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Published: December 19, 2022
Last Updated: December 28, 2022
Sepsis is a potentially life-threatening condition that occurs when the body has a systemic response to an infection. It is not caused by a specific type of bacteria but can be triggered by any type of infection, including bacterial, viral, or fungal. Most cases of sepsis in the hospital will be caused by severe bacterial infections.
According to the CDC, sepsis is a leading cause of death in the United States. It is estimated that more than 1.7 million cases of sepsis occur each year, and kills about 270,000 people each year. The mortality rate for sepsis varies, but it can be as high as 50% in severe cases. This mortality rate is highest in patients who are over 75 and have multiple comorbidites.
It is important for nurses to be aware of the signs and symptoms of sepsis and to know how to recognize and manage it.
Sepsis is a common clinical syndrome that represents the body’s response to severe bacterial infection. Within the hospital, you will take care of patients with sepsis in any department, but especially in the ER and ICU.
Sepsis is a severe condition with a poor prognosis.
Early sepsis– while not clearly defined – is the presence of infection and bacteremia (bacteria in the blood) – which can and likely will progress to sepsis without intervention. Recognizing and intervening early when the sepsis is still early can significantly improve patient outcomes.
Sepsis is now is defined as life-threatening organ dysfunction in response to infection. Organ dysfunction, usually from hypoperfusion, can be evidenced by hypotension, altered mental status, tachypnea, or increased sofa score by 2 points.
Sepsis used to be identified using SIRS criteria– Systemic Inflammatory Response syndrome. This is somewhat outdated and no longer used, but you still may often hear about this in your hospital.
SIRS was a term that was used to describe the early stages of sepsis. It was defined as the presence of two or more of the following criteria:
The idea behind using the SIRS criteria to diagnose sepsis was that it could help identify patients who were at risk of developing sepsis and who may need early intervention. However, over time, it became clear that the SIRS criteria were not sensitive or specific enough to accurately diagnose sepsis.
As a result, the SIRS criteria are no longer used to diagnose sepsis. Instead, the more recent Sepsis-3 criteria is recommended.
The Sepsis-3 criteria is now used to help clinicians detect and diagnose sepsis, which includes the following 3 criteria:
These criteria are designed to be more sensitive and specific than the SIRS criteria. It’s also more specific to identifying patients who are at high risk of dying from sepsis and are more likely to need aggressive intervention.
Criteria | Description | |
---|---|---|
1 | Suspected or confirmed infection | The presence of a suspected or confirmed infection, such as pneumonia, urinary tract infection, or septicemia |
2 | Serum lactate level above normal | A serum lactate level above the upper limits of normal, indicating tissue hypoperfusion and cellular injury |
3a | Hypotension requiring vasopressors | Hypotension that requires the use of vasopressors to maintain a mean arterial pressure of 65 mm Hg or higher |
3b | Serum lactate level greater than 2 | A serum lactate level greater than 2 mmol/L after adequate fluid resuscitation |
3c | Acute increase in lactate level | An acute increase in the serum lactate level by at least 2 mmol/L within 24 hours |
Septic shock is a type of distributive shock and occurs when the body is under severe distress and releases a lot of mediators and toxins which can cause vasodilation, decrease circulating blood volume, and tank the blood pressure. Septic shock is generally diagnosed when the patient has a MAP <65 mmHg and a lactic >2.0 mmol/L, often after their initial fluid bolus. These patients require vasopressors and should be monitored in the ICU.
Septic shock is a medical emergency and requires immediate treatment. If not treated promptly, it can lead to multiple organ failure and death.
Sepsis can be caused by any infection that is left untreated or resistant to antibiotics that eventually causes systemic infection and reaction. While severe viral or fungal infections can cause sepsis, this is less common. Common bacterial infections that are more likely to cause sepsis include:
Urinary Tract Infections (UTIs) are common causes of sepsis in elderly individuals. When a Cystitis (inflammation/infection of the bladder) can also travel up the ureters to the kidneys and cause pyelonephritis (infection of the kidney), which is more likely to cause sepsis as well. When a UTI becomes sepsis, this is called Urosepsis.
Pneumonia is a bacterial infection of the lungs. Left untreated, this commonly causes sepsis. In fact, severe sepsis can occur in almost half of patients admitted to the hospital with pneumonia.
Cellulitis is infection of the skin and surrounding tissue. Patient’s with severe cellulitis often have other risk factors, like obesity, diabetes, and other comorbid conditions which increase their liklihood of becomign septic.
Since sepsis isn’t only caused by one thing, the symptoms are going to depend on the underlying infection. However, there are some common symptoms that all sepsis usually share. These include:
Fevers and chills are classic for infection. A true fever is greater than 100.4° F or 38° C. Sepsis often presents with even higher fevers of 102°, 103°, or 104° F
Chills are subjective, and many patients will report them (even for minor infections). However, patients with sepsis often have signifiacnt chills and tremors.
Whenever the body is fighting infection, it takes a toll on energy levels. With sepsis it also does this, but to an even larger degree as this is a systemic response.
Altered Mental Status (AMS) commonly occurs with sepsis. This is due to decreased perfusion of the brain, as well as their body’s systemic reaction. Older and sicker patients are more likely to experience this. This is often exacerbated by dehydration. This can manifest as:
Other symptoms of sepsis will depend on the underlying cause of the infection. Some examples include:
The patient should be asked about symptoms that may indiciate a cause for the infection.
The physical exam is essential in patients with sepsis, as these patients are often very sick or on their way to becoming very sick.
It is important to note that not all people with sepsis will have the same physical findings, and some may not have any physical findings at all. This is why it is important for healthcare providers to perform a thorough and complete assessment to identify any signs or symptoms of sepsis.
When you suspect sepsis, there are multiple things you should do as the patient’s nurse. Timing is so important, and that’s why so many departments have quality metrics and procedures in place for septic patients to get things done quickly. The faster we act, the better the chances of the patient surviving.
Hook up the patient to the bedside monitor to monitor their vitals frequently, especially their heart rhythm and their blood pressure. Set the machine to check BP every 15 minutes.
Be sure to notify the provider ASAP, as these patients are very sick and need orders STAT.
Place at least two IVs, 18-20g, and draw blood. This is for fluid and medication administration such as antibiotics and maybe even vasopressors until a central line can be placed.
Once placing the IV, you can grab labs off of the IV site. You will want to grab a basic rainbow (Blue top, Mint or gold top, and a lavender top), as well as blood cultures and a lactic (if your facility protocol allows 1 blood culture from the IV site).
Prime fluids to be given once ordered – probably at least 2 liters. Septic patients need at least 30ml/kg bolus of isotonic fluids to improve their symptoms, stabilize their vitals, improve their lactic acidosis, and improve their survival rates!
Should your patient with ESRD or CHF get the same amount of fluids? Keep reading below to find out!
Since sepsis is a clinical syndrome, there’s not exactly a lab test that will definitely tell you whether the patient is in sepsis or not. However, there are common labs and imaging that may be ordered.
Usually have WBC counts above 12,000/mm3, although severe sepsis can also present with leukopenia of < 4,000/mm3. Bands over 10% are consistent with sepsis.
Bands are a type of immature white blood cells that when present in higher numbers indicate severe infection and sepsis. Bands are normally 0-5%, and bands >10% are worrisome.
A “left-shift” is an ill-defined term that refers to an increased number of bands in the absolute neutrophil count.
A complete metabolic panel is drawn to see evidence of anything else going on, any possible source of infection, or of any organ damage that the sepsis may have already occurred. This will look at:
Look at the CO2 in the CMP. This is equivalent to the Bicarb in a venous blood gas sample. If it is < 18, they are likely acidotic, probably from lactic acidosis
Coag studies (PT/INR, PTT) are ordered in septic patients to detect clotting abnormalities. Severe sepsis can activate the clotting cascade, cause organ dysfunction, and ultimately lead to DIC.
Aerobic and anaerobic blood cultures should be obtained from two different sites. This will be used for a gram stain and will be cultured to see if any bacteria grows, as well as to perform sensitivity reports to various antibiotics.
Procalcitonin is a non-specific inflammation marker (kind of like ESR and CRP). This isn’t always ordered for Sepsis, but it can help show clinical response to antibiotics, especially from bacterial respiratory infections. This can help guide the Provider to know when to switch to oral antibiotics or stop the antibiotics altogether.
If the lactic acid, or lactate, is greater than 2 mmol/L, this indicates lactic acidosis. High lactate levels indicate decreased tissue perfusion of the organs, which is classic in Sepsis.
