SBAR Paper on Urosepsis and Dehydration

Running head: SBAR: UROSEPSIS AND DEHYDRATION 1

SBAR: Urosepsis and Dehydration

Z1650675

Northern Illinois University

March 17, 2015

UROSEPSIS AND DEHYDRATION 2

Analysis

Urosepsis

Pathophysiology. Urosepsis is a severe infection originating from the urogenital tract

that causes a systemic, inflammatory response (Kalra & Raizada, 2009).

The urinary tract consists of the upper portion (kidneys and ureters) and lower portion

(bladder and urethra). The kidneys produce urine at a continuous rate of more than 0.5 mL/kg of

body weight per hour. Urine flows from the kidneys through the ureters and into the bladder,

which stores and expels urine via the urethra (Andersson & Michel, 2011, p. 2).

Urosepsis begins when pathogenic bacteria invade the urogenital tract. According to a

study conducted in 2002, Escherichia coli (E. coli) was the most prominent organism found in

61% of cases of urosepsis. Nevertheless, these pathogens interact with the host’s immune

system cells (e.g., macrophages, neutrophils, endothelial cells) causing an inflammatory reaction,

which leads to cellular damage and potential death. For instance, when endothelial cells are

affected, decreased blood pressure (hypotension) occur as a result of decreased blood vessel tone

and increased permeability (Wagenlehner et al., 2013).

Wagenlehner et al. (2013) state that a majority of patients survive this initial phase;

however, the subsequent phase has a greater mortality risk. The patient enters an

immunosuppressive state due to his/her dysfunctional immune cells. Other body systems are

affected, such as the coagulation system potentially causing a severe disorder, disseminated

intravascular coagulation (DIC). According to Levi and Schmaier (2014), DIC is characterized

by the formation of blood clots throughout the body, which can inhibit vital blood flow to organs

and cause them to dysfunction.


Risk Factors. Urosepsis is often a result from a complicated urinary tract infection

(UTI), which occurs with the presence of predisposing risk factors, such as a structurally

abnormal or dysfunctional urinary tract, an obstruction to urine flow, or a suppressed immune

system. An uncomplicated UTI in contrast occurs in an otherwise healthy patient (Kalra &

Raizada, 2009). Kalra and Raizada (2009) set examples of a structurally abnormal or

dysfunctional urinary tract in Appendix A. According to Wagenlehner et al. (2013), the most

common cause is an obstruction to the free flow of urine in the upper urinary tract, which can be

due to a ureteral stone, tumor, or structural anomalies.

Those at increased risk for urosepsis are the elderly, diabetics and immunosuppressed

patients (i.e., patients with AIDS, on a chemotherapy drug regimen, etc.). According to a study

conducted in 2003-2004, there was a 10% prevalence rate of hospital-acquired UTIs with

urosepsis occurring in one of ten of those identified cases. Therefore, these findings signify a

correlation between urosepsis and developing a UTI in the hospital (Kalra & Raizada, 2009).

Clinical Manifestations. Urosepsis may present as the hallmark signs of systemic

inflammatory response syndrome (SIRS), which includes the following: fever, increased heart

rate (tachycardia), increased respiration rate (tachypnea), and an abnormal white blood cell count

(leukocytes). These signs are not necessary for diagnosis, but they are considered a warning of

urosepsis (Kalra & Raizada, 2009).

The early manifestations of urosepsis can embody ‘warm shock’ with warm extremities,

low blood pressure, and bounding pulse. The later manifestations signifies ‘cold shock’ with

cold extremities and further loss in blood pressure. Further disease progression can potentiate

into respiratory distress, DIC, and multi-organ failure with kidney and liver dysfunction (Kalra &

Raizada, 2009).


Diagnostic Testing. Kalra and Raizada (2009) explain that the diagnostic evaluation

comprises a history, physical exam, urine and blood analysis and culture, and imaging tests. The

history is critical in order to deduce the underlying cause and should inquire about previous

infections, antibiotic use, and description of symptoms. According to Wagenlehner et al. (2013),

the physical assessment will reveal fever or hypothermia, hypotension, tachypnea, tachycardia,

altered mental status, high blood glucose in absence of diabetes, and edema.

