Page 154 Complete Your CE Test Online - Click Here SEPSIS IN THE ADULT PATIENT: IDENTIFICATION AND INITIAL CARE Self-Evaluation Exercises Questions are located throughout the course. You do not need to submit the self-evaluation exercise with your final examination sheet. Self-assessment answers 1. Answer: A. Rationale: Leukocytosis (elevated white blood cell count) may be present in the direct postoperative period as a result of circulating monocytes and neutrophils in response to injury. Neutrophils, in particular, are considered the first responders to injury and infection. WBC levels may peak the first postop day and gradually decrease in the days following surgery (Hughes et al., 2010). Hemoglobin and hematocrit levels are highly likely to be low following surgery because of blood loss. 2. Answer: C Rationale: The latest information on the pathophysiology behind sepsis maintains that sepsis development includes the dysregulation of proinflammatory mediators and antiinflammatory mediators in a complex back-and-forth process. Sepsis is not a localized inflammatory response. Sepsis always starts with an infection. 3. Answer: D Rationale: The nurse should be aware of a patient who is tachypneic and not oxygenating properly. The elevated blood sugar of 148 could indicate sepsis in a nondiabetic patient, but it may not have any clinical significance at this point for a diabetic patient. The body temperature is low and should be monitored at regular intervals but is not below 35.5˚C (96˚F) and is not a red flag for sepsis. The heart rate of 84 bpm is within normal parameters for adults, and the blood pressure is slightly elevated but does not indicate sepsis at present. The presence of suspected infection (increased swelling, redness, and pain at incision site) plus the presence of tachypnea and poor oxygenation is cause for alarm in this postop patient. 4. Answer: A. Rationale: A higher bilirubin level is associated with liver dysfunction and failure, thus making the SOFA score higher. 5. Answer: B Rationale: Measuring lactate levels is part of the 3-hour bundle recommendation that also includes obtaining blood cultures and administering antibiotics and intravenous fluids. Ensuring airway and proper oxygenation is not included in the bundle recommendation, as it is a standard of care that should be performed as priority as part of the ABCs (airway, breathing, circulation) of care. Diagnostic imaging is important for source control and identification of infectious source, but it is not part of the 3-hour bundle recommendation. Securing venous access is necessary for the administration of fluids but is not explicitly stated in the 3-hour bundle recommendation. 6. Answer: B Rationale: Parasitic infections are a rare cause of sepsis and account for 1% to 3% of all cases of sepsis. The other three statements are true. 7. Answer: B Rationale: The patient older than 65 years of age is actually 13 times more likely to develop sepsis than younger populations (Artero, 2012). All of the other statements are true regarding sepsis and the older patient. 8. Answer: C Rationale: Mary is at a greater risk for sepsis as a result of a multiple gestation that is highly likely to require invasive and diagnostic procedures that may cause infection, such as cervical cerclage, serial amnioreduction, and fetal or placental surgery. Any pregnant woman can develop urinary tract infections, not just those who have a multiple pregnancy. Mary is under 40 years of age, so she is not considered to be of an advanced maternal age that would carry additional risk for infection that may lead to sepsis. 9. Answer: B Rationale: A chest X-ray is the best imaging test for diagnosing a lung infection, such as pneumonia. MRIs are helpful in diagnosing soft tissue infection. Ultrasounds are useful in diagnosing infection in such sites as the gall bladder and ovaries. CT scans are useful in diagnosing infection in the appendix, bowel, pancreas, or kidney. 10. Answer: C Rationale: The nurse should administer oxygen to ensure adequate oxygen delivery to tissues and organs. Intravenous fluids should also be administered to maintain adequate perfusion. Because the hospital has a sepsis protocol in place, the nurse should notify the physician of suspected sepsis and obtain blood cultures. The nurse should immediately notify the physician or a sepsis response team if there is likelihood of sepsis and obtain blood and wound cultures, if possible, before starting antibiotic therapy ordered by the physician, as long as doing so does not significantly delay the administration of antibiotic therapy (> 45 minutes is considered a significant delay). Vasoactive medications may be indicated if blood pressure does not improve with fluids or drops below 90, but must be ordered by a physician. Prompt broad-spectrum antibiotic therapy is critical in stopping the progression of sepsis leading to septic shock, MODS, and death and should be administered as soon as possible.