This will often be repeated every 4-6 hours until the level becomes normal.
Remember that Lactic acid is checked with a gray top (sometimes dark green), and should be transported ON ICE!
Remember in cell biology learning about how cells make energy or ATP? They do this primarily with oxygen using the Krebs cycle. When oxygen isn’t as available, it switches to a backup method of creating energy called glycolysis, which a byproduct of that is lactic acid.
Checking a urine sample is a MUST for anybody with sepsis, as urinary tract infections are a super common cause of sepsis. The presence of leukocyte esterase and WBCs, nitrites, and bacteria supports a UTI diagnosis. Check out the full article on how to interpret a UA!
Other labs that might be ordered depending on the symptoms of the patient includes:
A CXR is always ordered in patients with sepsis to see if there is any pneumonia or to detect any other possible abnormalities.
Sometimes an abdominal CT may be ordered if the patient has abdominal signs/symptoms, or significantly elevated liver enzymes. Contrast is preferred as this will better visualize any abscesses or fluid collections present, assuming their kidney function isn’t too bad.
A CT of the thorax without contrast is sometimes recommended but the radiologist after a chest x-ray is obtained. A chest-xray only has a sensitivity for pneumonia of about 43%. aren’t perfect and could miss pneumonia or other findings that the CT will have much better sensitivity for picking up infection.
Sometimes a CT chest, abdomen, and pelvis is ordered when there is no known source for infection – this can be especially helpful when there is little history to go off of, and the patient is unable to express their symptoms.
Remember that sepsis is a systemic response to infection. Our first priority is to stabilize their vital signs and provide support. Our second priority is to give antibiotics to kill the bacteria. Because sepsis has such a high mortality rate, these should be done quickly!
All septic patients should get a bolus of crystalloid fluids (Normal saline or Lactated Ringers). It’s recommended that septic patients get 30ml/kg bolus – so a 70kg patient would get 2,100 mL of roughly 2 liters.
This should be run wide open, and if the patient is hypotensive, you should use pressure bags.
This bolus should be finished infusing within the first 3 hours after the patient presents to the ER.
Patients who are septic in the hospital often have fevers. Administering antipyretics can help reduce their fluid losses and improve their symptoms overall. Options include:
Even patients with CHF or renal failure need fluids during sepsis, although may require less. The nurse and Provider should continuously assess for signs of pulmonary edema, such as increased SOB, tachypnea, hypoxemia, and/or pulmonary crackles/rales. If this develops – stop the fluids, notify the provider, and expect to give diuretics and/or intubate the patient.
Antibiotics are crucial in treating sepsis, as we need to fight the underlying bacteria that are trying to kill our patients. These should be given within the FIRST hour after the patient gets to the ER.
The choice of antibiotics should depend on multiple factors including the patient’s history, risk factors, as well as the suspected source of infection. In practice, you will commonly see an agent that covers MRSA (Vanco), plus a broad-spectrum antibiotic. Common regimens include:
Sometimes fungal infections can cause severe sepsis, and should be considered in some cases. If the patient is neutropenic or has risk factors for a severe fungal infection, the provider may order antifungal medications. This is likely best decided by Infectious Disease.
Vasopressors or “pressors” are medications that increase blood pressure through various means, usually by causing vasoconstriction of the blood vessels. This improves perfusion to important organs like the brain and the heart. However, these are also high-risk medications and only ordered when absolutely necessary.
In sepsis, the vasopressor of choice is often Norepinphephrine (also known as Levophed).
Vasopressors can usually be started peripherally in a pinch but eventually will require a central line to be placed. This is primarily because vasopressors can damage tissue if there is extravasation.
All vasopressors need to be closely titrated by a critical care nurse, and the goal is usually related to the MAP, not the systolic blood pressure.
The MAP stands for Mean Arterial Pressure. This is the average pressure in the arteries from one cardiac cycle (systolic + diastolic). This gives a better idea of the perfusion of the organs. To read more about this, check out here.
Stimulates Beta-1 and alpha-adrenergic receptors to increase the strength of contractions, the heart rate, and causes vasoconstriction – all of which increases systemic BP and coronary blood flow.
0.05 – 0.15 mcg/kg/min; titrate to MAP ≥ 65 mmHg.
* Always follow facility protocol and orders*
1 – 3.3 mcg/kg/min
Hypertension, tachycardia, palpitations, headache,
nausea/vomiting, peripheral vasoconstriction
In general, steroids like Solu-Medrol are not recommended during sepsis. However, it may sometimes be ordered by the critical care physician if the patient does not respond well to fluids and vasopressors.
The lactic acid should be trended if it is elevated from the start. This is generally checked every 4-6 hours until it falls below 2 mmol/L
WBCs should be trended as well, at least daily until resolution. This will usually immediately decrease with fluids and antibiotic administration.
A foley is often placed to track this closely, and it a strong indicator of kidney perfusion. The goal is often to have a urine output ≥0.5 mL/kg per hour.
Septic patients are usually tachycardic, and they are at increased risk for arrhythmias as well as myocardial infarctions. Close monitoring per department protocol is warranted.
Gram staining will be performed of the blood cultures usually within 24 hours, and cultures will grow bacteria if present in about 48-72 hours. This will depend on your hospital’s lab. The antibiotics may be changed depending on sensitivities.
Blood pressure and MAP should be monitored for hypotension and improvement with interventions like fluids and vasopressors. Goal is usually a MAP ≥65 mmHg
The patient will need to be assessed per department protocol. You should be assessing for signs of worsening perfusion such as:
Assess the IV sites and/or central line sites per protocol. Remember vasopressors can cause vasoconstriction of the extremities, so monitor for signs of decreased circulation such as:
Patients who are septic are receiving plenty of fluids and are under a lot of stress overall. This can put a lot of strain on the heart, especially when the patient has a history of cardiac disease. Watch for s/s of fluid overload including:
If the patient is on vasopressors, make sure you are assessing their extremities pulses and capillary refill. Vasopressors can cause necrosis of the extremities like fingers or toes if they are clamping down too much.
Early recognition and treatment of sepsis are crucial for improving patient outcomes. The mortality rate for sepsis can be high, but quick action by nurses and doctors can make a significant difference in the patient’s outcome. It is important for nurses to be aware of the signs and symptoms of sepsis and to know how to recognize and manage it. By recognizing and treating sepsis early, nurses can help improve patient outcomes and save lives.
If you’d like to download this article in PDF form, click here!
Evaluation and management of suspected sepsis and septic shock in adults
Norepinephrine: Drug information
Tintanilli’s Emergency manual (8th edition): Chapter 89
Published: September 18, 2022
Last Updated: October 27, 2022
Unless you’ve buried your head under a rock, you probably have heard about the recent outbreak of Monkeypox.
Just like any infectious disease, nurses are on the front lines and we need to be educated about how to care for these patients, as well as how to minimize the risk of spread to our patients or families.
Monkeypox is a virus that is similar to smallpox because they are part of the same genus – the orthopoxvirus genus. It is a zoonotic disease, which means its natural hosts are animals – in this case primates and rodents. This virus causes a syndrome of fevers, body aches, malaise, and a pustular rash that is similar to smallpox, although less deadly and less contagious.
This is not a new virus, and normally tends to occur primarily in the tropical forests of West and central Africa. However, this does occasionally cause small outbreaks outside of these areas.
In 2003 there was a brief outbreak in the US, which included only 71 confirmed cases. Out of these, there was no spread to any healthcare staff or other patients within the hospital, and no associated deaths.
Since May 2022, there is another outbreak in the US that is current and continues to spread, this time much more prevalent with over 21,000 cases confirmed in Septemeber, and over 50,000 cases globally.
Check out CDC for updated statistics.
There are multiple ways in which viruses can be transmitted to other people.
Monkeypox has a few different routes of transmission, some more common than others. These routes of transmission include:
Skin-to-skin contact with an infected lesion is the most common route of transmission for monkeypox. This. ismost contagious when the lesions are present on the skin. This is why it is commonly transmitted via sex, even though it is not a sexually transmitted infection.
Despite what you may have heard on some news outlets, monkeypox is NOT a sexually transmitted infection and you cannot only get it through gay sex.
Most cases that are occurring are currently within the gay community of men who are having sex with men. This is sometimes how viruses work – they will spread in a certain community, and then make their way to other communities.
As with many viruses such as COVID, respiratory droplets can transmit infection. So if you cough sneeze or even speak, this can sometimes infect others depending on how close you are to them. Prolonged face-to-face contact may be required for this to occur with monkeypox.