Kalra and Raizada (2009) state that a urine culture is the initial step towards diagnosis;

however, a positive result does not confirm urosepsis except for the actual presence of bacteria in

the urine. A blood culture will be required prior to the start of empirical antibiotic therapy and

will identify whether bacteria has spread into the patient’s blood stream. Furthermore, a blood

analysis will reveal whether the body’s immune system cells (i.e., white blood cell count) are

abnormal and attempting to fight off the infection (Wagenlehner et al., 2013). Kalra and Raizada

(2009) clarify that the most precise diagnostic imaging tests of urosepsis are CT scans and MRI

tests. CT scans, more specifically, have an increased sensitivity for obstructive stone detection

(Dagli & Ramchandani, 2011). Wagenlehner et al. (2013) list the universally accepted

diagnostic criteria for sepsis in Appendix B.

Treatments. Urosepsis is a life-threatening illness with a mortality rate as high as 20-

40%. Thus, the early initiation of therapy is critical, and is associated with more prosperous

patient outcomes (Wagenlehner et al. (2013).

According to Kalra and Raizada (2009), the focus of initial management includes

maintaining the patient’s blood pressure and oxygenation within normal limits. If these vital

signs are abnormal, the administration of fluid expanders and oxygen is necessitated. Fluid


expanders, such as a crystalloid (e.g., normal saline), should be given at 500-1000 mL over 30

minutes for hypovolemia (Dellinger et al., 2004, p. 862).

Once the patient is stabilized, investigation of the underlying cause follows with

diagnostic imaging tests. Then, immediate control and/or extraction is needed when the

problematic factor is identified. Procedures typically consist of two stages: low-level invasive

treatment (e.g., percutaneous nephrostomy) for pain relief and urinary drainage, then definitive

removal of the underlying cause (e.g., ureteral stone) (Wagenlehner et al., 2013).

Antimicrobials are critical in the therapeutic regimen of severe infections; however, these

drugs are not initiated until there is a reduction in bodily temperature or control and elimination

of the primary cause. For empirical antibiotic therapy, E. coli infections can be treated with

piperacillin and tazobactam for a duration of three to five days (refer to Appendix C for further

drug information on piperacillin/tazobactam). Overall, early detection and treatment of urosepsis

is crucial and will significantly lower the patient’s mortality risk (Wagenlehner et al., 2013).

Nursing Management. The goals of nursing care are for the patient to demonstrate

signs of adequate perfusion and be rid of infection. Monitoring of the hemodynamic parameters

(e.g., heart rate and blood pressure) and serum lactate levels will ensure that the patient is

maintaining adequate tissue perfusion and oxygenation (Perrin, 2008).

The patient free of infection will show signs as evidenced by negative cultures (e.g.,

blood, sputum, urine) and normal temperature. It is the nurse’s responsibility to obtain the

cultures. In addition, the nurse will need to administer the initial broad-spectrum antibiotics,

then switch to a narrow-spectrum antibiotic once the specific organism has been revealed by

cultures (Perrin, 2008).


Dehydration

Pathophysiology. Dehydration is a condition in which the body does not contain an

adequate amount of water, or has a negative fluid balance. The type varies depending on the

sodium concentration in the blood stream (Braun & Anderson, 2007, p. 212). In Appendix D

Braun and Anderson (2007) outline the criteria for the different classifications: hyponatremia,

isonatremia, and hypernatremia.

The amount of sodium in the blood is significant since it reveals the fluid loss

composition and will have a different pathophysiologic impact. For instance, isonatremic

dehydration signifies an equal proportion of sodium and water loss. Hypernatremic dehydration

shows an abnormally increased level of sodium in the blood versus water; therefore, the body

seeks equilibrium by transporting fluids from the extravascular space into the intravascular space

(blood vessels). Hyponatremic dehydration occurs vice versa to hypernatremic dehydration.

The most prominent is isonatremic dehydration, which is found in 80% of cases (Huang,

Anchala, Ellsbury, & George, 2014).

The potential causes of dehydration includes a decreased fluid intake, excess fluid output,

and/or fluid shifts between body compartments (e.g., ascites, burns, and sepsis). Excess fluid

output occurs through the kidneys (i.e., urination), gastrointestinal tract (i.e., diarrhea), and

insensible means. (Braun & Anderson, 2007, p. 212).

Risk Factors. Those at increased risk for dehydration include young children, older

adults, and diabetics. Young children are at risk since they have a larger volume of bodily fluids

and immature kidneys. In addition, they might be unable to independently meet their own needs

in terms of hydration (Huang et al., 2014).


