Manajemen Asuhan

Keperawatan pada Pasien

Sepsis
Yunisar Gultom, SKp., MClNsg.

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 TUJUAN

Setelah mengikuti materi ini, peserta mampu:

• Memahami mengenali sejak dini tanda dan gejala klinis pasien sepsis dan syok sepsis
• Memahami patofisiolgi terjadinya sepsis
• Memahami peran perawat dalam perawatan pasien sepsis
• Memahami pencegahan terjadinya syok sepsis

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Studi Kasus Sepsis
Bapak T, 81 tahun, dengan riwayat sakit jantung dan hipotensi sejak usia 55 tahun (26 tahun yang lalu)
dan sejak itu berhenti merokok masuk ke ruang rawat inap melalui IGD. Pasien dibawa ke IGD dengan
keluhan merasa sangat lemas dan demam, batuk, pilek sejak 2 hari sebelum ke IGD, ada menggigil sejak 1
hari yang lalua. Di rumah sudah minum paracetamol 1 tablet (500 mg). Pasien juga mengeluh mual dan
muntah (sekitar 3 kali), makan hanya 2 -3 sendok makan dan minum sedikit-sedikit karena perut terasa
begah, dan susah b.a.b sejak 7 hari sebelum ke IGD.
Kesadaran pasien gelisah, TD 90/55 mmHg, Nadi 110 x/mnt, Pernafasan 28 x/mnt, Suhu tubuh 39, 1⁰C,
Saturasi O2 94% (room air). Capillary refill time > 2 tetik, Turgor kulit buruk (tidak elastis), akral teraba
dingin.
Ureum 29.3 mg/dL SGOT 22 U/L
Hasil laboratorium:
Creatinin 1.40 Mg/dL SGPT 23 U/L
Hemoglobin 15.1 g/dL
Natrium (Na) Darah 123 mEq/L CRP-Quantitative 288.5 mg/L
Hematokrit 41.7 %
Kalium (K) Darah 3.9 mEq/L Prokalsitonin 0.84 ng/mL
Jumlah Trombosit 182 10^3/µL
Klorida (Cl) Darah 91.9 mEq/L d-Dimer
Jumlah Leukosit 19.47 10^3/µL 6710 ug/L
Kuantitatif
9/22/2021 Yunisar Gultom, SKp., MClNsg.
Hasil radiologi:
Thoraks PA:
Infiltrat minimal di lapangan bawah paru kanan, suspek pneumonia DD/ corakan bronkovaskular yang
kasar.
Ukuran jantung tidak membesar.

Abdomen 3 posisi:
Fekal material prominen.
Tidak tampak gambaran ileus maupun pneumoperitoneum

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Pengertian Sepsis
Sepsis didefinisikan sebagai adanya (kemungkinan ataupun terbukti)
infeksi bersamaan dengan manifestasi infeksi sistemik.

Sepsis berat (severe) adalah kondisi sepsis disertai dengan disfungsi organ
atau hipoperfusi jaringan yang disebabkan oleh sepsis.

(Dellinger, R Philip et al. 2012)

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 FAKTOR RESIKO

• Malnutrisi
• Imunosupresi
• Komorbid
• Riwayat penggunaan antibiotic dalam waktu lama
• Terpasang alat-alat invasive (akses vena sentral, kateter urin, ETT)
• Usia (balita dan lansia)

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Patofisiologi Sepsis

Sintesa nitrit oxide

Hipotalamus
Vasodilatasi
Marginasi neutrofil, Agregasi trombosit
Febris DIC dengan thrombosis klinis dan/ atau
Takikardia pendarahan  Deplesi volume intravaskular
Takipnea

Asidosis laktat
Hipoksia selular
Resistensi vascular sistemik rendah
9/22/2021 Yunisar Gultom, SKp., MClNsg.
 PENGKAJIAN
Pengkajian umum:
Demam (> 38.3°C)
Hipotermia (temperature inti < 36°C)
Heart rate > 90 kali/menit atau lebih tinggi 2 kali dari nilai normal kelompok usianya
Takipnea
Perubahan status mental
Edema atau keseimbangan cairan positif (> 20 mL/kg dalam 24 jam)
Hiperglikemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) tanpa ada riwayat diabetes

