Nurses performance in early identification of sepsis: an integrative review

Abstract

Sepsis is a disease that occurs in response to an infection when it is not early diagnosed and treated, which can lead to septic shock, multiple organ failure and even death. To identify the main care of nurses and the early assessment of patients with sepsis in the Intensive Care Units. This is an integrative literature review by searching the virtual libraries Medline, Lilacs, PubMed research published in period 2014 to 2020. The main nursing care identified are: observation of heart rate; verification of CVP, venous oxygen saturation and arterial blood gases; monitoring tissue hypoperfusion – observing peripheral capillary refill, skin color and blood pressure; hypoxemia - continuous monitoring of SvpO2 and oliguria - daily fluid balance; perform blood culture collection and administration of antibiotics and vasoactive drugs according to protocol. Care must be optimized, based on scientific knowledge and constant updates, promoting competent and individualized care. There are many challenges during the process, which involve: restriction of nursing care in starting the three-hour package; difficulties in meeting antibiotic administration time due to delay in prescription or pharmacy delivery; delay in the response of the activated services (laboratory, pharmacy,) and delay in medical diagnosis.