Clinical Findings (Etiological)

Infection: Inflammatory response to microorganisms, especially those that release toxins or invade body tissues.

Fever: Temp >100.4°F (38°C); low-grade: temp. 100.4°-101°F (38.3°C); highgrade: temp. >101°F. Note: A patient may not exhibit a fever (normothermic) or may even be hypothermic if septic.

Systemic inflammatory response syndrome (SIRS): Systemic response to any severe clinical insult (e.g., infection, trauma, burns, or pancreatitis) includes two or more of the following:

• Temp >38°C (100.4°F) or <36°C (96.8°F)
• HR >90 bpm
• RR >20 bpm or PaCO₂ <32 mm Hg
• WBC count >12,000/mm³, <4000/mm³, or presence of >10% immature neutrophils

Sepsis: SIRS is triggered by infection caused when microorganisms (most often bacteria) enter systemic circulation. Symptoms include increased RR (early), fever (may also be hypothermic), chills, increased HR, decreased UO, shivering, skin rash, and warm skin.

Severe sepsis: Sepsis shows evidence of end-organ hypoperfusion (e.g., acute AMS, hypoxia, oliguria [UO <400 mL/day], or lactic acidosis). Complications include impaired blood flow to vital organs and DIC caused by toxins released by microorganisms. The body's own inflammatory response to the release of toxins also contributes to end-organ failure.

Septic shock: Sepsis with life-threatening hypotension (SBP <90 mm Hg or a reduction >40 mm Hg from baseline) occurs despite adequate fluid resuscitation or the requirement of vasopressors to maintain BP.

Surgical-site infection (SSI): Localized infection is evidenced by localized redness (or streaking), tenderness, swelling, and warmth as well as fever, purulent or serosanguineous drainage, foul odor, dehiscence, or evisceration.

Collaborative Management

• Monitor temp and vital signs.
• Fever: Offer cold compress to forehead or nape of neck, encourage fluids if not restricted, and administer antipyretic medication as ordered.
• Nausea: Position for comfort, provide emesis basin, offer cold compress to forehead or nape of neck, offer ice chips or small sips of clear liquids if tolerated; otherwise, keep NPO until nausea passes, and administer antinausea medication as ordered.
• Search for potential causes: blood transfusions, surgical and nonsurgical (decubitus ulcers) wounds, surgical drains, indwelling catheters (urinary, peripheral and central IVs).
• Encourage Pt to cough and breathe deeply (incentive spirometer).
• Monitor UO and fluid intake.
• Monitor closely for evidence of end-organ hypoperfusion (e.g., acute AMS, hypoxia, oliguria, and/or lactic acidosis).
• Administer oxygen, IV fluids, and antibiotics as ordered. Pts may also need vasopressors, ventilatory support, blood products, and dialysis.
• Diagnostic tests may include blood cultures (concurrent use of antibiotics can produce false-negative results), WBC, CBC with differential, BUN, creatinine, ABG, platelet count, DIC, and chest x-ray.