Concept Mapping Tool
Risk Factors
- the elderly and those under the
age of ten
- patients with liver cirrhosis,
diabetes mellitus,
cardiopulmonary diseases,
cancer, or hematological
malignancies
- those immunocompromised
- those with complement
deficienceies
- major surgeries, traumas, burns
- invasive procedures
- prolonged hospitalization
- childbirth, malnutrition
(Siloşi, Siloşi, Pădureanu, Bogdan,
Mogoantă, Ciurea, Cojocaru,
Boldeanu, Avramescu, Boldeanu,
& Popa, 2018).
Medical Management
(Pharmacological/Surgical)
- Oxygen therapy
- Tylenol administration
- Fluid resuscitation
- Vasopressor administration
- Norepinephrine administration
- Nitroglycerine administration
- Vasopressin administration
- Phenylephrine administration
- Sodium nitroprusside
administration
- Epinepherine administration
(Lewis et al., 2019).
Etiology Potential Complications
- Severe septicemia
Complex condition demonstrated by inflammation and coagulation because of microbial
- Septic shock
insult (Siloşi et al., 2018). This causes systemic inflammatory symptoms due to the
- Organ dysfunction
release of proinflammatory cytokines, procoagulants, and adhesion molecules from
(Siloşi et al., 2018)
immune cells or a damaged endothelium (Siloşi et al., 2018).
Diagnosis Nursing Management/Care
Ineffective peripheral tissue perfusion, risk for decreased cardiac tissue To be completed within 3 hours:
perfusion, ineffective cerebral tissue perfusion, and risk for impaired organ - Measure lactate levels
function (Carpenito, 2017). - Obtain blood cultures
- Administer broad spectrum
antibiotics
Signs & Symptoms Labs/Diagnostic Tests - Administer a crystalloid for
- Altered mental status, fever, - Complete blood count hypotension or elevated lactate
tachycardia, hyperglycemia (CBC) level
without diabetes, tachypnea - Blood chemistry To be completed within 6 hours:
- Elevated C-reactive protein and (sodium, magnesium, - Provide vasopressors to maintain
procalcitonin, leukocytosis or lactate, calcium, arterial blood pressure above
leukopenia glucose, phosphate) 65mmHg
- Hypotension - Renal and hepatic - Measure central venous pressure
- Hyperlactatemia, decreased function tests and oxygen saturation
capillary refill - Coagulation tests - Remeasure lactate levels
(Lewis et al., 2019) - Gram staining and
Lewis, Bucher, Heitkemper, Harding,
culture of secretions,
Barry, Lok, Tyerman, &
Assessment Findings peripheral blood, and
Goldsworthy, 2019),
- Hypotension tissues
- Fever - Sepsis biomarkers Teaching
- Tachypnea (serum lactate, pro- - Health promotion: exercise,
- Hyperlactatemia inflammatory cytokines, healthy eating, hand hygiene
- Cool skin, cyanosis anti-inflammatory - Adequate restv and fluids
- Altered mental function cytokines, c-reactive - Antibiotic adherence
- Positive blood cultures protein) (Lewis et al., 2019).
(Siloşi et al., 2018) (Siloşi et al., 2018)
 Concept Mapping Tool

References

Carpenito, L. (2017). Handbook of nursing diagnosis (15th ed.). Philadelphia: Wolters Kluwer.

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry, M. A., Lok, J., Tyerman, J., & Goldsworthy, S. (Eds.). (2019). Medical

-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (4th ed.). Elsevier Canada.

Siloşi, C. A., Siloşi, I., Pădureanu, V. L. A. D., Bogdan, M., Mogoantă, S. Ş., Ciurea, M. E., Cojocaru, M., Boldeanu, L., Avramescu, C. S.,

Boldeanu, M. V., & Popa, D. G. (2018). Sepsis and identification of reliable biomarkers for postoperative period prognosis. Rom J

Morphol Embryol, 59(1), 77-91.