Assessing a patient with sepsis
- Created by: MillieJohnson2004
- Created on: 04-03-22 16:31
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- Assessing a patient with sepsis: Stratification tool
- High risk
- Behaviour: Objective evidence
- Heart rate: More than 130 BPM
- Respiratory rate: 25 Breaths a min
- 40% oxygen or more to maintain SATS
- Systollic Blood pressure: 90mmHg or less, more than 40mmHg
- Not passed urine in over 18hours or for catheterised patients pass 0.5ml/kg of urine an hour
- Mottled or ashen appearance
- Cyanosis of skin lips or tongue
- Non-blanching red skin
- ONE OR MORE OF HIGH RISK CRITERIA MET
- ARRANGE IMMIDIATE REVIEW BY SENIOR CLINICIAN
- Carry out venous blood tests for the following:
- Blood gas for glucose and lactate
- Lactate over 4mmol/L OR systolic BP less than 90mmHg
- Give IV fluid (500ml over less than 15 min) then discuss wiht critical care
- Lactate 2-4mmol/l
- Give IV fluid (bolus injection) within one hour
- Lactate less than 2mmol/l
- Consider IV fluids (bolus injection) within one hour
- Lactate over 4mmol/L OR systolic BP less than 90mmHg
- Blood culture
- Full blood count
- C-reactive protein
- Uera and electrolytes
- Creatinine
- Clotting screen
- Blood gas for glucose and lactate
- Give IV fluids without delay within MAX 1 hr
- CONTINUE OBVS EVERY 30 MIN
- Moderate to high risk criteria
- Behaviour
- History from patient, friend or relative of new onset altered behaviour
- History of acute deterioration of functional ability
- Impaired immune system (illness or drug, including oral steroids)
- Trauma, surgery or invasive procedures in the last 6 weeks
- Respiratory rate between 21-24 breaths per minute
- Heart rate 91-130 bpm
- Pregnant women 100-130bpm
- New onset arrhythmia
- Systolic blood pressure 91-100mmHg
- Has not passed urine in the past 12 to 18 hours
- Catheterised patients 0.5ml/kg per hour
- Tympanic temperature les than 36
- signs of potential infection
- redness
- Swelling or discharge at surgical sit
- Breakdown of wound
- Behaviour
- High risk
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