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 PENGKAJIAN (lanjutan)
Variabel Inflammasi:
Leukocytosis (Lekosit > 12.000 )
Leukopenia (Lekosit < 4000)
Hitung Lekosit Normal dengan > 10% bentuknya immature
Plasma C-reactive protein (C-RP) 2 kali atau lebih di atas nilai normal
Plasma Procalcitonin (PCT) 2 kali atau lebih di atas nilai normal

Variabel Hemodinamik:
Arterial hipotensi (TD sistolik < 90 mmHg, MAP < 70 mmHg, or an TD sistolik menurun > 40
mmHg pada orang dewasa atau lebih rendah dari normal usianya)

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 PENGKAJIAN (lanjutan)
Variabel disfungsi organ:
Arterial hipoksemia (PaO2/FiO2 < 300)
Acute oliguria (urine output < 0,5 mL/kg berat badan/jam selama minimal 2 jam meskipun
resusitasi cairan cukup)
Creatinine meningkat > 0.5 mg/dL)
Coagulasi tidak normal (INR > 1,5 atau aPTT > 60 detik)
Ileus (tidak adanya bising usus)
Thrombocytopenia (trombosit < 100.000 μL)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL)
Variabel perfusi jaringan:
Hyperlactatemia (> 1 mmol/L)
Penurunan capillary refill (> 2 detik) atau adanya bintik-bintik di bawah kulit
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(Dellinger, R Philip et al. 2012)
 SEQUENTIAL ORGAN FAILURE ASESSESSMENT (SOFA) SCORE – SEPSIS
RELATED
SYSTEM ORGAN SCORE
0 1 2 3 4
Respiration > 400 < 400 < 300 < 200 with respiratory < 100 with
PaO2/FiO2mmHg support respiratory respiratory support
support respiratory support
Coagulation > 150 < 150 <100 <50 <20
Platelets, x 10³ /μL
Liver < 1.2 1.2-1.9 2.0-5.9 6.0-11.9 > 12.0
Billrubin, mg/dl
Cardiovascular MAP > 70 MAP < 70 Dopamine < 5 Dopamine 5.1-15 or Dopamine > 15 or
mmHg mmHg or dobutamine epinephrine < 0.1 or epinephrine > 0.1 or
(any dose) nor-epinephrine < 0.1 norepinephrine > 0.1
Central Nervous System 15 13 - 14 10 - 12 6-9 <6
Glassgow coma scale
Renal
Creatinine, mg/dl < 1.2 1.2 - 1.9 2.0 - 3.4 35 - 4.9 >5.0
Urine output ml/day < 500 < 200
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 qSOFA (QUICK SOFA) CRITERIA

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Diagnosa Keperawatan pada Kejadian Sepsis

• Gangguan pertukaran gas • Risiko perfusi gastrointestinal tidak

• Pola nafas tidak efektif efektif
• Hipovolemia • Risiko perfusi miokard tidak efektif
• Penurunan curah jantung • Risiko perfusi perifer tidak efektif
• Defisit nutrisi
• Ansietas • Risiko perfusi renal tidak efektif.
• Ketidakmampuan Koping Keluarga • Risiko perfusi serebral tidak efektif

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan pada Kejadian Sepsis
Tujuan:
 Mengendalikan infeksi
 Membalikkan respon-respon patofisiologi
 Memperbaiki metabolism tubuh
Pendekatan:
 Mengendalikan infeksi
 Membalikkan respon-respon patofisiologi
 Memperbaiki metabolism tubuh
9/22/2021 Yunisar Gultom, SKp., MClNsg.
 Care Plan pada Kejadian Sepsis
SURVIVING SEPSIS CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN 3 HOURS:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to
maintain a mean arterial pressure (MAP) 65 mmHg
6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or
initial lactate > 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)*
- Measure central venous oxygen saturation (ScvO2)*
7. Re-measure lactate if initial lactate was elevated*
*Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg,
ScvO2 of 70%, and normalization of lactate.
9/22/2021 Yunisar Gultom, SKp., MClNsg.
 Care Plan of Patients with Sepsis
Recognize those at risk
Identify patients at risk for developing sepsis
• Older adults
• lmmuno-compromised patients
• Patients undergoing surgical/invasive procedures
• Patients with indwelling catheters
• Mechanically ventilated patients

