Primary Nursing Diagnosis

Infection related to exposure to bacteria from trauma, invasive instrumentation, or contamination

OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection; Treatment behavior: Illness or injury

INTERVENTIONS. Infection control; Medication management; Environmental management; Surveillance; Nutrition management; Teaching: Disease process

Ü PLANNING AND IMPLEMENTATION Collaborative

The primary goals of treatment in septic shock are to maintain oxygen delivery to the tissues and to restore the vascular volume, blood pressure, and cardiac output. IV fluids are administered to increase the volume within the vascular bed; crystalloids (normal saline solution or lactated Ringer's injection) are usually the fluids of choice. Vasopressors, such as dopamine or norepi-nephrine (Levophed), may also be required to maintain an adequate blood pressure. The patient is also placed on broad-spectrum IV antibiotics. If the patient's hemoglobin and hematocrit are insufficient to manage oxygen delivery, the patient may need blood transfusions. A pulmonary artery catheter is inserted to monitor fluid, circulatory, and gas exchange status.

An aggressive search for the source of sepsis is an essential part of the treatment. Any indwelling catheters, whether they are urinary, intravascular, intracerebral, or intra-arterial, are discontinued if possible or moved to another location. A surgical consultation may be performed to search for undrained abscesses or to débride wounds. If complications such as ARDS develop, more aggressive treatment is instituted. Intubation, mechanical ventilation, and oxygenation are required for severe respiratory distress or failure. Patients often need ventilator adjuncts, such as positive end-expiratory pressure, pressure-control ventilation, or inverse inspiration-to-expiration ratio ventilation.

Total parenteral feeding or enteral feedings may be instituted for patients who are unable to consume adequate calories. Monitor the success of nutritional therapy with daily weights. During supportive care, the entire healthcare team needs to monitor the patient's condition carefully with serial cardiopulmonary assessments, including vital signs, physical assessment, and continuous hemodynamic monitoring. Patients should be attached to a pulse oximeter for continuous assessment of the arterial oxygen saturation. The patient's level of consciousness is important. In children, monitor the child's activity level and the response to parents or significant others.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Broad-

spectrum antibiotics

Varies by drug Varies by drug

Dopamine, dobutamine, phenyl-nephrine, or norepinephrine Examples: vancomycin, gentamicin, penicillin, cefotaxime (Claforan), cefuroxime (Zinacef), piperacillin and tazobactam (Zosyn), imipenem and cilastatin (Primaxin), clindamycin, meropenem (Merrem), metronidazole (Flagyl), Ciprofloxacin (Cipro)

Maintain an adequate blood pressure

Eradicate bacteria

Experimental and Other Therapies: Dopexamine (beta2-adrenergic and dopaminergic effects without any alpha-adrenergic activity), vasopressin (useful in patients with refractory septic shock to maintain blood pressure), inamrinone and milrinone (inotropic agents with vasodilating properties), nitric oxide inhibitor (endogenous vasodilator), recombinant human activated protein C (endogenous protein that not only promotes fibrinolysis and inhibits thrombosis and inflammation but also may modulate the coagulation and inflammation of severe sepsis).

Independent

Priorities of nursing care for the patient with septic shock include maintaining airway, breathing, and circulation; preventing the spread of infection; increasing the patient's comfort; preventing injury; and supporting the patient and family. Monitor the patient continuously for airway compromise and prepare for intubation when necessary. Maintain strict aseptic technique when you manipulate invasive lines and tubes. Use universal precautions at all times. Unless the patient is endotracheally intubated, place patients with a decreased level of consciousness in a side-lying position, and turn them every 2 hours to protect them from aspiration. To increase the intubated patient's comfort, provide oral care at least every 2 hours.

Maintain skin integrity by placing the patient on an every-2-hour turning schedule. Post the schedule at the head of the bed to increase the visibility of the routine. Implement active and passive range of motion as appropriate to the patient's condition. Provide the family with information about diagnosis, prognosis, and treatment. Expect the patient and family to have high levels of anxiety and fear, given the grave nature of septic shock. Support effective coping strategies, and provide adequate time for the expression of feelings.

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