nursing.elitecme.com Page 105 Complete Your CE Test Online - Click Here SIGNS AND SYMPTOMS OF INFECTION Sepsis always begins with an infection somewhere in the body. Nurses play a pivotal role in preventing the development of sepsis and early recognition of signs and symptoms of infection, especially for at-risk populations, such as the elderly, immunosuppressed patients, and those with a history of a chronic illness requiring frequent medical care. Early recognition of the risks can reduce the incidence and the development of sepsis and interrupt the sepsis cascade from progressing into septic shock. Nurses are often the first to encounter a patient in a health care or outpatient setting, and often spend the most time with patients. As such, the nurse should be familiar with the signs and symptoms of infection. Early identification of when an infection may be worsening, particularly in patients who may be at greater risk for developing sepsis, is critical to preventing progression of the infection. The following are general signs and symptoms of infection that should be recognized and monitored (Preventcancerinfections.org, n.d.): ● ● Fever. ● ● Change in cough or new cough. ● ● Nasal congestion. ● ● Diarrhea. ● ● Muscle aches. ● ● Chills and sweats. ● ● Sore throat. ● ● Burning or painful urination. ● ● Vomiting. ● ● Pain in the abdomen or rectum. ● ● Redness, soreness, swelling of wounds or surgical sites. ● ● Changes in skin, urination, mental status. ● ● Stiff neck. ● ● New onset of pain. Signs and symptoms of sepsis Nurses should be aware of signs and symptoms of sepsis in every patient who has an infection or suspected infection. Treating sepsis promptly can make a significant difference in the course of sepsis and prevent the patient’s condition from deteriorating and leading to septic shock, MODS, and possible death. If a patient has a known or suspected infection (especially infection of the lung, urinary tract, abdomen, or skin) and presents with shivering, extreme pain or discomfort, clammy or sweaty skin, altered mental status, shortness of breath, and high heart rate, the nurse should suspect sepsis (see Figure 1). Figure 1. Common infections and signs and symptoms of sepsis Physical exam Any high-risk patient presenting with an infection should be evaluated for signs of sepsis that may include fever, chills, sweating, tachypnea, and confusion (Al-Khafaji, 2016). Systemic tissue perfusion should be evaluated as well. In the beginning stages of sepsis, cardiac output might be normal, or even increased, with warm skin and extremities as the blood vessels dilate (Al-Khafaji, 2016). As sepsis worsens, stroke volume and cardiac output decreases, leading to cool extremities and skin and delayed capillary refill (Al-Khafaji, 2016). Look for the following signs that may indicate infection or sepsis (Al- Khafaji, 2016): ● ● Central nervous system: Profound mental status changes. ● ● Head and neck: Inflamed tympanic membrane, sinus pain, cervical lymphadenopathy, stridor. ● ● Chest and pulmonary infection: Rales or chest consolidation. Patient may be dyspneic or pale or have abnormal lung sounds. ● ● Cardiac infections: Murmur with regurgitation. ● ● Abdominal and gastrointestinal infections: Focal tenderness, rebound tenderness, rectal tenderness or swelling. ● ● Pelvic and genitourinary infections: Costovertebral tenderness, pelvic tenderness, cervical motion pain. ● ● Bone and soft tissue infections: Focal erythema, edema, tenderness. ● ● Skin infections: Petechiae and bruising. SCREENING TOOLS FOR SEPSIS Sequential (sepsis-related) organ failure (SOFA) screening tool Values for organ-specific dysfunction are used to help diagnose multiple organ dysfunction syndrome (MODS) and predict associated mortality. The sequential (sepsis-related) organ failure assessment score (SOFA) was first developed as a tool for sepsis-related organ failure, but it is also used to evaluate mortality with other conditions that may lead to MODS. The SOFA score is promoted by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine to help predict those with the greatest risk of death from sepsis (Kelley, 2017). SOFA score measurements ● ● Respiratory system: The ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2). A lower PaO2/FiO2 measurement correlates to a higher SOFA score. ● ● Cardiovascular system: The amount of vasoactive medication necessary to prevent hypotension. The higher the medication dosage, the higher the SOFA score. ● ● Hepatic system: The bilirubin level is measured. A higher bilirubin level correlates to a higher SOFA score. ● ● Coagulation system: Platelet concentration is measured. A lower platelet level corresponds with a higher SOFA score. ● ● Neurologic system: The Glasgow Coma score is used to evaluate the neurologic system. The lower the Glasgow Coma score, the higher the SOFA score. ● ● Renal system: The serum creatinine or urine output is measured. An increased creatinine level correlates to a higher SOFA score. Decreased urine output correlates to a higher SOFA score. A patient with a SOFA score greater than or equal to 2 is considered to be in a life-threatening situation with a mortality rate of greater than or equal to 10% (Singer et al., 2016). A patient with a SOFA score greater than or equal to 2 and who requires vasopressor therapy and has an elevated lactate level > 2 mmol/L despite fluid resuscitation has a mortality rate of 40% (Singer et al., 2016). The patient’s baseline SOFA score should be 0 unless the patient has known organ dysfunction before the onset of infection (Singer et al., 2016).