SIRS, Infection and Auto-Immune Disorders

What is the Procalcitonin lab test?

• Ordered: blood test used to help identify systemic bacterial infection and possible sepsis. It can help distinguish bacterial infections from viral infections and help guide decisions about antibiotic treatment.

  • Produced by liver in respone to pro-inflammatory cytokines

• S/S: Fever or chills, Elevated heart rate or respiratory rate, Low blood pressure, Altered mental status or new confusion, Suspected pneumonia or another bacterial infection, Worsening infection or concern for sepsis, A history of recent infection, hospitalization, or invasive procedure

• How is it measured: A blood sample is collected from a vein, usually in the arm, and sent to the laboratory.

• What it detects:

  • The amount of procalcitonin in the bloodstream

  • Higher levels can indicate a systemic bacterial infection and increased risk of sepsis. It does not identify the specific bacteria causing the infection.

  • Lower levels → typically viral

What are the antimicrobial resistance infections we learned about?

• MRSA: Methicillin-resistant Staphylococcus Aureus

• VRE: Vancomycin-resistant Enterococci

• CRE: Carbapenem-resistant Enterobacterales

• C. Diff: Clostridioides difficile

What are nursing interventions for a MRSA, CRE, C. Diff?

• MRSA & CRE: bathing patients with 2% chlorhexidine wipes

• MRSA: administering nasal mupirocin ointment

  • Can be positive in nares and carry it but it’s not active and causing symptoms

What is different with C. Diff cause and treatment?

• Vanco = problem and cure

• The most common cause of C. Diff is IV vancomycin

• Treatment of C. Diff is oral vancomycin → has to do with the way it functions different in the GI tract

What patient education should you provide for antimicrobial resistance?

• Performing frequent hand hygiene, including using hand sanitizers (not for C. Diff)

  • C. Diff requires enteric precautions and scrubbing hands with soap/water

• Avoiding close contact with people who have infectious wounds or active infection w/these

• Avoiding large crowds

• Avoiding contaminated surfaces

• Using good overall hygiene

What is the assessment process for a pt w/some sort of infection?

• Local site: pain, swelling, heat, redness/hyperpigmentation, pus

• Fever often above 101F

• Chills

• Malaise

• Enlarged lymph nodes

• Pharyngitis

• GI disturbance (vomiting/diarrhea)

After an assesment of someone with an infection what labs and diagnostics are typically ordered?

• PAN culture: Blood Cx x2, sputum, urine (3 things that are most likely cause)

  • Need blood from 2 different sites (for each site, one bottle of anerobin and aerobic), one set pos. and other neg. could mean the one area was contaminated and the blood isn’t actually affected

• Wound culture if present

• CBC

• CMP

• Lactic Acid

• Procalcitonin (bacterial or viral)

• ESR (pro inflammatory marker)

• Xray

• CT

What is the progression of an infection?

• Infection present or suspected

  • Increase in pro-inflammatory cytokines = widespread inflammation (pro-inflammatory cytokines trigger excessive widespread inflammation)

    • SIRS develops → Systemic Inflammatory Response Syndrome

What qualifies someone for sepsis?

• SIRS + confirmed infection source = Sepsis

What is the criteria for SIRS?

• Temperature: > 38C (100.4F) or < 36C (96.8F)

• Hear Rate: > 90 bpm

• Respiratory Rate: > 20 breaths per minute or PaCO2 < 32 mmHg

• WBC count: > 12,000/mm³ or < 4,000//mm³ or > 10% immature neutrophils (bands)

What are symptoms of SIRS?

• Fever or hypothermia

• Tachypnea

• Confusion or altered mental status

• Shaking or chills

• Tachycardia

• Fatigue or malaise

• Edema and redness

• Loss of consciousness

** RR and AMS = earliest signs of decline

What system is used to determine deteriorating patients?-

• MEWS: Modified Early Warning System

• Higher numbers indicate pt is at greater risk of deterioration or is actively deteriorating (the higher the score, the bigger the problem)

• Does not supersede critical thinking

When planning and implementing for infection what should you focus on for SMART goals?

• Focus on syptoms you assess

• Think about what is realistic and achievable for you shift based on how they are doing

  • Ex: pt’s temp won’t go above __ during this shift

What medication orders can you anticipate from providers for a pt with an infection?

• Control symptoms: antipyretics. antiemetics, antidiarrheals

What do antimicrobials do with treating infections?

• Fight susceptible pathogens by:

  • Inhibiting cell wall synthesis (penicillins and cephalosporins)

  • Injuring the cytoplasmic membrane (antifungal agents)

  • Inhibiting biosynthesis or reproduction (erythromycin and gentamycin)

  • Inhibiting nucleic acid synthesis (actinomycin)

What are nursing priorities/interventions for patients with SIRS?

• Recognize early s/s of sepsis (ALOC and RR)

• Intervene to promote hemodynamic stability (focus on HR and BP) and adequate organ perfusion

  • Interventions: low BP → put HOB level down, oral fluids (PO)

What orders from provders can you anticipate for a patient with SIRS?

• Early resuscitation with IV fluids → Priority! first line treatment!

• Suplemental oxygen → 2nd

• Broad spectrum antibiotics until culture results then narrow spectrum antibiotics → 3rd

What patient education should you provide for someone with an infection/SIRS?

• How to prevent infection

• Recognizing signs and symptoms

• When to seek medical care → teach about ALOC

• Educate about current treatments as they are happening

• Antibiotic therapy

What should you know about patients with autoimmune disorders and their risk of infections?

• Pt’s with autoimmune disorders already have an activated immune system or one that can be easily triggered

• They already have increased inflammation in their body which puts them at higher risk (esp. for SIRS)

• Flare up → increased inflammation → as a nurse need to be monitoring for decompensation

How does the progresion of an infection to SIRS look like for someone with an autoimmune disorder?

• Auto-immune trigger (stress, injury, environmental triggers, infection, hormones, medication)

  • Increase in pro-inflammatory cytokines = widespread inflammation

    • SIRS develops

      • SIRS + confirmed infection source = Sepsis