Fomite transmission is when the virus lives on a surface and another person picks up that object or touches that surface and then infects themselves. This can commonly be bed linens, clothing, or surfaces. This is different for every virus, and monkeypox has been known to be able to live on surfaces for up to 15 days!
A person is considered infectious from the onset of clinical symptoms until all lesions have scabbed over and re-epithelization has occurred.
The CDC recommends that if a patient is exposed to monkeypox in the community, they should:
It’s difficult to predict how dangerous monkeypox is for those in the US, as most of our data comes from Africa. In Africa, they have less access to quality healthcare, and the predominant strain (called a “clade”) is more deadly there.
From the data regarding Monkeypox in Africa, up to 3-6% of cases die.
So far. in the US, there have been one confirmed death from Monkeypox in LA.
Remember that most of the current monkeypox infections are circulating among younger, generally healthy men.
We have not yet seen monkeypox in large amounts in older patients with significant comorbidities and immunocompromised patients, and they’re expected to have higher rates of complications and death.
Even if monkeypox does not cause death, it can last for weeks and lead to very painful and sometimes scarring lesions.
Prevention is the most important aspect of infection control. If we can prevent spreading the virus, we can’t control the virus. This leads to better patient outcomes overall.
With monkeypox, there are ways to prevent the spread within and outside of the hospital. Monkeypox prevention includes:
Universal precaution should ALWAYS be used on all patients in every setting, and includes proper hand hygiene, and the use of clean gloves when dealing with or anticipating contact with a patient’s body fluids. This is one of the most important things we can do in healthcare to prevent the spread of infection.
Patients who have suspected or confirmed monkeypox should be placed into isolation as per your facility protocol. As we discussed, monkeypox is spread primarily through physical contact as well as through respiratory droplets. This means that you should be using contact and droplet precautions, so typically that involves the use of a gown, gloves, N95 facemask, and protective eyewear.
The CDC currently recommends N95 masks when entering a patient’s room with Monkeypox.
Smallpox, a similar but more contagious and deadly virus than monkeypox, was essentially eradicated in 1977 thanks to vaccinations. Because of this, routine vaccination was discontinued in 1980.
Because smallpox and monkeypox are so similars and comes from the same family of viruses, the smallpox vaccine is effective against monkeypox. However, it is in short supply and is being given to patients who meet high-risk criteria.
Currently, vaccination is recommended for patients who:
Patience with monkeypox will often present with a Prodromal period of symptoms, followed by the characteristic rash. During the prodrome, these symptoms will usually last up to 5 days and include:
A temperature above 100.4 F
Patients often complain of a severe headache
Myalgias and pain are common with monkeypox, as with many other viruses
Patients are often very fatigued and tired
Patients often have swollen lymph nodes, which can be localized toa specific area, or generalized throughout their body
The characteristic rash of monkeypox will typically develop 1-4 days after the prodromal symptoms start.
Monkeypox will cause a characteristic vesicular/pustular rash that progresses through different stages (See more on the stages below). These lesions are often in the same stage as each other, but not always.
Recent travel to an area where Monkeypox is Endmic, such as western Africa or the Congo Basin
Any recent contact with someone who may have had monkeypox
Any recent sexual contact or history that would place them at risk of getting monkeypox?
The physical inspection will primarily involve inspecting the skin for the monkeypox lesions, noting their quality, amount, number, and locations.
The characteristic monkeypox rash begins approximately 1-4 days after the start off the other symptoms, although some people get the rash first. This begins as a macule, then slowly develops into vesicles, pustules, and then scabs over.
The rash will typically last 2-3 weeks. Patients are considered infectious until the scabs fall off and a new layer of skin forms.
In some cases, lesions will first form in the mouth and/or on the tongue.
Macular lesions will first appear, which are basically just rounded red spots that are flat.
This stage lasts 1-2 days
The macular lesions will then turn into papules, which are raised red bumps.
This stage also lasts 1-2 days
The papular lesions will then turn into vesicles, which are raised bumps filled with clear fluid.
This stage also lasts 1-2 days
The vesicular lesions will then turn into pustules, which are raised bumps that are filled with pus (suppurative fluid).
Initially, these are deep-seated, meaning firm and hard. Eventually, they develop an umbilication in the center.
This stage lasts 5-7 days
Finally the pustules crust over and become scabs. These fall off after about 1 week.
This stage lasts 7-14 days
There are some nursing inventions that you can do right off the bat with these patients he suspected to have a monkeypox:
Patients with suspected monkeypox or even chickenpox should be placed in contact and droplet precautions. The difference with chickenpox is that that tends to be airborne, whereas monkeypox is not, so a negative air pressure room is not required, although may be prudent just in case of chickenpox or other airborne viruses.
Follow proper isolation precautions to minimize the acquisition and spread of the virus. Always refer to your facility’s protocols.
Place at least one IV, preferably 20 gauge or larger, in order to infuse normal saline once it’s ordered. These patients are usually tachycardic and have fevers, and fluids will help rehydrate them, improve their vitals, and help them feel better overall.
Prime at least 1 L of NSS spiked and ready to infuse. Verify a verbal or electronic order being administering (as always 😉).
If these patients are significantly ill and tachycardic, it would be a good idea to hook them up to a cardiac monitor. While doing so, a full set of vitals should be taken if not done already in triage.
Ask for and verify any medication that the patient may need, including antipyretics like Tylenol, an analgesic like morphine or Toradol, and/or an antiemetic like Zofran.
Diagnosis of monkeypox is largely clinical – so based on their history and the rash. However, it is recommended to confirm this in a lab due to the current outbreak.
There are a few ways monkeypox can be confirmed in the lab:
A swab of the lesions can be obtained and sent to the lab, they should be obtained with a dry synthetic swab. For more information on how to collect the swab – see here.
2 swabs should be obtained from at least 2 different lesions. Vigorously swabbing back and forth is fine, and you do not need to “unroof” the lesions.
Some facilities can check for IgG and IgM antibodies to monkeypox. IgM is typically detected 5 days after onset of rash, and IgG is detected 8 days after onset of the rash.
Monkeypox can be identified under a microscope as well, where the pathologist visualizes brick-shaped poxvirus virions (indistinguishable from smallpox).
There are other lab abnormalities that can present in patients with monkeypox, although these are NOT specific to monkeypox. these include:
With the current US outbreak, patients who get Monkeypox generally have a good recovery, and most can fully recover at home without hospitalization. So far only one death has been specifically attributed to monkeypox in the US during this current outbreak.
However, patients can present with more severe symptoms and complications, which can lead to worse outcomes and even death. These patients are kept in the hospital and given more extensive treatment.
For most people who get Monkeypox, treatment is going to be symptomatic, just like with most viruses. Symptomatic or supportive care includes:
Antipyretics like Tylenol or Ibuprofen can be used to control fever and symptoms of pain.
Encouraging oral hydration is important with any virus, and will help the body recover quicker, and prevent complications such as acute kidney injury. If the patient is admitted, these fluids can be given IV as well.
Resting while the body recovers from infection is important for any virus, and will help the body heal as quickly as it can.
TPOXX is the abbreviation for Tecovirimat – an antiviral used for severe monkeypox infections. This is reserved for patients who are admitted to the hospital and have severe disease. Although we don’t have much data in humans, this antiviral has been shown to decrease mortality rates in animals with monkeypox when started early in the course of the illness.
Potently inhibits the orthopoxvirus protein required for the formation of virus particles
600mg IV/PO Q12H x 14days (for 40-120kg)
Headache, Nausea, abdominal pain
Cidofovir has been shown to be effective in killing monkeypox in animal studies. Brincidofovir is a prodrug of cidofovir and was also approved for the treatment of monkeypox, however, did show some elevated liver enzymes in animal studies.
As discussed, most patients recover well at home, but there are certain complications and monitoring that you should watch for.
Patients at increased risk of developing more severe complications include:
Secondary bacterial infections can occur with viral infections, and this is no different than with monkeypox. Bacteria like to strike while the immune system is busy fighting the virus. This can lead to infections like pneumonia or sepsis.
Common secondary infections include:
Bacterial infections in any location can cause sepsis. This often happens from UTIs, lung infections, or skin infections.
Pneumonia should be suspected with productive cough, shortness of breath, adventitious breath sounds, and respiratory distress. This is evaluated with a CXR.
Encephalitis can occur with various infections and cause confusion, migraines, seizures, and overall altered mental status. This may be diagnosed by brain imaging (CT or MRI), EEG, and a lumbar puncture.
And hopefully that gave you a pretty good understanding of Monkeypox and how to care for your patients who may have it!