Clinical Manifestations. Huang et al. (2014) classify the manifestations of dehydration

into mild, moderate, and severe forms as present in Appendix E. Abnormal signs of mild

dehydration consist of slight tachycardia and decreased urinary output. Moderate signs display

lethargy, capillary refill of two to four seconds, dry mucous membranes, tachycardia, orthostatic

hypotension, slow skin turgor, and decreased urine output (oliguria) (Huang et al., 2014).

Severe dehydration shows signs of obtunded levels of consciousness, capillary refill

greater than four seconds, parched mucous membranes, very increased heart rate, oliguria, or no

urine output (anuria). The best indicators are the capillary refill time, respiratory rate and

pattern, and skin turgor. With worsening progression of dehydration, hypovolemic shock may

develop and lead to organ failure and/or death (Huang et al., 2014).

Diagnostic Testing. Huang et al. (2014) state that there are no definitive diagnostic tests

for dehydration. According to Braun and Anderson (2007), the diagnostic investigation involves

a recent history, evaluation of manifestations, and laboratory testing. The recent history can

serve as the basis of diagnosis and help identify the cause (e.g., malnutrition) and severity. The

physical assessment will distinguish the severity of dehydration based on certain clinical

manifestations (p. 213). Huang et al. (2014) clarify the clinical manifestations based on mild,

moderate, and severe forms of dehydration in Appendix E.

Typically, results of a blood test identifies an increase in blood substances, such as

hemoglobin, hematocrit, glucose, albumin, and various electrolytes. These findings occur due to

body water loss while substances in the blood remain (Ignatavicius & Vorkman, 2015, p. 157).

However, the serum sodium level will vary depending on the type of dehydration (e.g.,

hyponatremia, isonatremia, hypernatremia). The blood analysis also evaluates the kidney’s

perfusion by determining the blood urea nitrogen (BUN) and serum creatinine levels, which will


be increased in dehydration. In addition, it can reveal a lack of tissue perfusion, which will show

an increase in lactic acid (Huang et al., 2014). Refer to Appendix F for the comparison of lab

values consistent with dehydration versus a normal, healthy adult.

Huang et al. (2014) state that the urine sample’s purpose is to identify the concentration

by measuring the specific gravity, which will be elevated; however, a urine sample is not always

an accurate test. A urinalysis can also evaluate the classification of dehydration by measuring

the urine’s sodium content (Braun & Anderson, 2007, p. 213).

Treatment. The focus of management is to identify and treat the underlying cause and

replace fluid loss. For mild to moderate dehydration, the administrations of oral rehydration

solutions (e.g., Rehydralyte) is necessitated. The patient should drink at least 300 mL/hr over a

four hour duration. The type of solution is significant since it must contain certain amounts of

glucose, sodium, and potassium. Clear liquids are ineffective since they often consist of

excessive carbohydrates and insufficient amounts of sodium (Huang et al., 2014).

Severe dehydration is treated in two phases: emergency management and deficit

replacement. The initial phase requires the immediate administration of an isotonic crystalloid

solution through an intravenous line. The following phase consists of replacing the fluid and

electrolytes and providing maintenance fluids (Huang et al., 2014).

Nursing Considerations. The goals of nursing management is to monitor and replenish

the patient’s fluid and electrolyte loss. The expected outcome is for the patient to maintain a

normal urinary output, normotensive blood pressure and heart rate, and normal skin turgor.

Therefore, ongoing assessments, interventions, and education will be needed to ensure a positive

outcome (Galanes & Gulanick, 2002).


Galanes and Gulanick (2002) state that accurate measurements of the patient’s intake and

output should be recorded and include all forms of output (i.e., blood, emesis, stool, and urine).

The patient should maintain a urinary output of at least 0.5 mL/kg of body weight per hour

(Andersson & Michel, 2011, p. 2). Therapeutic interventions include encouraging the patient to

drink the prescribed amount of fluids and offering different forms of liquids (e.g., popsicles,

gelatin, sports drinks). The patient should be informed of the importance of complying with the

prescribed fluid intake, causes of fluid loss, and how to prevent dehydration in the future

(Galanes & Gulanick, 2002).

Ureteral stone obstruction

The onset of symptoms occur when a ureteral calculus becomes too enlarged. The

prominent symptom is excruciating, intermittent pain that begins in the flank and radiates to the

groin. Other symptoms include complaints of lethargy, frequent urination, and difficulty/burning

upon urination (dysuria). The risk factors for stone development includes the following:

increased sodium consumption, lack of fluid intake, personal and/or family history, and limited

physical activity (White, Duncan, & Baumle, 2011, p. 1204).

Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) utilizes high-intensity shock waves to

disintegrate calculi obstructions and enable their passage through urination (Schilling Mccann,

2002, p. 652). According to the National Guideline Clearinghouse (2010), when patients are pre-

medicated with midazolam (5 mg orally), 70% of patients reported pain relief during the

treatment. Refer to Appendix G for further drug information regarding midazolam. If necessary,

tramadol, which has been proven to be a safe and effective analgesic, may be given during the


procedure (refer to Appendix H for more drug information on tramadol). Post-treatment pain is

typically mild to moderate and oral analgesics (e.g. tramadol) can provide adequate relief

(National Guideline Clearinghouse, 2010). According to Schilling McCann (2002), after ESWL,

an indwelling urinary catheter should be inserted to help monitor the patient’s fluid balance and

urine characteristics. Blood-tinged urine and slight redness or bruising on the treated side is

normal for several days after the operation. The patient should be encouraged to ambulate and

increase fluid intake as ordered since this will aid in passage of calculi fragments (p. 653).

Situation

Good afternoon Dr. Kuchinski, my name is Michelle King and I am a nurse here on the

Medical/Surgical unit at NIU Hospital. I am calling in regards to your recently admitted patient,

19-year-old female, Amanda Grohl. She was admitted this afternoon at 1330 after her ESWL

treatment for further monitoring and care. She has no known allergies and is a full code.

During my admission history I found that she was diagnosed in the ED with urosepsis

due to an obstructive ureteral calculus. I am concerned that she is exhibiting signs of

dehydration, as evidenced by a heart rate of 110 bpm, supine blood pressure of 110/80, which

drops to 90/75 while sitting up, and respiration rate of 22 breaths per minute. On further

assessment, she had a capillary refill time of four seconds, slowed skin turgor, thready pulses on

palpation, and a urine output of 20 mL/hr with blood-tinged urine. The laboratory tests revealed

abnormal findings of increased blood glucose of 140 mg/dL, hemoglobin of 17 g/dL, hematocrit

of 54%, albumin of 55 g/L, BUN of 24 mg/dL, and lactic acid of 22 mg/dL.

Background

Michelle King, 03/16/15,

(http://emedicine.medscape.com/article/2172316-overview)


Amanda Grohl is a 19-year-old Caucasian female. She is living in an apartment in

DeKalb with her roommate. She is currently a full-time student at Kishwaukee College and is

unemployed. Amanda reported a family history of kidney stones on her father’s side of the

family. When asked about her daily hydration habits, the patient stated, “I try to avoid drinking

fluids, since I always have an urge to pee right after.” When asked about her recent nutrition

patterns, the patient stated, “I’ll admit I’ve been eating a lot of salty junk food.” The patient was

asked about the frequency of her physical activity and reported, “I haven’t done much physical

activity at all this year. I’ve just been feeling too tired for some reason.” The patient reported

the sudden, but intermittent onset of flank pain radiating to the groin (rated 10/10) since 1100

this morning. When asked about recent patterns in urination, the patient stated, “This past week

I had a hard time urinating and it would also burn. When my pain hit me like a brick wall, I just

couldn’t urinate at all!”

Amanda arrived to the Emergency Department (ED) at 1130 with complaints of lethargy

and severe flank pain radiating to the groin. She has no known allergies and is a full code. Her

admitting vital signs in the ED were temperature of 102.3 F, blood pressure 85/65 mmHg, heart

rate of 120 beats per minute, respiration rate of 24 breaths per minute, and oxygen saturation of

98% on three liters of oxygen. She located her pain at the right flank radiating to her groin. She

rated her pain 10/10 and described it as intermittent. She appeared agitated and was alert and

oriented to person, place, and time.

A fluid bolus of 0.9% normal saline was administered at 500 mL over 30 minutes in the

antecubital site, with a size 16-gauge catheter. The emergency physician ordered three liters of

oxygen through a nasal cannula in order to normalize her oxygen saturation levels above 94%.

The ED completed blood work with abnormal results identifying increases in white blood cell


count (13,000 mcL), calcium (12.0 mg/dL), creatinine (0.6 mg/dL), blood glucose (145 mg/dL),

and lactate (2 mmol/L). The blood culture was positive for E. coli. The imaging results from the

non-contrast CT scan was positive for a ureteral calculus. Amanda had a percutaneous

nephrostomy temporarily inserted for pain relief and urinary drainage. She received midazolam

(5 mg orally) prior to the ESWL treatment for anticipatory pain relief. Then, she was given

tramadol (25 mg PO) during the ESWL for further pain relief. She reported a reduction in pain

(2/10) throughout the procedure.