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Monitor for sepsis
Signs of infection including
• Fever or hypothermia, tachycardia, hypotension, tachypnea
• Altered mental state
• New compliant of pain
• Adventitious breath sounds, increased oxygen requirement, new infiltrate on radiograph
• Change in appearance of urine, pyuria, bacteria on urine culture
• Change In wound appearance or drainage
• Leukocytosis, thrombocytopenia on complete blood count (CBC)
• Elevated blood glucose

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Signs of impaired organ perfusion
• Hypotension, tachycardia, tachypnea
• Elevated serum lactate
• Skin mottling
• Change in capillary refill
• Change in renal function: drop in urine output, elevated creatinine and blood urea nitrogen (BUN)
• Change In liver function: elevated transaminases
• Change in dotting: bruising, bleeding, elevated international normalized ratio (INR)

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Collaborate with the healthcare team to Initiate Immediate resuscitation
• Circulatory support with fluids and vasopressors
• Empiric antibiotics
• Source control
• Monitor and report patient response to treatment

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Provide supportive care to patients with sepsis
• Frequent monitoring of hemodynamic status to determine patient response to treatment
• Avoid aspiration: provide semi or high fowler position, place NGT
• Use supplemental oxygen or lung protective mechanical ventilation as indicated
• Apply interventions in the ABCDEF bundle to prevent delirium
• Provide enteral nutrition to prevent malnutrition and lower the risk of bacterial trans location
• Give ulcer prophylaxis If risk factors for GI bleeding exist
• Administer pharmacologic or mechanical interventions to prevent venous thrombo-embolism (VTE)

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Patient/ Famlly-centered care
• Promote patient comfort, assess and treat pain, use a validated scale to guide the use of
sedation
• Assess patient/family understanding of diagnosis and prognosis
• Participate in discussions of goals of care with the healthcare team and with the
patient/family
• Limit the visitors

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 Care Plan of Patients with Sepsis
(lanjutan)
Sepsis prevention
• Hand hygiene
• Specific measures to prevent hospital-acquired infections include:
- Remove urinary catheters and central lines when no longer indicated
- Use aseptic technique when handling lines and catheters
- Facilitate weaning from mechanical ventilation through the use of spontaneous breathing
trials, appropriate use of sedation, and early mobility
- Adhere to transmission based precautions including the use of standard, contact, droplet and
airborne precautions as appropriate
• Educate members of the healthcare team on prevention and recognition of sepsis
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 CONCLUSION
 A large number of infections leading to sepsis in critically ill patients are acquired
during hospitalization and may be avoided with infection prevention tactics.

 Hand hygiene remains the single most effective method forpreventing the spread of
infection.

 Other measures such as meticulous mouth care to prevent ventilator-associated

pneumonia, prompt removal of urinary catheters, and aseptic technique when
handling central lines can help prevent sepsis in critically ill patients.

9/22/2021 Yunisar Gultom, SKp., MClNsg.

 DAFTAR PUSTAKA
Angus, Derek C & van der Poll, Tom. 2013, ‘Severe Sepsis and Septic Shock’, The New England Journal of
Medicine, August 2013, vol. 369, No. 9.
Barrier, Kendra M. 2018, ‘Summary of the 2016 International Surviving Sepsis Campaign: A Clinician’s
Guide’, Critical Care Nursing.
Dellinger, R Philip et al. 2012, ‘Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012’, Critical Care Medicine and Intensive Care Medicine, February
2013, Vol. 41, No. 2, pp.580-637
Grishaw, Julie. 2019, ‘Multisystem Problems’, AACN Essentials of Critical Care Nursing, 4th ed, New York:
McGraw-Hill.
Makic, MBF & Bridges, E. ‘Managing Sepsis and Septic Shock: Current Guidelines and Definitions’,
Advanced Journal Nursing, February 2018, Vol. 118, No. 2.

9/22/2021 Yunisar Gultom, SKp., MClNsg.

9/22/2021 Yunisar Gultom, SKp., MClNsg.
 DISCUSSION
1. What are this patient's risk factor for sepsis?
2. What clinical manifestations may be suggestive of sepsis?
3. Is his qSOFA positive?
4. What is the nursing diagnosis experienced by Mr. T?
5. What nursing interventions need to be performed for Mr. T?

9/22/2021 Yunisar Gultom, SKp., MClNsg.