Epidemiology, clinical manifestations, and diagnosis of monkeypox
Treatment and prevention of monkeypox
Author | Nurse Practitioner
An I&D or Incision and Drainage is a procedure that is done to treat infections that have turned into abscesses.
Knowing how to perform an I&D is important for a nurse practitioner in most settings, but especially in the ER or Urgent Care.
An I&D or Incision and Drainage is performed when there is an accumulation of fluid within the body that needs to be drained.
This is usually from a skin abscess.
An I&D is performed in urgent cares, emergency departments, or in outpatient clinics like general surgery.
Patients with an abscess will usually complain of pain, welling, and redness of the affected area.
Abscesses can occur anywhere on the body, but commonly occur:
While anyone can get an abscess, these are more common in those with poor hygiene, as well as those who are immunocompromised.
Diabetics and patients who are obese are also at risk for abscess formation.
An I&D is performed to drain purulent fluid (pus) from the body.
These collections of pus are termed “abscesses”, and draining them is the best way to treat the infection, as well as preventing the abscess from getting bigger and causing a more serious infection.
If there is no fluctuance palpated (fluid felt underneath the skin), then a trial of PO antibiotics can likely be used without having to do an I&D.
Most cases of obvious abscesses will benefit from an I&D.
There are certain abscesses that require the expertise of a surgeon to drain. These include:
It is also best for abscesses >5cm to be drained and managed by a surgeon.
While antibiotics can help for skin infections like cellulitis, they often won’t be able to fully treat an infection if an abscess is there.
This is why an I&D is necessary.
Young, healthy patients who are not immunocompromised do not need antibiotics if an I&D is performed on a small abscess < 2cm.
Most others will require systemic antibiotics including:
However, these antibiotics likely won’t work without also performing an I&D!
Like skin infections, most abscesses are caused by staphylococcus aureus and other gram-positive bacteria.
However, MRSA is very common, especially with abscess formation. This means that standard antibiotics for cellulitis like Keflex may not work.
MRSA-covering PO agents include:
Perirectal abscesses that are drained will need additional coverage for gram-negative bacilli and anaerobes, so options include:
Severe infections and abscesses that require inpatient admission would be started on IV Vancomycin +/- Cipro/Flagyl or Zosyn.
Aerobic and anaerobic cultures should be obtained and sent to the lab to guide antibiotic use.
Patients at risk of bacterial endocarditis should be started on antibiotic prophylaxis. These should be given 1 hour prior to the I&D.
Antibiotic prophylaxis is given to certain people at risk for developing bacterial endocarditis. These oral antibiotics should be given 1 hour prior to the I&D.
Antibiotic prophylaxis should be given for patients with:
Antibiotic prophylaxis for bacterial endocarditis include:
An I&D is an invasive procedure and will require some equipment.
An I&D is also considered a clean procedure, so you do not need sterile gloves or a sterile field, although some do still utilize sterile technique.
Your facilities may have kits put together which contain much of what you need for the I&D.
I&D Kit | PPE |
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ANESTHETIC | IRRIGATION |
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PACKING & DRESSING | Culture Swabs |
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Once your equipment is ready, you need to prepare the patient.
Inform them of what the procedure will entail. A procedural consent form may or may not be required depending on your facility’s protocols.
Position the patient in a relaxed position where you can easily access the abscess.
Raise the stretcher or bed if able, and set up the bedside table or suture cart where you will set up your equipment.
Systemic analgesics may be required in larger abscesses, as they can be very painful.
IV or IM Morphine 4mg or Dilaudid 1mg is usually sufficient, if needed at all.
Before you make the incision, you should anesthetize the area you are going to cut.
Abscesses are already irritated and will be very painful.
Unfortunately, lidocaine doesn’t work as well as usual because abscesses are an acidic environment.
Draw up your 1-2% lidocaine into your 3cc syringe with a blunt needle.
Switch out to the smaller gauge needle (25-30g) and prime the lidocaine. You are now ready to infiltrate.
You have a few options when it comes to HOW you are going to anesthetize the area.
For smaller abscesses <5cm, locally infiltrate the lidocaine in a line where the incision will be, across the entire length of the abscess. This will be painful for the patient.
Incisions should be made along the lines of the body that have decreased tension to reduce scarring.
Local infiltration involves sticking the needle just underneath the epidermis, and injecting a small amount of lidocaine while you gently pull the needle back out.
You are infiltrating the subcutaneous tissue, but not deep enough to actually inject into the abscess itself.
This is done multiple times until the projected line where you will cut is fully infiltrated.
After 3-5 minutes, you can begin the incision.
For larger abscesses >5cm, the linear approach above should be used, IN ADDITION to a ring or field block.
A field block is achieved by injecting a ring of subcutaneous 1% lidocaine around the abscess, approximately 1cm peripheral to the erythematous border.
This means for lidocaine 1% (10mg/mL) the max dose would be 30mL in most adults over 65kg – you hopefully should not be using anywhere near this amount.
Lidocaine should start working in 45-90 seconds, but you should give it 3-7 minutes to fully kick with an abscess.
Once you have given enough time for the lidocaine to work (3-5 minutes), make a linear incision with the scalpel.
This needs to be deep enough to penetrate the abscess wall, but not too deep to cause injury.
It helps if you have 4×4 gauze in the other hand, as purulent fluid will usually immediately start gushing out.
Cut the entire length of the abscess, as not making a wide enough incision is one of the main causes of a recurrent abscess.
Young healthy patients with small abscesses <2cm who won’t get antibiotics don’t need cultures obtained.
Patients started on antibiotics should have cultures obtained if:
Make sure to obtain swabs for both aerobic and anaerobic gram stain and culture.
Abscesses have a tendency to become loculated. This means there can be individual pockets of pus within the abscess itself.
To “break these up”, insert a hemostat into the incision and open it up in all directions in order to break up any possible loculations. This is often painful.
Draw up sterile saline with the 20-60cc syringe, attach the splash guard or IV catheter, and irrigate the incision to effectively clean out the abscess.
This is best practice although not always performed, especially for smaller abscesses.
I&D incisions are almost never closed with sutures but are left open to heal by “secondary intention”, meaning naturally.
Sometimes packing should be used.
Packing is when you insert special gauze into the wound that promotes drainage.
Packing is generally recommended for:
If you decide to pack the wound, do not over-pack the wound too tightly. This increased pressure can cause tissue damage.
Gently insert the iodoform ribbon into the wound with a blunt object such as a cutip swab. This does not have to “stuff” the wound. Leave a 1cm tail outside of the wound.
Cover the packing with an absorbable dressing.
Patients with packing will need to return for a wound check-in 2 days. If there is still significant drainage, more packing can be placed.
Before discharge, make sure their tetanus is uptodate.
I&D without packing should soak in warm soapy water 2-3 times per day, and f/u in 7-10 days or sooner if systemic signs of infection present.
I&D with packing should return in 24-48 hours. Once packing is removed and the drainage stops, warm soapy soaks can be started.
Approach to management of drainable abscess or skin infection with purulent drainage in adults. (2021). UpToDate. Retrieved September 7, 2021, from https://www.uptodate.com/contents/image?imageKey=ID%2F114919&topicKey=ID%2F110530
Graphic 114919 Version 10.0
Buttaravoli, P. M., & Leffler, S. M. (2012). Cutaneous Abscess or Pustule. In Minor emergencies (3rd ed., pp. 655-659). Saunders.
Downey, K. A., & Becker, T. (2021). Techniques for skin abscess drainage. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/techniques-for-skin-abscess-drainage
Sexton, D. J., & Chu, V. H. (2021). Antimicrobial prophylaxis for the prevention of bacterial endocarditis. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/antimicrobial-prophylaxis-for-the-prevention-of-bacterial-endocarditis
Last updated: January 27, 2021
The new mRNA vaccines for COVID are being distributed, and as a nurse, it is important to know these vaccines, how they work, and their safety data!
Our patients respect our medical opinion, and we need to give accurate information so they can make an informed decision.
This article mainly focuses on the mRNA vaccines (Pfizer and Moderna), as they are currently the vaccines being distributed as they have obtained FDA emergency use authorization.
With these vaccines being so new – it leaves many wondering, “is it’s safe?”
I’m going to go over what the data tells us and hopefully give you enough insight into making an informed decision, and help your patients do the same!
Quick Note: I want to preface this article by first stating that I am a nurse practitioner and I see many COVID patients on the frontlines in the ED. I am not, however, an epidemiologist or scientist who works directly with COVID in a lab, so I am simply basing my own opinions on what the data says, as well as my understanding of the virus by seeing it firsthand.
