This document defines sepsis and related terms like SIRS, severe sepsis, and septic shock. It discusses the etiology (causes) of sepsis as various infections. It lists risk factors and potential clinical manifestations such as metabolic acidosis, decreased systemic vascular resistance, and organ dysfunctions. Nursing diagnoses are identified like presence of infection, ineffective airway clearance, ineffective breathing, and imbalanced nutrition related to the disease process. Complications of sepsis can include low blood pressure leading to septic shock, ARDS, tissue death, and multiorgan failure.

2. MS.SNEHAL PATIL
CCN STUDENT

3. DEFINITION :
1. SIRS (Systemic Inflammatory Response Syndrome):

4. 2. SEPSIS : It is defined as SIRS in response to an
infectious process .
3. SEVERE SEPSIS : It is defined as sepsis with sepsis
induced organ dysfunction or tissue hypoperfusion
(manifesting as elevated lactate or decreased urine
output).
4.SEPTIC SHOCK: It is severe sepsis plus persistently
low blood pressure following the administration of
intravenous fluids.

5. Etiology :
 INFECTION :
Lung infection (pneumonia)
Flu (influenza)
Lining of the GI system (peritonitis)
Infection of GU system
Skin infection (cellulites)
post surgical infection
Infection of nervous system

6. RISK FACTORS :

7. RISK FACTORS :

8. CLINICAL MANIFESTATIONS :

9. CLINICAL MANIFESTATIONS :

10. CLINICAL MANIFESTATIONS :
 Metabolic acidosis
 Decreased systemic vascular resistance
 Higher cardiac output
 Dysfunctions of blood coagulations
 Diarrhea
 Nausea and vomiting
 Cold , clammy and pale skin

12.  TO BE COMPLETED WITHIN 24 HOURS :
1.Glucose Control : maintained on average <150
mg/dl
2.Drotrecogin alfa (activated) : administered in
accordance with hospital guideline
3.Steroids : for equal to or grater than 6 hours
4.Lung protective strategy : maintain plateau
pressure < or equal to 30 cm of H2O

13. NURSING DIAGNOSIS :
 Presence of infection related to disease pathology
secondary to multiple invasive lines
 Ineffective airway clearance related to
tracheobronchial secretions as evidenced by changes
in respiratory rate & decrease gag reflex
 Ineffective breathing pattern related to inflammatory
process as evidenced by tachypnea, respiratory depth
changes, peripheral cyanosis.
 Imbalanced nutrition less than body requirement
related to increased metabolic needs caused by disease
process as evidenced by inadequate calorie intake.

14.  Self care deficit related to bedfast condition as
evidenced by personal hygiene not maintained.
 Risk for bedsore as evidenced by prolonged immobility

15. COMPLICATIONS:
 Severe drop in B.P. leading to septic shock
 ARDS
 Tissue death leading to gangrene
 Multiorgan failure