Andrea NortonN400 4/2011Simulation Lab Questions

1. Differentiate the following terms:

• Systemic Inflammatory Response Syndrome (SIRS): The first symptoms of pathologic inflammation are called the systemic inflammatory response syndrome (SIRS). Manifests as two or more of the following conditions:• temperature greater than 38°C or less than 36°C • heart rate greater than 90 beats/min • respiratory rate greater than 20 breaths/min, arterial carbon dioxide lower than 32 mm Hg, or need for mechanical ventilation • leukocyte count greater than 1,200/μL or less than 4,000/μL or greater than 10% immature band forms (neutrophils)

• Sepsis: Systemic response to infection, manifested by 2 or more of the following conditions as a result of infection: • temperature greater than 38°C or less than 36°C • heart rate greater than 90 beats/min • respiratory rate greater than 20 breaths/min, arterial carbon dioxide lower than 32 mm Hg, or need for mechanical ventilation • leukocyte count greater than 1,200/μL or less than 4,000/μL or greater than 10% immature band forms (neutrophils)

• Severe sepsis: Sepsis associated with organ dysfunction, hypo perfusion, or hypotension. Hypo perfusion abnormalities may include: lactic acidosis, oliguria, or an acute alteration in mental status.

• Septic shock: Sepsis induced shock with hypotension despite fluid resuscitation, along with the presence of perfusion abnormalities: lactic acidosis, oliguria, altered mentation. (Vasopressors are needed)

• Multiple Organ Dysfunction Syndrome (MODS): Altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.

2. Identify the nursing priorities in the care of the patient with sepsis and septic shock. Nursing priorities in the care of the patient with sepsis and septic shock:1. Eliminate infection.2. Support tissue perfusion/circulatory volume.3. Prevent complications.4. Provide information about disease process, prognosis, and treatment needs.

Monitor neurological status, including mental state and LOC Monitor BP, HR, rhythm, pulse quality, CVP, PAP, CO Monitor color and character of skin Monitor ABGs, blood counts, clotting times, platelet counts

Monitor RR, rhythm and breath sounds Monitor temp Q2 hrs Monitor I&O; report < 30 ml/h Give antibiotics IV Give fluids IV (NS, LR) to increase BP Nutrition Drugs, such as dopamine or norepinephrine (which cause blood vessels to narrow), may

be needed to increase blood flow to the brain, heart, and other organs. Oxygen given through a mask, through nasal cannula, or, if a breathing (endotracheal)

tube has been inserted, through that tube. If needed, a mechanical ventilator is used to help with breathing.

3. What class of bacteria is responsible for more than one half of the cases of septic shock? What are some common causes of this?

Gram + bacteria: Exogenous sources include the hospital environment and the health care team. Endogenous sources include the patient’s skin, gastrointestinal tract, respiratory tract, and urinary tract.

4. Explain why myocardial depression is almost always present in a patient with septicshock despite an initial rise in cardiac output.

Cardiac dysfunction develops as a result of the release of myocardial depressant cytokines. Ventricular failure eventually occurs. In response to stimulation by the inflammatory cytokines, tissue factor is released producing widespread micro vascular thrombosis, furthering the alterations in the cardiovascular process.

5. Discuss the cascade of host inflammatory responses that produce the major detrimentaleffects seen in sepsis due to gram-negative bacteria.

Viruses and fungi can cause sepsis, but more often bacteria do. Gram (-) bacteria contain endotoxins [lipid A, within a lipopolysaccharide] just inside their membranes. As the host immune response lyses these cells, the endotoxin is released. The immune system responds to these events with the following cascade:1: Cytokines are released [bradykinin, complement, interleukin, tumor necrosis factors, etc]--these cause endothelial cell damage and cause the blood vessels to 'leak' fluid.The endothelial cells are also 'activated' which causes these things:a) vasoconstriction [thromboxane, endothelin, angiotensin II, etc]b) vasodilation: [prostanoids, nitric oxide]Both of these things impair vascular smooth muscle tonec) Increase in endothelial permeability, fluid leaks to the interstitial zone causing intravascular hypovolemia.d) Coagulation cascade [platelet adhesion and aggregation, formation of microemboli--meaning little clots in little capillaries and less clotting factors in other circulation.]e) Aggregation and adhesion of lymphocytes that damage healthy tissue--well that' not good, because your immune cells are globbing together and sticking to something and causing damage,

instead of going out and fighting off bacteria. This causes more clotting factors reacting to damage. And then you have a lot less circulating blood volume. You therefore have low CO, low perfusion, tissue hypoxia, which then begets anaerobic respiration and lactic acid buildup. You also get "maldistribution of circulating blood volume" meaning blood is shunted to certain vital organs and away from others (esp skin, lungs, and kidneys).

In the end, the bacteria is not your problem-- it's the immune system freaking out and causing trouble that kills you.