Vaccines generally work by introducing a dead or weakened virus, or part of a virus into your bloodstream via an Intramuscular or subcutaneous injection.
This creates an immune response that helps your body be able to attack the real virus whenever it comes into contact with it in the future. Typical vaccines include those with:
The mRNA Vaccines (Pfizer and Moderna) actually do not inject the virus or any of it’s parts into you.
Instead, it contains mRNA which codes for the COVID spike protein – a protein specifically found on the COVID virus.
RNA is a single-stranded molecule that normally takes information from your DNA in the nucleus of the cell, and brings it to the ribosome of the cell to create proteins which basically keep the cell running and functioning appropriately.
So what scientists at Pfizer and Moderna have done is isolated the genome sequence of the mRNA which codes for the spike protein in the coronavirus, as this protein is not naturally found within your body. So what does the body do with this mRNA?
The mRNA is absorbed into your cells and carried to your ribosome where it is used as instructions to create the spike protein of COVID.
This protein cannot lead to disease, but it should lead to an immune response. Your body sees this foreign entity and creates antibodies to kill it and any future proteins it detects.
If the actual COVID virus now enters your body, your body should be able to detect it, and your immune system will target the cell and destroy it before it has a chance to replicate enough to cause disease and hopefully prevent you from spreading it.
This isn’t an easy question since it is so new, but so far it seems to be very safe and effective.
While mRNA vaccines have not actually been used in the US, researchers have been studying them for decades and have tested them on humans before for viruses like rabies, flu, CMV, and Zika.
In order to test the safety and efficacy of these new vaccines, clinical trials were conducted.
Pfizer and Moderna injected this vaccine into willing people and followed them for any adverse side effects, as well as those who ended up getting symptomatic COVID or severe disease.
Over 30,000 people were enrolled in the Moderna trial and over 40,000 people in the Pfizer trial.
Those who got the Pfizer vaccine get 2 injections, 21 days apart. Those who got the Moderna vaccine get 2 injections, 28 days apart.
Pfizer was tested on people 16 years and older, and Moderna was tested on adults 18 years and older.
Long story short – what they found was that most symptomatic covid cases were occurring in the placebo groups, which means those who did not receive the vaccine. Severe cases of COVID almost exclusively occurred in the placebo group!
The Pfizer vaccine boasts 95% efficacy beginning 1 week after the second dose, and Moderna boasts 94.1% efficacy 2 weeks after the second dose.
Both mRNA vaccines essentially use the same mRNA, basically the same ingredients, and both had very similar findings in their trials. This in and of itself is reassuring and offers an element of reproducibility.
The data from these trials are overall VERY reassuring. You can read more about the Pfizer or Moderna trials to get more information!
Common side effects include local injection site pain, headache, and fatigue. These vaccines should not cause COVID symptoms such as cough or SOB. It is impossible for these vaccines to cause actual COVID disease.
These vague side effects are common and expected when getting a vaccination, and are often an indication of the body’s immune response. They are short-lived and not severe.
Symptoms after the first injection tend to be less severe, and symptoms after the second injection were more significant – although both were very short lived (1-2 days).
Anecdotal Note: I have received both injections from the Moderna Vaccine. After the first shot, I had arm soreness which was worse than a typical vaccine, but resolved over 1-2 days. The day after my second injection, I had body aches and fatigue which resolved by the next day.
These symptoms seem common based on my colleagues experiences as well. Those who had symptomatic COVID anecdotally reported worsened symptoms after the first dose, although still short-lived.
Are all side effects mild and short-lived? We’ll dive more into that in future questions!
Just like any medication or vaccine, allergic reactions can occur.
Anaphylactic reactions have occurred after COVID vaccine administration, although not common, and seem to mainly occur in those with a history of severe allergies.
Overall it seems to be very rare – 11 people per million. Regardless, we know how to treat anaphylaxis and allergic reactions very well – Benadryl, Solumedrol, and Pepcid!
The CDC recommends those without a history of anaphylaxis to wait 15 minutes after their injection for monitoring, and those with a history of anaphylaxis to wait 30 minutes – just to be on the safe side.
Related Article: “Adverse Drug Reactions Nurses Need to Know”
Bell’s palsy is unilateral facial paralysis that can occur, which is usually temporary.
In the COVID vaccine trials, there were 7 reported cases of Bell’s palsy, in the over 70,000 participants in Pfizer/Moderna’s clinical trials.
While there were slightly more cases in the vaccine groups than the placebo groups, this rate is consistent with bell’s palsy rates in the general public, so likely not statistically significant.
However, some viruses and vaccines have been associated with bell’s palsy in the past, although rare.
Even if there is a small rare chance of the COVID vaccine causing Bell’s Palsy – it is usually temporary and treatable, and the benefits outweigh the risks.
Related Article: “The Cranial Nerve Assessment for Nurses”
No – it is physiologically impossible for it to cause COVID disease.
Vaccines that contain live “weakened” viruses do have the capacity to cause disease in those who are immunocompromised – an example being the MMR vaccine.
However, those with only pieces of the virus or mRNA that code for pieces of the virus cannot cause COVID. So mRNA Vaccines cannot cause COVID illness.
No, the vaccine should not alter PCR or antigen testing. Test swabs collect viral particles and test for their genetic code. These swabs are collected from areas where you are expressing the virus, like the nasopharynx.
While the mRNA causes your cells to produce the COVID spike protein, they are not expressed or spread outside of your body.
The PCR and antigen tests check for active infection and do not check for antibodies. The vaccine should not alter these test results.
No. Only specific viruses can alter your DNA. These viruses are called retroviruses and require a specific protein called reverse transcriptase.
The mRNA in the COVID vaccines do not alter your DNA in any way.
No – this is nonsense and I’m not really sure what else to say about it.
There is no convincing evidence to suggest that the mRNA vaccines cause infertility.
This idea was picked up and used by anti-vax propaganda. This myth started when a German Epidemiologist and a former Pfizer employee asked the FDA to not grant authorization to use the vaccine.
They said that the COVID vaccine’s mRNA is similar to the syncytin-1 protein which is used in mammals to help create placenta during pregnancy.
While the proteins do share a minimal amount of similar code, the scientist and medical community at large reject the notion that it could cause infertility.
While it is still so new – it cannot be said with certainty because we don’t have the data. However, 23 women did conceive during these trials, and they are still being followed.
This is a decision that should be discussed with the patient’s OBGYN, and they can come to a decision together.
The clinical trials did not study vaccination in pregnant mothers, so we don’t have specific data regarding pregnant individuals. There were some animal studies that looked promising.
The American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet the criteria for vaccination based on priority groups.
This means it is likely a good idea for pregnant mothers who are at an increased risk of getting COVID to get the mRNA vaccine.
What we do know is that pregnant mothers are at increased risk from side effects and complications if they get COVID.
They are more likely to be hospitalized, placed in the ICU, ventilated, and die than if they weren’t pregnant.
Again – this decision should be made with the patient’s OBGYN and Pediatrician.
There is just not enough data studying this to make a sweeping recommendation.
It is unlikely that the vaccines would be unsafe for the baby, and there is a possibility of passing on some passive immunity obtained from the vaccine to a breastfeeding infant.
While there doesn’t appear to be any specific contraindications, this is something that should be discussed with the patient’s physician / Rheumatologist.
The risks of getting symptomatic COVID may be worse than the risks of getting the COVID vaccine.
The idea is that if you had symptomatic COVID – you should have natural antibodies already for the virus – so why get the vaccine?
This is a decision you have to decide on with your Provider. It likely won’t hurt and could help, so the CDC is in favor or those who had COVID to also get vaccinated.
While it may be recommended to wait 90 days after symptomatic covid for the infection, this is not a rule and there is no specific timeline established.
This is more to allow those who have not built any immunity to receive the vaccine first.
You should get the vaccine after you recover from symptomatic COVID and when you feel it is appropriate.
Related Article: “These 8 COVID nursing tips could save your life”
As of today COVID has killed over 400,000 people in the US and 2.15 million people worldwide. This number is rising very quickly.
Even if COVID doesn’t kill you or your patients, it can cause many long-lasting side effects.
During an active COVID infection, it can cause multifocal pneumonia and respiratory failure leading to hospitalization, ventilation, and possibly death.
Severe COVID can also cause blood clots leading to pulmonary embolisms and embolic strokes.
It can cause inflammation of your brain and heart as well, leading to irreversible damage in some cases.