Amanda was admitted to the Medical/Surgical floor at 1330 for further monitoring and

postoperative care from the ESWL treatment.

Assessment

Amanda has been admitted into the Medical/Surgical unit since 1330 and her current vital

signs are: temperature of 98.9 F, heart rate 110 bpm, supine blood pressure of 110/80 rpm and

drops to 90/75 rpm while sitting up, respirations of 22 breaths per minute and oxygen saturation

is 100% on two liters of oxygen via nasal cannula. She is 56.7 kg (125 pounds) and is 162.5 cm

(5’ 4” tall). She appears lethargic, but she is oriented to person, place, and time. Her eyes

appear sunken with pupils that are reactive and appropriate to room light. She has a slowed skin

turgor and dry skin on palpation. She reports a dull pain of 3/10 at the right flank. The treatment

site (right flank) from the ESWL has slight petechiae and redness. On auscultation, her S1 and

S2 heart sounds were heard with a regular rhythm. In addition, her anterior and posterior lung

sounds on auscultation were clear bilaterally. Her breathing pattern appears regular and

unlabored and she reports no shortness of breath. Her bilateral radial pulses are thready with a

capillary refill time of four seconds. She has full range of motion of her extremities, equal

strength bilaterally, and no swelling or masses were palpated. She has an indwelling urinary


catheter and has a urine output of 20 mL/hr with blood-tinged urine. Abdomen is soft and flat

with bowel sounds active in all four quadrants.

The laboratory tests revealed abnormal findings of increased blood glucose of 140

mg/dL, hemoglobin of 17 g/dL, hematocrit of 54%, albumin of 55 g/L, BUN of 24 mg/dL, and

lactic acid of 22 mg/dL.

She has a left antecubital IV running with 3.375 g of Zosyn diluted in 200 mL of normal

saline over 30 minutes. The IV dressing is dry and intact with no signs of inflammation. At

1400 the patient received 25 mg of tramadol for pain of 3/10 in the right flank area. The patient

has been encouraged to ambulate and drink the prescribed amount of fluids (3-4 L/day) to help

the passage of calculi fragments. A diet low in sodium has been informed. The patient’s bed has

been placed in the lowest position, call light is within reach, and the patient is wearing non-slip

socks.

Recommendations

I am recommending a prescription of an oral rehydration solution, Rehydralyte, for

Amanda to drink at least 300 mL/hr over a four hour duration. This prescription is needed in

order to prevent further worsening of dehydration and replace her fluid deficit. The desired

outcome is for Amanda to have the following within normal limits: heart rate, respiration rate,

urinary output, and positional changes in blood pressure. I will call you back in an hour for an

update on whether she shows improvement from this treatment. Until then, I will continue to

monitor her vital signs and intake and output. In addition I will encourage her to drink the

prescribed amount of fluids. Is there anything else I can do for you at this time?


References

A.D.A.M. Medical Encyclopedia. (2013). Dehydration. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001977/

Andersson, K. E., & Michel, M. C. (Eds.). (2011). Handbook of experimental pharmacology:

Urinary tract (Vol. 202). Springer-Verlag Berlin Heidelberg.

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health. Troy, D. B., Alvarez, R. J., LeBon, M., Bertling, S. (Eds.). Baltimore, MD.,

Philadelphia, PA: Lippincott Williams & Wilkins.

Dagli, M., & Ramchandani, P. (2011). Percutaneous nephrostomy: Technical aspects and

indications. Seminars in Interventional Radiology, 28(4), 424-437. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312169/

Dellinger, R. P., Carlet, J. M., Masur, H., Gerlach, H., Calandra, T., Cohen, J., … & Levy, M. M.

(2004). Surviving Sepsis Campaign guidelines for management of severe sepsis and

septic shock. Critical Care Medicine, 32(3), 858-873. Retrieved from

http://www.alabmed.com/uploadfile/2013/1212/20131212035346792.pdf

Farinde, A. (2014). Lab values, normal adult. Retrieved from

http://emedicine.medscape.com/article/2172316-overview

Galanes, S., & Gulanick, M. (2002). Nursing care plans: Nursing diagnosis and interventions.

