Stephanie Swanson RN, BSN

Philosophy
Through staff education early signs of sepsis can be identified and aggressive treatment implemented. Safe and effective management will improve patient survival rates.

(Pickard, 2006)

Mission
To educate floor staff on sepsis, systemic inflammatory response syndrome (SIRS), multi-organ dysfunction (MODs). Providing them with the knowledge of the process, signs for early identification and treatment plans.

Learning outcomes
To have an understanding of the infective process as it

relates to sepsis Understand SIRS as it relates to MODs Identify early signs of sepsis Identify the four indicators of patient advancement toward SIRS Know when and how to initiate non-ICU sepsis protocol Know your role in the non-ICU sepsis protocol Identify when patient may not be appropriate for non-ICU setting

Course sequence
Part one What is sepsis Understanding possible sources Progression of sepsis, SIRS and MODS

Sepsis + organ dysfunction Sepsis + organ dysfunction + volume resistant hypotension

Mortality rate Who goes septic? Patient presentation (whats my septic patient look

like?)
(Gunthrie-Chu,2009)

Course one description

Microorganisms invade a body system and initiate

systemic inflammatory response (SIRS)

Gram- negative and gram positive aerobes, anaerobes,

fungi, exogenous sources and endogenous sources.

SIRS wide spread inflammatory response to severe

infective process progresses to multiple organ system dysfunction syndrome (MODS). (Urden, Stacey, Lough, 2010)

Course descripton
Severe sepsis occurs in > 750,000 patients in the U.S.

annually
Leading cause of death in non-coronary critical care

units
Mortality rate of 38- 59 %
(Urden, Stacey, Lough, 2010)

Course description
I go, you go, we all go every patient with a severe infection have potential to become septic. Consider coexisting health conditions Source of infection Patient presentation PNA and UTI are most commonly associated with sepsis
(Urden, Stacey, Lough, 2010)

Course description
Look at holistic picture Dont get tunnel vision Look for worsening trends Skin color, LOC, orientation Changes in vital signs. Remember not everyone is septic Age does not predict sepsis anyone can go septic
(Urden, Stacey, Lough, 2010)

Objectives part one

RN will be able to provide early identification of

patients with potential of progression to sepsis

RN will report assessment finding to physician and

request initiation of non-ICU sepsis protocol.

Identify SIRS score Severe sepsis vs. septic shock

Part two
SIRS criteria
Vital signs What to watch for Lab values Blood cultures Lactate WBCs Neutrophils

(Matthews & Harsh, 2010)

Part two
The plan Know when to act
Be prepared with what to expect Understanding nursing action on sepsis protocol
(Matthews & Harsh, 2010)

Course description
Identify SIRS criteria rating of patient
Report patients with two of the following parameters

to physician
Temp < 98.6 or > 100.4 Pulse > 90/min Resp >20 or pCO2 < 32 WBC <4000 or >12000 or bands > 10% neutrophils
(Matthews & Harsh 2010)

Course description
RN monitoring of septic patients will increase
Strict Q2hr I & O report output of < 30ml/hr after

6hr. Vitals signs Q1hr x 4 hr, Q2hr x 2, Q4hr x 24 frequency may be increased based upon nursing judgement Give antibiotics as ordered Treat fever > 101F, hyperglycemia protocol, and DVT prophylaxis. (Matthews & Harsh, 2010)

Objectives part two

The RN will identify and report patients with any 2 of

4 SIRS criteria to physician

RN will request non-ICU sepsis protocol and initiate RN monitoring will increase

Part three
Using the protocol outside the ICU
Treatment of hypotension with fluids. When to know a higher level of care is required

Trends in vital signs to watch for Urinary output Skin color

(Matthews & Harsh 2010.)

Course description
Please look at past medical history, pre- existing conditions

may require a more reserved fluid resuscitation efforts. Give 500 mL of NS over 30 min, repeat x1 for systolic < 90
Notify physician if systolic BP < 90 or HR > 100 after 2

boluses. If unresponsive to initial fluid bolus be prepared to begin aggressive resuscitation with 500 mL bolus of NS Q 30 min (parameters will be established by physician on volumes) Remember this is an intravascular depletion and volume resuscitation can exceed 6L for the severely septic patient.
(Matthews & Harsh 2010)

Course description
Worsening trend in vital signs Temp > 103 Systolic blood pressure < 60 Heart rate > 140 Respiratory rate > 35 Urine output of < 30mL/hr Increased O2 needs or decreasing O2 sats Mottled skin Acute mental status changes (Matthews & Harsh 2010)

Course description
Patient requires a higher level of care!
Unsuccessful volume resuscitation may require

pressors for vascular support.

End goal is adequate end organ tissue perfusion.
(Urden, Stacy, Lough 2010)

Part three objectives

The nurse will implement sepsis management bundle
Administer IV antibiotics as ordered Begin fluid challenge Increase monitoring by RN maintained.

Course one evaluation

Evaluation of content will be assessed through written

exam. Exam will include multiple choice, fill in the blank. Content will include definition of sepsis Risk factors Identification of organisms responsible for sepsis Identification of when to report Case study Score > 90% required for completion and advancement to course 2

Course two Evaluation

Written exam that includes SIRS criteria Identification of at risk patient Identification of expected nursing interventions Exam will be multiple choice and fill in the blank Case study Score > 90% required for completion and advancement to course 2

Course three evaluation

Each participant will receive 3 different case studies at

end of part 3 for completion in 1 hour.

Evaluation will require a written evaluation of 3

separate case studies. Case studies will include assessment of patient, lab interpretation, clinical presentation of patient and individualized plan of care for all 3 cases.

Instructor Evaluation
Upon course completion please complete survey

received with case studies. Survey will address:

Course content Applicability in clinical setting Instructor knowledge of content Strengths and weakness of course content

Strengths and weakness of instruction method

Suggestions.

References
Matthews, J, & Harsh, H. (2010). Identifying your septic patient. Informally published manuscript, Department of Nursing Educaton, Exempla Health system Guthrie-Chu, C. (2009). Sepsis and septic shock. American Journal of Critical Care Nursing, 16(2), 110-119. Larson, E. (2007). Development and implementation of multi-disciplinary sepsis protocol. Critical Care Nurse, 23(3), 43-54. Urden, L., Stacy, K., & Lough, M. (2010). Critical care nursing diagnosis and management. St. Louis, Mo.: Mosby.