There have been observational studies done which show that up to one-third of patients who had symptomatic COVID had persistent symptoms after resolution of the virus. These include:
There may still be other long-term side effects that we still don’t know about.
So what’s riskier? Getting a vaccine that seems to be very safe and doesn’t seem to have any serious long-lasting side effects, or take your chances with getting COVID?
I can’t make that decision for you or your patients.
But if you do decide to get the vaccine, what can you expect?
You can expect to get 2 injections, 21 days apart with Pfizer or 28 days apart with Moderna.
The full efficacy seems to be established about 1-2 weeks after the second injection, depending on the vaccine (1 week after Pfizer, 2 weeks after Moderna).
These were the timelines studied in the clinical trials.
Well – no, not immediately.
Remember that even a 94-95% efficacy still leaves that 5-6% of people who will still get symptomatic COVID.
These people will likely be contagious, and they still could get severe COVID and have to be hospitalized or worse.
Secondly, both Pfizer and Moderna require 2 shots before full efficacy is expected. The body takes time to build up an antibody response. It can take 1-2 weeks after the second dose for full efficacy.
Additionally, it has not been proven by evidence that these vaccines prevent you from spreading COVID. The trials only prove that they are 94-95% effective at reducing symptomatic COVID.
That’s right. Even if you don’t get symptomatic COVID – you could possibly spread it.
Theoretically, it is unlikely that you will be spreading the virus after vaccination.
Hopefully, your body has created an immune response and antibodies which will attack COVID before it can replicate and cause disease or be contagious.
HOWEVER – we don’t have the data to back this up, and there another important consideration – Mucosal Immunity.
We don’t know how well the antibodies penetrate the nasal mucosa. There is a possibility that the virus can still replicate in the mucosa of your nasopharynx.
While it may not cause symptomatic disease since you should have circulating antibodies – you might still spread it to others when coughing, sneezing, or even breathing.
This is something that we should have more data on soon.
This is why it is imperative to continue to wash our hands, wear our masks, and practice social distancing.
It is going to take some time for the majority of the US to become vaccinated.
This means we need about 70%+ of the population to be vaccinated or infected before some type of herd immunity can be expected and established.
Herd immunity occurs at different percentages of vaccinated/infected individuals based on each specific virus.
This number is unknown for COVID, but experts say at least 70% need to be vaccinated and/or infected for some type of herd immunity to protect us.
It is unlikely that mask mandates and social distancing will become a “thing of the past” until we get to this point.
Unfortunately, there are multiple mutated strains or variants popping up in the UK, Africa, and other places.
These strains are spreading fast as they are more contagious (30-70% more transmissible).
However, these don’t necessarily seem to be more deadly. However, with surges in COVID cases and hospitalizations, increased deaths could occur due to the burden put on the healthcare system.
As far as we know, these vaccines should be effective against these mutated variants.
However, preliminary data does suggest that the vaccines may not work as well against the South African variant! Just in case, Moderna has already begun production on a “booster shot” which would specifically target these variants.
As mentioned above – complete immunity is not guaranteed.
However, if antibodies are created, it is unknown how long they will last.
What we do know is that immunity wanes over time. Those who get symptomatic illness tend to build a better immune response than those who get vaccinations.
Many patients who had symptomatic COVID in early 2020 still have antibodies – this is good news!
We don’t know how long immunity will last, and we don’t know how much further mutations will alter the effectiveness of the immunity.
Pfizer and Moderna are mRNA vaccines which have already obtained emergency use authorization (EUA) from the FDA.
There are two other vaccines that may obtain approval as well. These are not mRNA vaccines. They include:
These do not appear to be as effective as the mRNA vaccines, but may still prove helpful, and we must continue to follow the data.
Production and distribution of the mRNA vaccines will prove tough, and additional effective vaccines will be helpful!
That’s for you to decide, based on the data and taking into account what your physician or healthcare provider recommends.
Additionally, it is for your patients to decide based on informed consent.
It is not your job to judge them or tell them what to do. All you can do is offer evidence-based recommendations and up to date information, and allow them to make that decision for themselves.
You can also lead by example and get the vaccine for yourself, trusting the science and once again being that hero that we were once called in the beginning of this pandemic.
I think frontline workers and those with a high risk should seriously consider getting vaccinated.
As far as everyone else – that’ a decision you (or they) have to make, but the data looks promising and this could be our chance at returning to a state of semi-normalcy.
Note: If you want more information – you should follow Dr. Kat the Epidemiologist on TikTok! She creates great content backed in science on all things COVID and mRNA Vaccines!
I got my vaccine! Did you? Why or why not? Let us know in the comments below!
You might like: “These 8 COVID nursing tips could save your life”
Pfizer / Moderna Studies:
Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine (Pfizer)
Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in Older Adults (Moderna)
Vaccine Info:
Coronavirus disease 2019 (COVID-19): Vaccines to prevent SARS-CoV-2 infection (UTD)
Facts about COVID-19 Vaccines (CDC)
Understanding mRNA COVID-19 Vaccines (CDC)
Anaphylaxis:
Bell’s Palsy:
FDA: Track Vaccine Recipients for Facial Paralysis
Pregnancy & Breastfeeding:
COVID-19 Vaccines and Pregnancy: Conversation Guide for Clinicians (ACOG)
Vaccination Considerations for People who are Pregnant or Breastfeeding (CDC)
Why COVID Vaccines are Falsely Linked to Infertility
Persistent COVID:
COVID-19 (coronavirus): Long-term effects (Mayoclinic)
Herd Immunity / Still Wear Masks:
Coronavirus disease (COVID-19): Herd immunity, lockdowns and COVID-19 (WHO)
Here’s Why Vaccinated People Still Need to Wear a Mask
How Long Does Immunity Last After COVID-19? What We Know
New Strains of COVID:
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Whether we want to admit it or not, the COVID19 pandemic is not ending anytime soon. Even with the vaccines coming soon, there is still be months of hard work ahead of us. Using these COVID nursing tips might be able to help!
As nurses, COVID can be exhausting and even somewhat demoralizing. I have felt plenty of burn-out since this all began, and nurses across the nation can relate.
In this article, I will list some COVID nursing tips for ER and inpatient nurses – to help you get through your shift safely!
This is easier said than done – but minimize your contact with patients who have symptoms consistent with COVID. If you need a refresher, common symptoms of COVID include:
As an NP, this is actually fairly doable. I can conduct my history at 3-6 feet away, and perform a very limited physical assessment, often without even touching the patient. Sounds terrible, but the safety of healthcare workers is essential.
Bedside nurses are much more hands-on. What I’m going to say might be controversial, but you do not need to listen to every patient with lung sounds. We are going to get a chest X-ray anyway. Minimize contact, minimize exposure, and minimize your risk as best possible.
Patients with COVID often have normal or somewhat diminished lung sounds. Knowing this does not change management. When I do listen to lung sounds, they are patients with asthma, COPD, or CHF, because I’m specifically looking for wheezes or rales.
Make sure you get everything you need before garbing up and entering the room. Bring with your IV equipment and blood tubes, vital sign hookups if not already in the room, any medications already ordered, a COVID nasopharyngeal swab, etc.
If the patient may be discharged and an ambulatory pulse ox might be ordered – might as well get them up and walk them around the room while recording their SPO2. This is using your nursing judgment to anticipate orders. Let’s face it – not all Providers are great about putting in every order at the same time (guilty!).
Don’t take your N95 for granted, because they’re running out! At least, that was the worry when this pandemic started and is definitely a possibility if infections and hospitalizations continue as they have been in the US.
However, we can’t afford to be wasteful. Before COVID, we would use an N95 like a surgical mask – apply it when taking airborne precautions, and removing it upon leaving the room. This life of luxury is no more.
Many hospitals have decontamination protocols for N95s – where they decontaminate them in some capacity. However, not every hospital will do this. If needed, there are multiple ways that you can decontaminate your N95 yourself using the following COVID nursing tips.
No, really – throw that N95 in the oven! Baking with dry heat at 75° C (167° F) for 30 minutes effectively kills Sars-COV-2. Researchers at Stanford found that this can be done for 20 cycles without significantly reducing the filtration efficiency. Other studies indicated that only 2 cycles proved safe.
Hang the N95 from the oven rack with a wooden paperclip, or place an oven-safe fabric on a metal sheet. Do not place the N95 directly on the metal as this can overheat the mask.
COVID has been found to survive on hard surfaces for 48 hours, plastic for 72 hours, and cardboard for 24 hours. While scientists aren’t 100% sure on the specifics of covid spread via surfaces, they do know that COVID doesn’t spread much through touch.