(5th ed.). St. Louis, MO: Elsevier Health Sciences.

Huang, L. H., Anchala, K. R., & Elssbury, D. L., George, C. S. (2014). Dehydration. Retrieved

http://www.alabmed.com/uploadfile/2013/1212/20131212035346792.pdf


http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001977/


from http://emedicine.medscape.com/article/906999-overview

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(8th ed.). Workman, L. M. (Ed.). St. Louis, MO: Elsevier Health Sciences.

Kalra, O.P., & Raizada, A. (2009). Approach to a patient with urosepsis. Journal of Global

Infectious Diseases, 1(1), 57-63. Retrieved from


Levi, M. M., & Schmaier, A. H. (2014). Disseminated intravascular coagulation. Retrieved from


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management. Retrieved from http://www.guideline.gov/content.aspx?id=23897

Perrin, K. O., & MacLeod, C. E. (2008). Understanding the essentials of critical care nursing.

Upper Saddle River, NJ: Pearson Prentice Hall

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Elsevier

Schilling McCann, J. A. (2002). Illustrated manual of nursing practice. (3rd ed.). Mayer, B.,

Kowalak, J. P., Chohan, N. D., Duksta, C., Eggenberger, T., Follin, S. A., … Robinson,

K (Eds.). Springhouse, PA: Lippincott Williams & Wilkins.

Wagenlehner, F.M., Lichtenstern, C., Rolfes, C., Mayer, K., Uhle, F., Weidner., W., & Weigand,





M.A. (2013). Diagnosis and management of urosepsis. International Journal of Urology

20(10), 963-970. Retrieved from

http://onlinelibrary.wiley.com/doi/10.1111/iju.12200/pdf

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NY: Delmar Cengage Learning.

http://onlinelibrary.wiley.com/doi/10.1111/iju.12200/pdf


Appendix A

The following information provides examples of the various causes of urosepsis related to

abnormalities of the genitourinary tract.

Table 1: The Abnormalities (Structural and Functional) of the Genitourinary Tract that Correlates with Urosepsis.

Obstruction Congenital: Ureteric or urethral strictures, phimosis,

ureterocele, polycystic kidney disease.

Acquired: Calculi, prostatic hypertrophy, tumors of

the urinary tract, trauma, and radiation therapy.

Instrumentation Indwelling catheter, ureteric stent, nephrostomy tube, urological procedures.

Impaired voiding Neurogenic bladder, cystocele, vesicoureteral reflux.

Metabolic abnormalities Nephrocalcinosis, diabetes, azotemia.

Immunodeficiencies Patients on immunosuppressant drug or with an abnormally low neutrophil count (neutropenic).

(Kalra & Raizada, 2009)


Appendix B

The following table lists the diagnostic manifestations of sepsis based on different variables.

Table 1: Clinical diagnostic criteria for sepsis

Suspected or documented infection and some of the following factors:

General variables Fever (> 38.3 C) Hypothermia (core temperature < 36.0 C) Heart rate > 90 bpm or more than two SD

above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid

balance (>20 mL/kg over 24 h) Hyperglycemia (plasma glucose >140

mg/dL) in the absence of diabetes.

Inflammatory variables Leukocytosis (WBC count > 12,000) Leukopenia (WBC count < 4,000) Normal WBC count with greater than

10% immature forms Plasma C-reactive protein more than two

SD above the normal value Plasma procalcitonin more than two SD

above the normal value

Hemodynamic variables Arterial hypotension (SBP < 90 mmHg, MAP < 70 mmHg, or an SBP decrease > 40 mmHg in adults or less than two SD below normal for age)

Tissue perfusion variables Hyperlactemia (> 1 mmol/L) Decreased capillary refill or mottling

Organ dysfunction variables Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hours despite adequate fluid resuscitation)

Creatinine increase > 0.5 mg/dL(Wagenlehner, 2013, p. 964)


Appendix C: Piperacillin/tazobactam

Medication name

Dose range Mechanism of action

Required assessments (vitals, labs, etc)

Data that indicates the med is effective

piperacillin/tazobactam(Zosyn)

Functional class: Antiinfective, broad spectrum

Chemical class: Extended-spectrum penicillin, β-lactamase inhibitor

4.5 g q6hror 3.375 g q4hr with an aminoglycoside or antipseudomonal fluoroquinolone X 1-2 weeks.

Interferes with cell-wall replication of susceptible organisms; tazobactam is a β-lactamase inhibitor that protects piperacillin from enzymatic degradation.

