Systematic Inflammatory Response

Syndrome
Presented by: Group 1
(acuna, basinang, bernardino & lavadia)
 A serious condition in which there is inflammation throughout the
whole body. It may be caused by a severe bacterial infection
(sepsis), trauma, or pancreatitis.
Systemic inflammatory response syndrome
(SIRS). Venn diagram showing overlap of
infection, bacteremia, sepsis, SIRS, and
multiorgan dysfunction.
 Risk Factors
Modifiable risk factors
Non Modifiable Risk Factors
 Malnourishment
 People with;  Age: Young and Elders
 Community acquired pneumonia  Gender: Men>Women
 Urinary Tract Infection (UTI)  Race: Americans
 Pyelonephritis
 Candidiasis
 Cholecystitis
 Influenza
 Intra abdominal infections
 Trauma
 Diabetic foot infection
 Invasive procedures
 SIRS criteria's:
 Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)

 Heart rate of more than 90 beats per minute

 Respiratory rate of more than 20 breaths per minute

 arterial carbon dioxide tension (PaCO2) of less than 32 mm Hg

 white blood cell count greater than 12,000/mm3 or less than 4,000/mm3
 Other manifestations

 Hypotension
 Decreased urine output
 Changes in mental status
 Elevated lactate levels
 Complications
 Severe sepsis
 Septic shock
 Multiple organ failure
 death
 Nursing Diagnosis:

 Impaired gas exchange related to interference with oxygen delivery.

 Risk for deficient fluid volume related to massive vasodilation.
 Risk for decreased cardiac output related to decreased preload.
 Risk for shock related to infection.
 Nursing Management:
 ABC’s:
 First priority is to secure adequate airway and oxygenation
 Supplemental oxygen is given
 Adequate amount of fluids to restore the perfusion of the vital organs
 Infection Control:
 Assess client for a possible source of infection (e.g., burning urination, localized abdominal
pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines)
 Maintain hand washing before and after each care.
 Maintain sterile technique when changing dressings, suctioning, and providing site care, such
as an invasive line or a urinary catheter.
 Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral
nutrition lines. Document signs of local inflammation and infection and changes in character
wound drainage, sputum, or urine.
 Encourage client to cover mouth and nose with a tissue when coughing or sneezing.
 Wear mask when providing direct as appropriate.
 Proper Disposal of soiled dressings and other materials in proper waste bags
 Wear gloves and gowns when caring for open wounds or anticipating direct contact
with secretions or excretions.
 Monitor vital signs and ABG’s
 Monitor blood levels- BUN, creatinine, WBC, hemoglobin, hematocrit, platelet
levels, and coagulation studies.
 Assess physiologic status- assess the patient’s hemodynamic status, fluid intake and
output, and nutritional status.
 Pharmacologic therapy. The nurse should administer prescribed IV fluids and
medications including antibiotic agents and vasoactive medications (Drotrecogin
alfa )