An alternative method to decontaminating your N95 is to leave it in a safe, warm, dry area and allow it to “air-dry” for 3-4 days. Placing it in a paper bag may be useful for this. This will kill the coronavirus without degrading the filter.
If you have three or four N95s, you can start a rotation cycle and effectively never run out of N95s.
Please note this does not appear to be a well-studied decontamination procedure and is solely based on theory.
There are other methods to decontaminate your N95, including moist heat, UV radiation exposure, boiling, and even steaming. These all kill COVID but degrade the N95 at varying rates, and are likely more difficult to perform while at home.
If the idea of having to decontaminate and then reuse your N95 does not fit your desires – you can always skip this COVID nursing tip and buy a reusable N95 Device.
They do make reusable N95 devices which are somewhat affordable and probably worth it.
Using a reusable N95 is more comfortable, less of a hassle, and can leave you feeling more protected.
Envo Mask is all the rage in my ER, and for good reason. This reusable N95 is comfortable and won’t fog your goggles. There are replaceable filters that you use, making this usable forever (but hopefully COVID won’t last forever too).
You can also buy a respirator, which can be cheaper depending on which one you get. If you do, you need to make sure you buy the appropriate filter though, as many of these respirators were intended to be used for occupational exposure. The 2091 filter is recommended by the CDC.
Please be aware it can be somewhat difficult to speak to people with a respirator on, as they can have a hard time hearing. This can be especially difficult over the phone.
We’ve all seen those horrid photos of nurses who worked 12+ hours in an n95 mask, with deep facial markings to prove it. Many of us have experienced this firsthand.
You shouldn’t only worry about your patient’s skin breakdown. Wearing an N95 for 12 hours straight can cause your own skin-breakdown, and it can be very irritating, painful, and eventually lead to open wounds. There are a few different COVID nursing tips regarding your skin protection that can help!
To minimize skin breakdown, frequent removal of the N95 is recommended. However, with the COVID pandemic among us – that is not always feasible.
If able to safely remove your N95, the recommendation is to take a 15-minute break every 2 hours. For the vast majority of us, this just won’t work.
Probably one of the safest options, you can apply a liquid skin protectant onto your skin. Once applied and allowed to dry, this creates a protective barrier that minimizes moisture and friction.
Any skin protectant should work, and skin repair creams with dimethicone can also be effective. Apply it over the areas where the N95 will cause the most skin breakdown (nasal bridge, cheeks, behind ears). Avoid getting the product in your eyes or mouth.
Good skin protectants to use:
Make sure to always allow the product to fully dry before applying your N95.
If skin protectant doesn’t do the trick – you can try a protective dressing.
The issue with protective dressings is they can alter the fit of the N95. Unfortunately, that could mean catching COVID. This is why skin protectant is a safer option. Still – if your skin really needs it – you can likely put a protective dressing in a safe manner.
Cut a thin dressing into small pieces, and apply a thin layer to the nasal bridge, the cheekbones, and behind the ears.
You should use a foam dressing that has a non-permeable outer layer, so any hydrocolloid dressing should work well. A good example is the Duoderm Hydrocolloid Dressing.
You should attempt to confirm the N95 fit by blowing out and seeing if there are any leaks. Definitive fit testing can also be done and is more accurate, although may not be feasible on the unit.
Even with using our N95s, we are still recommended to be using a surgical mask on top of that. This prevents soiling of the N95 mask and adds that extra layer of protection for splashes.
Unfortunately, surgical masks wrap around your ears and they can lead to skin breakdown of your ears and just hurt.
There are scrub caps and headbands with buttons sowed on which you can loop the surgical mask onto, which takes the pressure off of your ears entirely.
They also make plastic devices that connect both sides and loop around the back of your neck. You can even MacGyver your own version with some rubber hands and/or paper clips.
No – wearing a mask won’t give you hypercarbia… But it can give you hyper-halitosis. If you have bad breath – you’ll definitely notice it now. Sure, bad breath won’t kill you, but it’s just not fun to be breathing in for 12 hours.
Working 12-hour shifts without time for water breaks will cause dry mouth and will increase the odor of your breath as well!
One easy fix is to buy some gum. This leaves your breath smelling minty and fresh. If you’re someone who needs more help for your halitosis, you can try special toothpaste or special mouthwash.
Make sure you are able to stay hydrated. Drink plenty of water before your shift (not that you’ll have much time to pee). Try to take a few breaks throughout the shift just to drink some water and stay hydrated.
No – I’m not talking sex-ed. I’m talking about your smartphone!
Let’s be real, we all bring our phones to work. No, we probably don’t have time to scroll Instagram (follow me!), but we occasionally check the time and maybe our messages.
I personally use multiple apps on my phone throughout my shift to help with antibiotic selection or to reference something related to patient care.
The problem is, we don’t want to contaminate our phones with COVID or who knows what else.
One simple COVID nursing tip is to bring a Ziplock baggie to work that your phone easily fits in. Ziplock it shut. Your touch screen actually works through the ziplock bag!
You could also just leave your phone at home – but if that doesn’t give you anxiety thinking about it, then something is wrong with you.
If you risk it and just use your phone while at risk, you should know how to decontaminate your phone. Pro Tip: Don’t put your phone in the oven like the N95!
After a long shift working with COVID patients ALL day (or night), there is nothing you probably want more than to get home and crawl in bed. But you are also aware of all the NASTINESS on your body, scrubs, and everything else you’ve touched.
You need to have a procedure for how you clean yourself and your items. The last thing you want to do is infect members of your household!
Leave anything items you can at work, like your stethoscope, scissors, pens, penlights, etc. If you have a locker – use that!
Make sure you carry hand sanitizer in your car. Use it immediately once you get in before touching the steering wheel. Do not touch your face now that you are maskless.
Once you get home, find a way to strip quickly without touching anybody or anything. I put anything in my pockets (like my phone) on the island counter. I put my clothes directly in the washing machine. Take an immediate shower with hot water and plenty of soap.
After this, I personally go through and wipe down everything I touched including the doorknob, the bathroom door, etc with a disinfectant. I then wipe down all the items I had placed on the island counter. You can use clorox wipes, lysol wipes, but I personally use Original Pine-sol which kills COVID within 10 minutes (THAT’S the power of Pine-sol baby).
Other related content:
As always you should ALWAYS be following hospital policy and procedures whenever implementing any of these COVID nursing tips. This is an unconventional time, so there may not be much oversight regarding infection control practices, but make sure anything you do is safe for you and your patients.
Comment down below your COVID Nursing tips!
COVID risk and statistics
Sustainability of Coronavirus on Different Surfaces
Covid Skin Breakdown:
NPIAP position statement on preventing injury with N95 mask
COVID Decontamination:
Assessment of N95 respirator decontamination and re-use for SARS-CoV-2
Respirator:
Early sepsis– while not clearly defined – is the presence of infection and bacteremia – which can and likely will progress to sepsis without intervention. Sepsis used to be identified using SIRS criteria– Systemic Inflammatory Response syndrome. This syndrome is defined as the presence of at least 2 of the following 4 clinical indicators: Fever >38C or <36C, HR >90bpm, RR > 22/min or PaCO2 <32 mmHg, or WBC >12,000/mm3, <4,000/mm3, OR 10% BANDS. Once SIRS is identified with suspected source of infection – sepsis diagnosis was met. However, the definition of sepsis has changed with 2016. Sepsis is now is defined as life-threatening organ dysfunction in response to infection. Organ dysfunction, usually from hypoperfusion, can be evidenced by hypotension, altered mental status, tachypnea, or increased sofa score by 2 points (see below). Septic shockis defined as those patients who have received fluid resuscitation and still have a MAP <65 mmHg and a lactic >2.0 mmol/L. These patients require vasopressors and should be monitored in the ICU.
Sepsis can be very serious and even fatal. Because of this – it is important to kn ow the steps to take in sepsis management. Performing these correct steps can literally mean the difference between life and death.
The most important aspect of sepsis management is recognizing it’s presence and acting quickly. Common symptoms of sepsis include fever, chills, sweats, and confusion. Common signs include altered mental status, elevated temperature, tachypnea, tachycardia, and hypotension.
Initial management should include investigating the extensiveness of their infection, and applying initial measures to help them. After vital signs are taken an IV should be established and lab work drawn. If the patient’s blood pressure is low – consider starting 2 large-bore IVs. Be sure to draw at least 1 set of blood cultures per IV site (up to 2) as this will need ordered in all sepsis patients. Make sure the blood cultures get drawn before antibiotics are started.