6. What is early goal directed therapy in the management of sepsis?

Goal: optimize O2 delivery and decrease O2 consumptionA. Optimize oxygen delivery1. O22. fluid resuscitation to optimize preloadB. Drugs:1.Positive inotropes: dopamine, dobutamine, milrinone2.Afterload reductionC. Decrease O2 consumption: decrease total body work, decrease pain, anxiety, temperature

7. Identify the treatment guidelines currently recommended for the management of sepsisand septic shock.

The stop sepsis campaign defines a "6 hour bundle" that includes the following rapid treatment strategy. Bundle Element 1: Measure serum lactate.Bundle Element 2: Obtain blood cultures prior to antibiotic administration.Bundle Element 3: Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission.

Bundle Element 4: In the event of hypotension and/or serum lactate >4 mmol/L:a. Deliver an initial minimum of 20 mL/kg of crystalloid or an equivalent b. Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) >65 mm Hg * Treat Hypotension and/or Elevated Lactate with Fluids * Apply Vasopressors for Ongoing HypotensionBundle Element 5: In the event of persistent hypertension despite fluid resuscitation (septic shock) and/or lactate >4 mmol/L:a. Achieve a central venous pressure (CVP) of >8 mm Hgb. Achieve a central venous oxygen saturation (ScvO2) > 70% or mixed venous oxygen saturation (SvO2) > 65% .Within the first 24 hours the nursing priorities should also include: 1)Administering low-dose steroids 2)Administer dotrecogin alfa (activated) 3) Maintain adequate glycemic control 4) prevent excessive inspiratory plateau pressures.

http://www.survivingsepsis.org/implement/bundles

8. Discuss how the drug dobutamine affects cardiac output. Identify the nursing implications with the administration of this drug.

Dobutamine is an inotrope, and increases cardiac output. It Stimulates beta1(myocardial)-adrenergic receptors with relatively minor effect on heart rate or peripheral blood vesselsTherapeutic Effect(s): Increased cardiac output without significantly increased heart rateImplications for the nurse are to:

▪ Correct hypovolemia by administration of appropriate volume expanders prior to initiation of therapy.

▪ Monitor therapeutic effectiveness. At any given dosage level, drug takes 10–20 min to produce peak effects.

▪ Monitor ECG and BP continuously during administration.▪ Note: Marked increases in blood pressure (systolic pressure is the most likely to be

affected) and heart rate, or the appearance of arrhythmias or other adverse cardiac effects are usually reversed promptly by reduction in dosage.

▪ Observe patients with preexisting hypertension closely for exaggerated pressor response.▪ Note: Tolerance has been observed with continuous or prolonged infusions; adverse

reactions are no different than those seen with shorter infusions.Monitor I&O ratio and pattern. Urine output and sodium excretion generally increase because of improved cardiac output and renal perfusion.

9. Discuss how norepinephrine works and its indications for use. Identify the nursingimplications with the administration of this drug. Norepinephrine is indicated for the treatment of acute hypotension and is a potent a- adrenoceptor agonist and is there- fore a strong vasoconstrictor, increasing systolic and diastoiic blood pressures. In addition, norepinephrine increases both heart rate and contractility. Nursing implications are to: Monitor constantly while patient is receiving norepinephrine. Take baseline BP and pulse before start of therapy, then q2min from initiation of drug until stabilization occurs at desired level, then every 5 min during drug administration.

▪ Adjust flow rate to maintain BP at low normal (usually 80–100 mm Hg systolic) in normotensive patients.

▪ Observe carefully and record mental status (index of cerebral circulation), skin temperature of extremities, and color (especially of earlobes, lips, nail beds) in addition to vital signs.

▪ Monitor I&O. Urinary retention and kidney shutdown are possibilities, especially in hypovolemic patients. Urinary output is a sensitive indicator of the degree of renal perfusion. Report decrease in urinary output or change in I&O ratio.

▪ Be alert to patient’s complaints of headache, vomiting, palpitation, arrhythmias, chest pain, photophobia, and blurred vision as possible symptoms of over dosage. Reflex bradycardia may occur as a result of rise in BP..

10. Discuss how drotrecogin alfa works and its indications for use. Identify the nursing implications with the administration of this drug.

The protein C coagulation pathway has emerged as the major regulatory mechanism that can cause excess thrombin production and inappropriate thrombosis that leads to strokes and heart attacks. Activated protein C interacts with protein S to inactivate both coagulation factorsV and VIII, subsequently decrease thrombin production. In addition, protein C has anti-inflammatory properties, and has been shown to decrease both the inflammatory and coagulant effects of gram-negative .By limiting leukocyte activation, cytokine production, and micro vascular coagulation, activated protein C prevents organ damage. Nursing implications are to: Monitoring of laboratory markers because Drotrecogin alfa may prolong the PTT interval.  If the PTT exceeds 100 seconds, the infusion should be held and restarted when <100 seconds.  Hold the infusion if the INR rises to >3.0 or the platelet count drops <15,000, because of an increased risk for bleeding.

