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NUR 265 sim lab
- Course
- ATI NUR265
- Institution
- Galen College Of Nursing
Sim lab prep work for NUR 265
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SIRS: a widespread inflammation reaction in the body due to infections or non-infections liketrauma or burns.
Diagnosis: When two or more of the following are present:
1. High or low body temperature
2. Fast heart rate
3. Rapid breathing or low carbon dioxide levels in the blood
4. High or low white blood cell count
Sepsis is a severe response to infection that causes organ damage
Septic shock is a critical condition from sepsis with dangerously low blood pressure and poor
blood flow regardless of treatment.
Diagnosis: Sepsis with:
1. Very low blood pressure needing medication to maintain adequate blood pressure
2. High levels of lactate in the blood, indicating poor tissue oxygenation, even after
receiving fluids
Nursing priorities in the care of the patient with sepsis and septic shock:
1. Early identification (monitor vital signs, recognize early signs of infection, altered mental
status, decreased urine output, and abnormal labs.
2. Immediate intervention: oxygen therapy, fluid resuscitation, med admin- broad
spectrum antibiotics and vasopressors
3. Monitor and management: continuous use of cardiac and hemodynamic monitoring,
regular kidney function, monitor blood cultures, lactate levels
4. Supportive care: pain management, nutritional support and positioning and mobility
5. Prevent complications: infection control, DVT prophylaxis, pressure ulcer prevention
Common cause of septic shock:
Class of bacteria: Gram negative bacteria: E coli (UTI, abdominal infection), pseudomonas
aeruginosa (resp infection), Neisseria meningitidis (meningococcal sepsis)
Gram positive bacteria: staphylococcus aureus (MRSA), streptococcus pneumoniae
(pneumonia)
, Explain why myocardial depression is almost always present in a patient with septic shock
despite an initial rise in cardiac output:
Initial rise in output due to vasodilation and compensatory mechanisms. Inflammatory and
cellular damage weaken the heart over time. Then circulatory issues and metabolic problems
further reduce heart function.
Discuss the cascade of host inflammatory responses that produce the major detrimental effects
seen in sepsis due to gram-negative bacteria:
Body recognizes the pathogen, body activates immune response (cytokine release), systemic
inflammatory response (increase of cytokines and other inflammatory mediators cause
increased permeability and coagulation), leading to impaired blood flow and tissue hypoxia,
metabolic dysregulation (lactic acidosis- cells switch to anaerobic metabolism, producing lactic
acid and causing metabolic acidosis), MODS (organ failure)
What is early goal-directed therapy in the management of sepsis:
Early indication by rapidly identify patients with sepsis through clinical signs and symptoms, lab
tests and vital signs
Fluid resuscitation: IV crystalloids 30 mL/kg within the first three hours
Vasopressors and inotropic agents
O2 maintain above 90%
Early antibiotic: within 1st hour
Identify the treatment guidelines currently recommended for the management of sepsis and
septic shock:
Within the 1st hour:
Antibiotics, fluids and vasopressors, infection control
Discuss the importance and rationale for central line placement in a patient with sepsis:
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