Nur 213: Clinical Pathos: Sepsis

This study source was downloaded by 100000865965430 from CourseHero.com on 06-20-2023 14:33:28 GMT -05:00https://www.coursehero.com/file/198396229/Patho-Sepsisdocx/Powered by TCPDF (www.tcpdf.org) NUR 213: Clinical Pathos: Sepsis Related Concept(s)Oxygenation, Perfusion, Infection, Mobility Related Exemplar(s)Sepsis, Septic Shock, PNA, UTIPathophysiologySepsis is a dysfunction caused by immunological overactivity, when an infection becomes systemic, your body has been continuously producing an immune cascade and now the system is saturated and oversaturation of these enzymes and proteins causes vasodilation, more permeable membranes and then fluid and these cells can lek and cause damage to tissue and organs Risk FactorsInfection, older than 65 years old, younger then 3 months old, pregnant women, immunosuppressed, patients with co-morbidities, recent invasive procedures, poor nutrition. Clinical Manifestations (Signs & Symptoms) Shivering Pale Fever Very cold Temp greater than 100.4 Tachycardic- arrhythmias Tachypnea- Shallow Extreme pain or discomfort Sleepy or AMS Short of breath Feelings of doom Any symptoms related to pre-existing infection. Low blood pressure/MAP Decreased urine output Priority Assessments Priority Labs & Diagnostics Priority Plan of Care1. Thorough history 2. Neurological 3. Cardiovascular 4. Vital signs 1. WBC >12,000 (CBC w Diff)2. Blood cultures 3. Lactic >2mmol4. Chest X-ray 1. Maintains adequate tissue perfusion. 2. Maintains adequate fluid volume status. 3. Eliminate infection.Priority Nursing