Show Menu

Nursing Sepsis Ax & Care Cheat Sheet (DRAFT) by

This is a draft cheat sheet. It is a work in progress and is not finished yet.


SIRS (>2):
T >10­0.4­/<95.0 HR >90
RR >20 or PaCO2 <32
WBC >12­/<4 or Bands >10%
Sepsis: SIRS + Infection
Severe Sepsis (>1 org dysf):
SBP <90­/de­crease by >40 or MAP <65
Cr >2.0 or UO <0.5 mL/kg/hr x2hr
Platelets <10­0,000
INR >1.5 or PTT >60
Lactate >2
Septic Shock: Severe Sepsis + Refractory Hypote­nsion
Persistent tiss hypope­rfusion after fluid resusc
SBP <90­/de­crease by >40 or MAP <65
Lactate >4
MODS: >1 End-organ dysfun­ction

Phases of Septic Shock

Early / Hyperd­ynamic Phase
hypote­nsion, tachyc­ardia, tachypnea, Ꝋ/↑ CO, ↓SVR, bounding pulse
warm, well perfused extrem­ities but ↓visceral flow
flushed, moist skin
Late / Hypody­namic Phase
hypote­nsion, tachyc­ardia, tachypnea, narrow thready pulse, vasoco­nst­ric­tion, CO declines
cold, poorly perfused extrem­ities
pale, dry skin

Sepsis Bundles

Within first 3 hours:
O2 support. IV access x2 (large bore).
Measure lactate level
Obtain blood cultures x2 prior to abx adm
Adm broad spectrum abx (w/in 3 hr of ER adm or w/in 1 hr of adm to hospital unit)
Adm 30 mL/kg crysta­lloid for hypote­nsion or lactate >4
Within first 6 hours:
Draw 2nd lactate level if initial lactate >2
Measure CVP or ScvO2 for refractory art hypote­nsion or initial lactate >4. Maintain CVP >8 & Scvo2 >70.
Add vasopr­essors for persistent hypote­nsion following fluid resusc. Maintain MAP >65.
Persistent shock- Consider adding Vasopr­essin 0.04 units/min.
Within 24 hours from severe sepsis dx:
Lung protective ventil­ation- Maintain insp plateau pressures <300 cmH2O for vent pts. Avoid tidal volume >6 mL/kg for ARDS pts.
Steroids - Adm low dose steroids for septic shock (hydro­cor­tisone)
Glucose contro­l/I­nsulin therapy

Nursing Diagno­sesAlt

R/F infection: superi­nfe­ction
R/F fluid volume deficit
Altered tissue perfusion
Impaired gas exchange
Knowledge deficit


Glycemic control - IV regular insulin to maintain blood glucose <180 (goal <150)
VTE prophy­laxis - Adm low-dose UFH/LMWH
Stress ulcer prophy­laxis - PPI or H2 rec antag
Vasoactive Meds:
Norepi­nep­hrine 2-20 mcg/min; titrate q5min
Dopamine 5-20 mcg/kg/min
Dobutamine 2.5-20 mcg/kg/min
Vasopr­essin 0.4 units/min
Vent Meds:
Propofol 5-10 mcg/kg­/min; max 50 mcg
Midazolam 1-2 mg/h; max 0.3 mg/kg/hr
Lorazepam 1-2 mg/h; max 10 mg/hr
Morphine 1-2 mg/h; max 0.3 mg/kg/hr
Fentanyl 50-100 mcg/hr; max 3 mcg/k/min

Nursing Care

Client­-family education
Enteral feeding
Urinary catheter
Strict aseptic technique
Consider ECHO, EKG, Troponin levels
Assess fluid & perfusion status freque­ntly.
Monitor coagul­ation studies (PT, PTT, INR, fibrin­ogen, FDP, platel­ets). Adm platelets if counts <5.
Monitor H/H. Assess for signs of bleeding. Adm PRBCs if Hgb <7.
Monitor VS, hemody­namics, EKG closely. Adm anti-a­rrh­ythmic as needed. VS q5m during titration.
Monitor temp. Fever reduction as needed. Assess & maintain skin integrity.