Intake and output:- Report hematuria- Report oliguria because

penicillin in high doses is nephrotoxic

- Maintain hydration unless contraindicated

Blood studies:- WBC RBC, Hct, Hgb,

bleeding time before treatment and periodically thereafter

- Monitor serum potassium levels

Renal studies:- Urinalysis, protein, blood,

BUN and creatinine before treatment and periodically thereafter.

Therapeutic response to drug:- Absence of

fever, purulent drainage, redness, and inflammation; culture shows decreased organisms.

Adverse and life threatening effects

Food, drug and med interactions

Patient teaching

CNS: Seizures

Cardiovascular: Cardiac toxicity

Gastrointestinal: Pseudomembranous colitis and pancreatitis

Genitourinary: Oliguria, proteinuria, hematuria, glomerulonephritis and renal failure

Hematology: Bone marrow

Decreases piperacillin’s effects:- Tetracyclines and

aminoglycosides IV

Drug/lab test:- Increases the

following: Eosinophilia, neutropenia, leukopenia, serum creatinine, PTT, AST, ALT, bilirubin, BUN and electrolytes.

Teach patient:- That culture may be obtained after

completed course of medication.- To wear or carry emergency ID if

allergic to penicillins.- To notify nurse of diarrhea.- To report the following symptoms:

o Superinfection: Sore throat, fever, and fatigue.

o CNS effects: Anxiety, depression, hallucinations and seizures.

o Pseudomembranous colitis: Fever, diarrhea with blood, pus, and mucous.


depression, agranulocytosis and hemolytic anemia.

Systemic: Serum sickness, anaphylaxis, Stevens-Johnson syndrome

- Decreases the following: Hct, Hgb, and electrolytes.

- False positive for the following: Urine glucose, urine protein and Coombs’ test.

(Skidmore-Roth, L., 2015, p. 952-954)


Appendix D

The following table provides the characteristics of the different types of dehydration based on its

sodium concentration levels.

Table 8.3: Classifications of Dehydration: Sodium Considerations

Dehydration Category

Sodium Concentration

Frequency of Diagnosis

Type of Fluid Loss

Fluid Shifts

Hyponatremic < 130 mEq/L 5-10% Hypertonic Intravascular to

Extravascular

Isonatremic 130-150 mEq/L 80% Isotonic None

Hypernatremic > 150 mEq/L 5-10% Hypotonic Extravascular to

Intravascular

(Braun & Anderson, 2007, p. 213)


Appendix E

The following table lists the clinical manifestations of dehydration based on its different forms:

mild, moderate and severe.

Table 1: Clinical Findings of Dehydration

Symptom/Sign Mild Dehydration Moderate Dehydration

Severe Dehydration

Level of

consciousness

Alert Lethargic Obtunded

Capillary refill * 2 seconds 2-4 seconds > 4 seconds, cool extremities

Mucous membranes Normal Dry Parched, cracked

Heart rate Slightly increased Increased Very increased

Respiratory

rate/pattern *

Normal Increased Increased and hyperpnea

Blood pressure Normal Normal, but orthostasis

Decreased

Pulse Normal Thready Faint or impalpable

Skin turgor * Normal Slow Tenting

Eyes Normal Sunken Very sunken

Urine output Decreased Oliguria Oliguria/anuria

* Best indicators of hydration status

(Huang et al., 2014)


Appendix F

The following table lists the normal laboratory values for an adult as reported by Farinde (2014).

In addition, it states the abnormal findings consistent with dehydration as explained by

Ignatavicius and Vorkman (2015, p. 157).

Lab values Normal findings Abnormal findings consistent with dehydration

Blood glucose 65-110 mg/dL > 110 mg/dL

Hemoglobin 13 - 17 g/dL (men)

12 - 15 g/dL (women)

> 17 g/dL (men)

> 15 g/dL (women)

Hematocrit 40% - 52% (men)

36% - 47% (women)

> 52% (men)

> 47% (women)

Albumin 35 – 50 g/L > 50 g/L

Blood urea nitrogen 8 – 21 mg/dL > 21 mg/dL

Creatinine 0.8 – 1.3 mg/dL > 1.3 mg/dL

(Farine, 2014), (Ignatavicius & Vorkman, 2015, p. 157).