Diagnostics should investigate the source of the infection – sometimes it is not obvious. If unsure – it is a good idea to obtain a urinalysis with culture to r/o UTI and a Chest x-ray to r/o pneumonia should be ordered. A wound culture, sputum culture, or abdominal imaging may be ordered if clinically indicated. Blood work will usually include blood cultures x 2, CBC with differential, CMP, and a lactic acid level. Sometimes in severe cases, an ABG can be ordered to evaluate acid-base status.
Lactic acid levels are very important in sepsis. Lactate is released from cells when they are forced to utilize glycolysis instead of the Kreb’s cycle (throwback to Cell Biology!). This means that there is decreased tissue perfusion due to decreased volume, increased oxygen demand, and decreased oxygen delivery. Lactic levels correlate with severity of sepsis.
Apply oxygen at 2 L/min unless contraindicated – titrate if SPO2 <92%. During sepsis, oxygen demand increases and delivery diminishes. Supplemental oxygen will help put less stress on the body and may help diminish lactic acidosis.
The qSOFA (Quick Sequential Organ Failure Assessment) score is now starting to be used as a clinical tool for sepsis. This is usually used within the hospital to stratify the mortality of patients with sepsis (see infographic for more details).
Fluid resuscitation during sepsis is the staple of sepsis management. Evidence shows early fluid intervention decreases mortality. There is such a massive need for fluid because during sepsis there is poor tissue perfusion and often hypovolemia. To correct this – large amounts of fluids are needed.
Typically, 0.9% normal saline is used 9 times out of 10. The recommended standard volume is a 30 ml/kg bolus. So if a patient was 70 Kg, they would receive 2100 ml total. This should be given as quickly as possible – as tolerated. This amount is typically given to anybody recognized as possibly having sepsis, but is especially indicated in those with sever sepsis, fast heart rate, or low blood pressure. Traditionally even larger amounts of fluids were given (5-6 Liters), but several randomized control trials showed no difference in mortality compared with the now-recommended 2-3 Liters.
Exceptions to receiving this bolus includes those with active pulmonary edema. Those with a history of Heart Failure, end-stage renal disease, or severe liver disease should still receive fluids. However – it is recommended to give fluids in 500mL bolus increments and to reassess lung sounds and breathing status after each bolus. If pulmonary edema ensues – the bolus should be stopped and the patient may need diuretics.
Another very important aspect of sepsis management is early antibiotics. The term empiric simply means antibiotics based on the best “clinical guess”.
The choice of empiric antibiotics will be selected based off of the patient’s signs or symptoms and where the likely source – since certain organisms are more likely from one source as opposed to another. This means the antibiotic regimen should be geared towards covering all likely gram-positive and gram-negative organisms. For sepsis – usually a broad spectrum antibiotic like Zosyn or a Carbapenem is combined with another antibiotic of a different lass – such as Vancomycin. Vanco is often added when the patient has risk factors for MRSA.
Correct regimen of antibiotics are important – however timely administration of those antibiotics are just as important. Antibiotics should be initiated within the first hour after suspecting sepsis – especially during severe sepsis or septic shock. This is because several observational studies have shown poorer outcomes with delayed antibiotic initiation. Once again, try to be sure you obtain both sets of blood cultures before you start the antibiotics!
As nurses, it is often up to you to choose which antibiotic to start first as both are often ordered concurrently. If you have both Zosyn and Vancomycin ordered – start with the broad-spectrum antibiotic first. But what exactly is broad-spectrum? This means heavy-hitter antibiotics that cover most pathogens – both gram positive and negative. Contrary to popular belief – vancomycin is NOT broad-spectrum. In fact, it has a very narrow spectrum specific for gram positive organisms such as Staph or Strep. Most cases of sepsis are from gram negative sources. This means starting the Zosyn first should be your priority. Additionally – Zosyn runs much quicker as a loading dose (4.5 grams over 30 minutes) – whereas vancomycin usually runs over 1.5 hours.
Sometimes when sepsis becomes severe – distributive shock can occur. This is termed septic shock. When this occurs – hemodynamic compromise is present. If blood pressure remains low, the patient’s tissue perfusion continues to suffer and steps need to be taken to improve outcomes.
The patient may require more fluid if they are still hypovolemic after the initial bolus and can tolerate more fluids. However, the mainstay of treatment of septic shock is intravenous Vasopressors. For the most part – Norepinephrine (Levophed) is the go-to pressor for sepsis. However, other choices can be chosen based on clinician discretion (i.e. If very tachycardic consider Vasopressin which has no beta stimulation). Sometimes, multiple vasopressors may need to run concurrently to manage septic shock.
When a patient is in septic shock with hemodynamic compromise – they should have a central venous catheter inserted and/or an arterial line. Vasopressors can be started in a peripheral line, but a central line should be ordered as vasopressors can be caustic and damaging to the peripheral vasculature. Additionally, these catheters can monitor CVP and continuous blood pressures. If a patient is in cardiogenic shock and has inadequate cardiac output – cardiac inotropes can be added such as dobutamine or epinephrine.
Sometimes during severe septic shock, IV glucocorticoids may or may not help. Usually this is ordered if fluid resuscitation and vasopressors have failed.
Monitoring is the essential last step to sepsis management. Patient’s with sepsis can respond well to the regimen – or they can decompensate unexpectedly. Sepsis has a high mortality and the patient’s should be monitored very closely.
If the patient has any hemodynamic compromise and are on pressors – they should be monitored in the ICU for a few days until they become stable. Patient’s with mild to moderate sepsis should be closely monitored on a med-surg or telemetry floor. Continuous cardiac monitoring is essential during sepsis. The increased tissue demand for oxygen places the heart at a greater risk for having cardiac events secondary to the sepsis. It is not uncommon for someone with sepsis and cardiac comorbidities to have secondary myocardial ischemia and/or infarctions.
Blood pressure should be monitored closely – especially initially. Normotensive blood pressure should be maintained (SBP >100). However – maybe even more importantly the MAP (mean arterial pressure) should be monitored closely. The goal of MAP should be >65mmHg – this ensures adequate tissue perfusion (i.e. brain). Heart rate is also an important metric to monitor. Tachycardia is usually present – often in the 120s-130s during fever and sepsis – sometimes higher. While giving fluids – heart rate should improve. This can be somewhat helpful in monitoring the response of fluid therapy. Fever should be monitored as well – as sometimes it can become very high and increases insensible water losses and further propitiates hypovolemia. Remember a rectal temperature is preferred in those with suspected sepsis – especially the elderly. Urine output is also often monitored during severe sepsis – as secondary hypoperfusion of the kidneys can cause acute kidney injury and decreased urine output.
Nursing assessments should include skin color and perfusion, mucous membranes (i.e. dry vs moist), mental status, and heart/lung sounds. Nurses should be vigilant in recognizing flash pulmonary edema or cariogenic shock which may develop after rapid administration of fluids with underlying comorbidities (i.e heart failure, ESRD, etc).
If the initial lactic acid level is elevated > 2 mmol/L, then a repeat level should be drawn in 4 – 6 hours. The lactic acid level should respond quickly to changes in tissue perfusion. CBC should be trended each day to monitor for resolution of the leukocytosis, bandemia, and/or thrombocytopenia. Electrolytes and kidney/liver function should also be monitored closely dpeneding on which abnormalities are present.
Last but certainly not least – the patient needs to be sent to the correct unit, needs the correct consults, and needs adequate follow-up. Almost all patients admitted to the hospital with sepsis will warrant an Infectious Disease consultation. Additionally, if they have any pre-existing comorbidities these consults should be made as well (i.e. cardiology for heart failure, nephrology for kidney disease).
Patients should have frequent nursing assessments and daily physician assessments, with close follow-up of labs. Blood cultures can start showing growth at about 24 hours. The pathologist will gram-stain the growth and give a report of “gram positive cocci” a similar description. This tells the clinician if they are on the right track and can guess at the offending organism. At about 48 hours, most clinically significant bacteria will be identified and a sensitivity is done to detect the bacteria’s sensitivity vs resistance to various antibiotics. Urine, wound, and sputum cultures have similar timelines. Antibiotics may be changed depending on the results. Remember, Infectious Disease should likely be involved in this decision.
And those are the six steps to sepsis management. Knowing the general steps to sepsis can help you as the nurse provide high quality care to your septic patients and help improve outcomes. As always, it is a collaborative team effort in offering you patients the best possible care.
Do you have any other sepsis tips? leave them in the comments below!
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