Identify early, subtle signs of septic shock
Identify early, subtle signs of septic shock
Act before it's too late
In a septic patient, the normal defenses of the body against overwhelming infection are breaking down. Bacterial germs are loose and multiplying in the bloodstream.
"Once this state has arisen, the patient's chances for recovery begin to decline rapidly," Melissa Gaines, RN, BSN, education clinical coordinator for emergency services at Sts. Mary & Elizabeth Hospital in Louisville, KY. "Septic shock and death will follow if this condition is left untreated for long."
At Sts. Mary & Elizabeth Hospital's ED, a septic work-up includes obtaining culture specimens of blood, urine, and spinal fluid via lumbar puncture or spinal tap. "While awaiting these test results, powerful antibiotics are administered intravenously in high doses until the situation is clearer. The patient is truly, gravely infected or perhaps suffering from another illness, often viral, which is not serious," says Gaines.
Gaines says in fact, most septic work-ups are false alarms. "But they are a small price to pay for saving lives. Children are more at risk, especially young infants as they cannot tell us exactly what is happening within their body," she says.
Early, subtle signs of shock are agitation, confusion, lethargy, pale skin, dry mucous membranes, generalized weakness, and tachycardia, says Holly Mason, RN, BS, CEN, unit manager of the pediatric ED/Fast Track/clinical decision unit/observation unit at Wake Forest University Baptist Medical Center in Winston-Salem, NC. Also, patients with nausea, vomiting, diarrhea, or fevers are at high risk. "Elderly and pediatric patients are more at risk for developing septic shock," adds Mason. "What may first appear as a mild case of dehydration can quickly develop into an emergent situation, due to volume depletion and infection."
Perform these interventions immediately for patients in septic shock, says Mason:
- Give intravenous hydration to address volume depletion.
- Perform cardiac, noninvasive blood pressure, and pulse oximetry monitoring.
- Draw labs.
- Monitor urinary output closely to assess for kidney failure.
Wake Forest's ED nurses use a protocol with several indicators, including a patient's history and vital signs, to identify sepsis. "It is initiated immediately and includes a standardized list of orders for rehydration and antibiotics if indicated," says Mason. "100% of these patients are QI'd to ensure that we are identifying and treating septic patients appropriately." [The sepsis protocol used by ED nurses is included.]
For more information on identifying early signs of sepsis, contact:
- Sheri Belanger, RN, BSN, CEN, SANE, Emergency Department, St. Joseph Mercy Hospital, Ann Arbor, MI. Phone: (734) 712-3000. E-mail: [email protected].
- Melissa Gaines, RN, BSN, Education Clinical Coordinator, Emergency Services, Sts. Mary & Elizabeth Hospital, Louisville, KY. Phone: (502) 361-6740. Fax: (502) 367-3340. E-mail: [email protected].
- Holly Mason, RN, BS, CEN, Pediatric Emergency Department, Wake Forest University Baptist Medical Center, Winston-Salem, NC. Phone: (336) 713-9054. E-mail: [email protected].
Watch for these vague signs of sepsis in elders
Because an 84-year-old man who owned a business and worked there every day was suddenly unable to remember what day it was, his family brought him to the ED at St. Joseph Mercy Hospital in Ann Arbor.
ED nurses quickly obtained labs, obtained a urine specimen, performed a nursing assessment, and administered intravenous fluids and antibiotics. "Within four hours, the patient was back to his baseline mental status and was improving," says Sheri Belanger, RN, BSN, CEN, SANE, an ED nurse.
Look for these subtle changes in your patients over the age of 55, says Belanger:
"Patients need to be screened at the time of triage for any of the above changes," says Belanger. "Do a conscious, thorough questioning of the patient and their family."
Patients without spleen are high risk for sepsis
Before a young man was able to walk up to the triage nurse at Sts. Mary & Elizabeth Hospital in Louisville, KY, she noticed he was weak and his color was grayish.
"She immediately assisted him and obtained a wheelchair," says Melissa Gaines, RN, BSN, education clinical coordinator for emergency services. "His blood pressure was in the 80s diastolically, so she wheeled the patient to a trauma bed and alerted the physician of his presence."
A septic work-up was performed, including obtaining blood cultures, labs, urine, and rapid administration of intravenous fluids and strong antibiotics, but these interventions were too late.
"The patient's body shut down. His pressure continued to rapidly decline despite the numerous interventions," says Gaines. "Within three hours, the 24-year-old normally healthy man coded twice and died."
Emergency nurses struggled through the rest of the shift. "The ED doctor repeated his clinical findings over and over to make sure he did not miss anything that could have altered this young man's fate," says Gaines.
It was determined that the patient must have contracted bacteria from an intensive care unit, where he had visited a sick uncle. "Not having a spleen hastened the growth of the bacteria in the patient's system," says Gaines. "In short, when any patient arrives with a history of vomiting and diarrhea that does not have a spleen, I take them to a bed immediately to start the work-up."
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