Sepsis Concept Map

NCLEX

Sepsis Concept Map

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Nursing Concept Map Template (Cheatsheet)

Outline

Overview

Concept maps
1. Many types, variations, layouts
2. Primary diagnosis
  1. Typically in center of maps
  2. Connects to
    1. Contributing factors
    2. Medications
    3. Labwork
    4. Patient education
    5. Nursing diagnoses
      1. Interventions
      2. Evaluations

Nursing Points

General

Nursing diagnosis
1. Risk for shock
  1. Monitor trends in blood pressure
    1. Early recognition of pressure changes
  2. Assess for skin changes
    1. Early recognition of advancing shock
  3. Monitor for changes in mentation
    1. Identify advancing shock early
2. Risk for deficient fluid volume
  1. Assess for dry mucous membranes, poor skin turgor
    1. Patient has appropriate skin turgor
  2. Monitor intake and output
    1. Appropriate urinary output r/t intake and output
  3. Monitor heart rate and blood pressure
    1. Early recognition of changes in BP and HR
3. Deficient knowledge
  1. Explain disease process
    1. Patient gains understanding of sepsis
  2. Explain risk factors
    1. Patient understands prevention
  3. Teach proper nutrition for proper healing
    1. Patient follows nutrition guidelines

Assessment

Contributing factors
1. Infections
  1. Pneumonia
  2. Urinary tract infections
  3. Bacteremia
2. Very old
3. Very young
4. Immunocompromised
5. Diabetic
6. Wounds
  1. Burn
7. Cirrhosis
8. Invasive Devices
  1. Catheter
  2. IV
  3. ET tube

Therapeutic Management

Lab work
1. Gram stains/cultures of infected site
  1. Identify organism
2. Blood culture
  1. Identify bacteria in blood
3. Sputum culture
  1. Identify bacterial pneumonia
4. Urine culture
  1. Identify organisms in urine
Medications
1. Antibiotics
  1. Vancomycin (500 mg IV q6h or 1 g IV q12h)
2. IV fluids
  1. Normal saline (30 ml/kg IV)
3. Vasopressors
  1. Norepinephrine (8 to 12 mcg/min IV)

Nursing Concepts

Clinical judgment
Infection control
Immunity
Perfusion

Patient Education

Patient education
1. Teach patient/family
  1. Treatment modalities
  2. What to expect
    1. Symptoms
    2. Disease process
  3. Prevention of sepsis

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Transcript

Hey guys! Let’s take a look at a concept map for sepsis.

So in this lesson we will take a look at the components of a concept map including contributing factors, medications, lab work and the significance, patient education, and associated nursing diagnoses with interventions and evaluations!

Ok so here is a basic example of a concept map, guys there are many different variations and this is just one example. First, we start with the primary diagnosis typically in the center of the concept map which leads to nursing diagnoses and interventions and also contributing factors, medications, labwork, and patient education which are associated with the primary diagnosis. Lets jump in! Lets start with contributing factors in this upper corner. Contributing factors for sepsis include really any type of infection but the most common being pneumonia, urinary infections, and bacteremia. If your patient is very young, very old, has a compromised immune system, is diabetic, has wounds or injuries like burns, cirrhosis, or has an invasive device like catheters or ET tubes are all additional contributing factors.

In this next circle here we will add medications that we may see when treating sepsis. Antibiotics are an obvious choice but will depend on the type of infection to determine the correct antibiotic. One possible antibiotic is vancomycin (500 mg IV every 6 hours or 1 g IV every 12 hours) which works by inhibiting cell wall synthesis of bacteria. Ceftriaxone (1 to 2 g IV once per day) is another antibiotic which works by inhibiting the mucopeptide synthesis of the bacterial cell wall. Because sepsis can cause massive vasodilation IV fluids like normal saline (30 ml/kg) are often given for this reason. If IV fluids cannot maintain the patient’s blood pressure they may even be given a vasopressor like norepinephrine (8 to 12 mcg/min IV continuous infusion) which acts by stimulating adrenergic receptors causing vasoconstriction.

Ok additional information included in a concept map is commonly patient education and significant labwork. So in this circle here lets add important patient education information including teaching the patient and family about treatment modalities, what to expect while hospitalized, and ways to prevent future sepsis. Labwork associated with a sepsis diagnosis include gram stains and cultures of an infected site to identify the causative organism, blood cultures to detect bacteria in the blood and appropriate antibiotics, urine cultures to see if the infection is urinary, sputum culture to identify bacterial pneumonia. Other lab tests include CBC, blood gases, CMP, PT/PTT, and CRP.

Finally, in the three circles that are left we will add nursing diagnoses with interventions and evaluations for sepsis. One appropriate nursing diagnosis could be risk for shock which can be caused by sepsis with the reduction of arterial and venous bloodflow and vasoconstriction. Interventions which we can apply to this diagnosis are monitoring trends in the patients blood pressure paying close attention to a widening pulse pressure because as shock progresses cardiac output is severly depressed. This intervention is evaluated by the early recognition of pressure changes. Assess the skin for changes in color and temperature because in late stages of shock shunting of blood occurs to the vital organs which reduces blood flow peripherally which creates cool, dusky skin in these areas. This intervention is evaluated by early recognition of advancing shock. Another intervention appropriate for risk of shock is assessing or monitoring closely changes in mentation which can identify acidosis in the patient or decreased cerebral perfusion which is evaluated by early identification of advancing shock.

Another nursing diagnosis which can be applied to sepsis is risk for deficient fluid volume. Interventions that can be applied here include assess for dry mucous membranes and poor skin turgor which could be a sign of hypovolemia which is evaluated by the patient having appropriate skin turgor. Another intervention is monitoring your patients intake and output including insensible losses which we worry about because of the potential of third spacing and edema which is evaluated by appropriate urinary output related to intake and output. A final intervention is to monitor heart rate and blood pressure as a reduction in circulating blood volume can result in decreased blood pressure but an increased heart rate because of compensatory mechanisms which is evaluated by early recognition of changes in blood pressure and fluid volumes.

A final nursing diagnosis which we can apply to the sepsis patient is deficient knowledge. Interventions include explaining the disease process to the patient evaluated by the patient being able to make informed choices. Teach the patient about risk factors of their disease evaluated by the patient gaining an understanding of ways to prevent sepsis. Finally, teach the patient about proper nutrition to facilitate healing and strengthen the immune system which is evaluated by the patient following nutrition guidelines.

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Outline

Overview

Nursing Points

General

Assessment

Therapeutic Management

Nursing Concepts

Patient Education

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