11. Describe the concept of ScvO2 monitoring. Identify the significance of abnormally highand low ScvO2 readings.

The major goal was to achieve a central venous oxygen saturation (ScVO2) of 70% or more, because ScVO2 reflects cellular oxygen extraction, an early indicator of cellular hypoxia. ScvO2 reflects the balance between oxygen demand and oxygen supply to the tissues. Restoring the balance between demand and supply is the goal of treatment in clinically relevant abnormal ScvO2. Low ScvO2 is associated with increased morbidity and mortality. A low SVO2 can indicate that either the O2 extraction is increased or the O2 delivery is decreased. This can be caused by anemia, decreased cardiac output, low arterial oxygen saturation or an increased VO2I. A high SVO2 is often more difficult to interpret. It can indicate the inability of the tissues to extract oxygen, which can be seen in sepsis. Another cause could be a hyper dynamic circulation or an increased oxygen delivery.

12. Describe the nursing responsibilities in assisting with central line insertion. The nurse should: Explain the procedure to family or patient Ensure that all the necessary consents are signed Have emergency equipment available

Gather all the equipment for line setup and PAC insertion per institutional guidelines. Prepare a sterile field Depending on the contents of the catheter insertion tray, gather additional 4 x 4 gauze,

sterile towels, and a sterile gown Obtain syringes with 10 ml saline flush solution Flush all ports along with any attached stopcocks, using sterile technique Cover the prepared tray with sterile towels

13. Discuss the importance/rationale for central line placement in a patient with sepsis.

A central line is an intravenous catheter or IV placed into a large vein. A central line is needed to give the medical team access to a large vein that can be used to give fluids, measure the amount of fluid in the body, or to give medication that might be irritating to smaller veins. Having a central line allows for the necessary interventions and monitoring of blood gases needed for favorable outcomes for sepsis patients.

14. Describe the physiologic alterations of each organ system identified below that may beassociated with aging and potentially impact a patients ability survive sepsis or septic shock.The physiologic changes associated with aging, coupled with pathologic and chronic disease states, place the older individual at increased risk of developing a state of shock and possibly MODS.• Cardiac The heart does not function well in hypoxemic states, and the aging heart may respond to decreased myocardial oxygenation with dysrhythmias that may be misinterpreted as a normal part of the aging process. Several studies documented an increased production of IL-6, IL-1 and nitric oxide during severe sepsis in elderly patients. IL-6 and IL-1 are well known factors reducing myocardial contractility, while nitric oxide is a powerful vasodilation mediator. The result is that the heart of an aged septic patient may not be able to provide the increase in cardiac output required by the septic syndrome.• Renal: In older septic patients pharmacokinetics and pharmacodynamics of antibiotics can be modified by age-related renal alterations, changing the effects of medication for the aging population. Since renal oxygen extraction is reduced in sepsis, it can be appreciated how in some circumstances, sepsis could induce worsened renal damage in the elderly due to reduced 02 reserves. Thus, changes in renal blood flow, due to capillary leak and decreased ability to increase CO for the elderly population, leads to increased risk for MODS and death.• Immune: The immune system of the elderly is different from that of younger adult patients. All the components of the immune system appear to be someway altered in the elderly. The atrophy of the thymus associated with age is associated with a shift in the characteristics of the cytokine environment. Aging affects the magnitude and the quality of the host immune response to pathogens by the altered inflammatory environment. Also, it seems that sepsis produces a more pronounced inhibition of the mitochondrial respiratory chain. This leads to a more severe mitochondrial damage causing increased cellular apoptosis in the elderly. • Hematologic :Aging is associated with a procoagulant state. Activated factor VII is increased as well as prothrombin, factor IX, factor X, and thrombin- antithrombin complexes. Increases in plasminogen activator inhibitor type 1 has also been found increased in the elderly magnifying the coagulation cascade with sepsis.

15. If a patient has no advanced directives and no immediate family to make a decision regarding his care, what options are available to the healthcare team? Discuss if you feel this patient should or should not be a full Code Blue. Defend your position.

In emergency situations, physicians and nurses, who have no knowledge of whether a patient wishes resuscitation, will error on the side of caution, and with the interest of the patient in mind determine whether cardiopulmonary resuscitation will be performed. If this is not an emergency situation, however, then facility Policies and procedures approved by the medical staff should be available for patients who lack the capacity, have left no instructions, and have no surrogate decision makers. Facility policies should require that any decision to forgo life-sustaining treatment for a patient be subject to review to ensure that the proposed action is ethically sound. The goal should be to assure that the decision made is consistent with the patient’s best interests. Joint Committee on Biomedical Ethics of the Los Angeles County Medical Association instituted the body of work titled: Guidelines for Physicians: Forgoing Life-Sustaining Treatment for Adult Patients. The policy states that reviews, should involve a formally constituted interdisciplinary advisory committee, which may be the facility’s bioethics committee. The advisory committee should: (1) Review all relevant medical information regarding the patient’s medical history, current condition, and prognosis.(2) Determine whether the treating physicians generally agree on the patient’s prognosis(3) Hear the views of all interested parties.(4) View the burdens and benefits of continued treatment from the point of view of the patient;(5) Exclude from consideration any economic impact on providers (physicians or facilities) of the patient. (8) Indicate whether or not the proposed decision is an ethically acceptable option.

The advisory committee’s recommendation should be entered in the patient’s medical record. The patient’s attending physician is ultimately responsible for the patient’s treatment.