minute
Acute
confusion
or decreased level of consciousness
Hyperglycemia (
blood glucose > 7.7 mmol/L
in patient without diabetes)
Oliguria
(urine output less than 0.5 mL/kg/hour) (Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour)
Sepsis risk factors
Re-presententation within 48 hrs
Immunocompromised
Recent surgery or wound
Age >65
Fall
Indwelling medical device
Signs and symptoms of Infections
Fever
Dysuria
cough/sputum/breathlessness
Line associated infection/redness/swelling/pain
Altered cognition
Sepsis management - Sepsis six (OBLFAM)
Oxygen
: maintain SpO2>95%
Blood cultures
: 2 aerobic, 2 anaerobic, FBC, EUC, LFTs (live function test), coags, glucose, +/- wound, urine, sputum or other cultures
Lactate:
formal lactate or VBG
IV
fluid:
20mL/kg 0.9% sodium chloride STAT → MAP >65mmHg or SBP>100mmHg.
If no response, repeat 20mL/kg 0.9% sodium chloride unless pulmonary oedema.
No response → inotropes (increase contraction) and senior doctor
IV
antibiotics
: within 60 mins from triage of diagnosis or within 30 mins if haematology/oncology patients
Monitoring
: RR, SpO2, BP, HR, temperature, LOC, fluid balance, urinary output. Review antibiotics when blood/specimen results available
Prioritise your nursing interventions for Mr Wong at this stage using the ABCDEFG Alogarithm to guide your decision.
Nursing interventions
A – patent and independently maintained; no intervention
B – intermittent breaks from CPAP→high flow Hudson Mask
C – maintain MAP >70
D – regular neuro obs; pt currently alert, orientated to person, not place or time
F – IV fluid resus; monitor urine output
G – monitor BSL
E – pt afebrile
