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  • Asuhan Keperawatan Pasien Dengan Sepsis: Ns. Anastasia Hardyati., M.Kep., Sp. KMB

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    Sepsis is a clinical syndrome characterized by a systemic inflammatory response due to infection. Signs of sepsis include temperature above 38°C or below 36°C, heart rate above 90 beats per minute, respiratory rate above 20 breaths per minute, and abnormal white blood cell count. Sepsis can progress to severe sepsis, indicated by organ dysfunction, and septic shock, indicated by hypotension despite fluid resuscitation. Common sources of sepsis include the respiratory, urinary, intra-abdominal, and central nervous systems. Treatment of sepsis involves giving oxygen, intravenous fluids, and antibiotics according to local guidelines.

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    Sepsis

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    Sepsis is a clinical syndrome characterized by a systemic inflammatory response due to infection. Signs of sepsis include temperature above 38°C or below 36°C, heart rate above 90 beats per minute, respiratory rate above 20 breaths per minute, and abnormal white blood cell count. Sepsis can progress to severe sepsis, indicated by organ dysfunction, and septic shock, indicated by hypotension despite fluid resuscitation. Common sources of sepsis include the respiratory, urinary, intra-abdominal, and central nervous systems. Treatment of sepsis involves giving oxygen, intravenous fluids, and antibiotics according to local guidelines.

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    46 views17 pages

    Asuhan Keperawatan Pasien Dengan Sepsis: Ns. Anastasia Hardyati., M.Kep., Sp. KMB

    Uploaded by

    chika wahyu sasqiautami
    Sepsis is a clinical syndrome characterized by a systemic inflammatory response due to infection. Signs of sepsis include temperature above 38°C or below 36°C, heart rate above 90 beats per minute, respiratory rate above 20 breaths per minute, and abnormal white blood cell count. Sepsis can progress to severe sepsis, indicated by organ dysfunction, and septic shock, indicated by hypotension despite fluid resuscitation. Common sources of sepsis include the respiratory, urinary, intra-abdominal, and central nervous systems. Treatment of sepsis involves giving oxygen, intravenous fluids, and antibiotics according to local guidelines.

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    ASUHAN KEPERAWATAN PASIEN

    DENGAN SEPSIS
    Ns. ANASTASIA HARDYATI., M.Kep., Sp. KMB
    PENGANTAR
    • Infeksi : Proses patologis yang disebabkan invasi oleh Mikroorganisme
    pathogen atau potensial pathogen ke dalam jaringan, cairan atau
    rongga tubuh
    • Sepsis : Sindroma klinik yang ditandai infeksi (biakan darah positif) dan
    respon radang sistemik, yang ditandai >2 gejala : suhu >380C atau
    <360C, HR > 90x/ menit, P > 20x/ menit, PaCO2 <32 mmHg, Lekosit
    >12.000 sel/Ul atau < 4000 sel/Ul
    • SIRS (Systemic Inflamatory Response Syndrome) : memiliki salah satu gejala
    namun tidak ada bukti infeksi
    ACTORS
    Micro-organism
    • Virulence
    • Innoculation dose
    • Multi-drug resistance
    Host
    • Genetic polymorphisms
    • Co-morbidities
    • Age
    • Chronic health status
    • Immuno-modulatory medications
    PERJALANAN SEPSIS
    DIAGNOSTIC CRITERIA FOR SEPSIS

    Severe Sepsis Septic Shock


    SIRS Sepsis
    •Sepsis plus •Sepsis-induced
    •Infectious & non •SIRS plus hypo-perfusion or
    infectious causes •Presumed or •Sepsis-induced hypotension
    •Clinical response confirmed organ persisting despite
    arising from a non infection dysfunction or 30 mls/kg fluid
    specific insult tissue rescusitation
    hypoperfusion
    SIRS CRITERIA

    • T > 38.3, < 36


    • HR > 90
    • RR > 20
    • WCC > 12, < 4
    • BSL > 7.7 mmol/l in non-diabetic
    • Altered mental status
    Komplikasi
    Sepsis
    SOURCES OF SEPSIS
    • Respiratory 38%
    • Urinary tract 21%
    • Intra-abdominal 16.5%
    • CRBSI 2.3%
    • Device 1.3%
    • CNS 0.8%
    • Others 11.3%
    TANDA DAN GEJALA SEPSIS
    Give 3 Take 3
    1.OXYGEN: Titrate O2 to saturations of 1. CULTURES: Take blood cultures before
    94 -98% or 88-92% in chronic lung giving antimicrobials (if no significant
    disease. delay i.e. >45 minutes) and consider
    source control.

    2. FLUIDS: Start IV fluid resuscitation if 2.BLOODS: Check point of care lactate


    evidence of hypovolaemia. 500ml bolus & full blood count. Other tests and
    of isotonic crystalloid over 15mins & investigations as per history and
    give up to 30ml/kg, reassessing for signs examination.
    of hypovolaemia, euvolaemia, or fluid
    overload.

    3. ANTIMICROBIALS: Give IV 3. URINE OUTPUT: Assess urine output


    antimicrobials according to local and consider urinary catheterisation for
    antimicrobial guidelines. accurate measurement in patients with
    severe sepsis/septic shock.
    DIAGNOSA KEPERAWATAN
    • Penurunan CO berhubungan dengan penurunan afterlod, penurunan preload, ketidak
    efektifan kontraktilitas otot jantung, deficit volume cairan.
    • Penurunan perfusi jaringan berhubungan dengan kardiak output yang tidak mencukupi.
    • Deficit volume cairan berhubungan dengan kehilangan cairan yang berlebihan.
    • Kerusakan pertukaran gas berhubungan dengan ketidakefektifan ventilasi, edema
    pulmonal.
    • Pola nafas tidak efektif berhubungan dengan kelelahan otot pernafasan.
    • Ketidakseimbangan nutrisi : kurang dari kebutuhan tubuh berhubungan dengan
    peningkatan metabolism.
    • Risiko ketidakseimabangan temperature tubuh behubungan dengan proses infeksi.
    • Gangguan mobilitas fisik berhubungan dengan kardiak output yang rendah, ketidak
    mampuan mencukupi metabolism otot rangka, kongesti pulmonal yang menyebabkan
    hipoksia, dan status nutrisi yang buruk.
    • Risiko kerusakan integritas kulit berhubungan dengan penurunan perfusi jaringan dan
    adanya edema
    KESIMPULAN

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