Appendix G: Midazolam


Medication name Dose range Mechanism of action

Required assessments (vitals, labs, etc)

Data that indicates the med is effective

midazolam

Controlled substance (Schedule IV)

Functional class: Sedative, hypnotic, anti-anxiety

Chemical class: Benzodiazepine, short-acting

Preoperative sedation:Adult: IM 0.07-0.08 mg/kg ½-1 hour before general anesthesia

Depresses subcortical levels in CNS; may act on limbic system, reticular formation; may potentiate y-aminobutyric acid (GABA) by binding to specific benzodiazepine receptors.

Cardiovascular:- Monitor blood

pressure and pulse.

Respiratory:- Monitor

respirations.- This drug has a

Black Box Warning of respiratory depression insufficiency.

Therapeutic response of drug:- Induction of

sedation.


Food, drug and med interactions Patient teaching

CNS: Retrograde amnesia

Cardiovascular: Cardiac arrest

EENT: Loss of vision

Respiratory: Apnea, bronchospasm, laryngospasm, and respiratory depression.

Increases respiratory depression:- CNS depressants, alcohol, barbiturates,

opiate analgesics, verapamil.

Drug/Herb:- Increases sedation: Kava and valerian- Decreases midazolam’s effect: St. John’s

wort.Drug/Food:- Increases midazolam’s effect: Grapefruit

juice

Teach patient:- That

amnesia occurs and events may not be remembered.

(Skidmore-Roth, L., 2015, p. 795-796)

Appendix H: Tramadol

Medication Dose range Mechanism of Required assessments Data that


name action (vitals, labs, etc) indicates the med is effective

tramadol(Conzip, Ultram, Zytram)

Functional Class: Analgesic

For mild to moderate pain:

Adults: PO25-400 mg/day.

25 mg daily, titrate by 25 mg after two days to 100 mg/day (25 mg qid)

Then, may increase by 50-100 mg q4-6hr. Must not exceed 400 mg daily.

Binds to μ-opioid receptors and inhibits reuptake of norepinephrine, serotonin.

Pain assessment:- Assess the following

characteristics of pain: location, type, and character.

Respiratory assessment:- Assess the respiration

rate.- The drug must be

withheld if respiration rate is less than 12 breaths per minute.

Changes in lab values:- Increase: Creatinine and

hepatic enzymes- Decrease: Hemoglobin

Therapeutic response to drug:- A

reduction in pain.

- An absence of adverse reactions.


Food, drug and med interactions

Patient teaching

CNS: Seizures

Systemic: Anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis

CNS depression:- If taken with

alcohol, hypnotics, sedatives and opiates

- Or if taken with certain herbs (e.g., chamomile, hops, kava, skullcap, and valerian)

Serotonin syndrome:- If taken with SSRIs,

SNRIs, serotonin-receptor agonists

Decreases drug effects:- Barbiturates,

phenytoins,

Teach patient:- To rise slowly when changing

positions from lying to sitting or standing due to potential orthostatic hypotension.

- To report any abnormal symptoms, such as CNS changes, allergic reactions, serotonin syndrome, and seizures.

- To not taper off the drug versus discontinuing the drug abruptly.

- To avoid OTC medications, herbs, supplements, CNS depressants, and alcohol unless approved by the prescriber.

http://en.wikipedia.org/wiki/%CE%9C-opioid_receptor


rifampin, rifabutin.

(Roth-Skidmore, L., 2015, p. 1193-1194)

Extra Credit NCLEX Question


1.) Which of the following hospitalized clients would the nurse be most concerned is at risk

for developing an imbalance related to water loss? Select all that apply.

A. A 50-year old undernourished female

B. A 75-year old female of average body weight

C. A 60-year old male of average body weight

D. A 45-year old obese male

The correct answer is: B and D

Rationale:

A. This patient does not pose a risk for dehydration. She is under the age of 65 and

is not obese.

B. After age 65, total body water may reduce to as much as 45-50% compared to the

total body weight. Therefore, an age greater than 65 is at increased risk for

dehydration.

C. This patient is not at risk for dehydration due to lack of risk factors. He is not

above age 65 and is average body weight.

D. The greater the total body weight is, the lesser the proportion of fluid volume in

the body. Therefore, the obese patient has a higher risk of dehydration.

Reference

LeMone, P., Burke, K. (2007). Medical-surgical nursing: Critical thinking in client care. (4th

ed.). Upper Saddle River, NJ: Prentice Hall.

SBAR Paper on Urosepsis and Dehydration

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Transcript of SBAR Paper on Urosepsis and Dehydration