ð Scanned to Pharmacy STAT
DATE ___/ ___ /___ TIME:
Signature______
1. Could it be an infection?ð No / ð Yes
2. Could it be sepsis?
Are 2 boxes checked at right? / ð Fever > 100.4
ð Hypothermia < 96.8
ð Tachycardia > 90 bpm / ð Tachypnea RR > 20
ð Chills/rigors
ð Weakness/malaise
ð No / ð Yes
3. Is the patient high risk for severe sepsis?
ð No / ð Yes
Is any box checked at right? / ð Age > 50
ð Immunocompromised
ð Recent Chemotherapy, Cancer
ð Diabetic
ð Hypoxia <93% on room air / ð Chronic Kidney Disease
ð Chronic Liver Disease
ð Acutely altered mental status
ð Hypotension or relative hypotension (SBP 40 mmHg decrease from usual)
Implement ANI Orders (back page)
ED Severe Sepsis Screen & ANI Orders
Page 1 of 2 Revised 9/8/10
ð Scanned to Pharmacy STAT
DATE ___/ ___ /___ TIME:
Signature______
· MD notified immediately for patient positive for severe sepsis screening. Time: ______
· Obtain complete set of vital signs and document on ED record.
· Continuous EKG monitoring.
· Continuous pulse oximetry monitoring.
· Oxygen to keep SpO2 > 95%
· Establish large bore IV at TKO rate
o For systolic blood pressure <90 mmHg, infuse 2 liters Normal Saline IV over 30 minutes (Critical Action)
· Labs/Diagnostic tests – Call lab for STAT draw
o Lactate
o Complete metabolic panel
o CBC with differential
o Blood cultures x2
o UA and Culture: I+O cath if patient unable to provide sterile specimen
o PT + PTT
o Portable chest x-ray
· For Fever ( >38.9 C O or >39.5 C R):
o Tylenol 1 gram orally or 650 mg rectally (in patients >65 kg.)
· For Nausea:
o Zofran 4 mg ODT x 1 dose
· Anticipate antibiotic orders & administer immediately after 2 blood cultures drawn.
· Anticipate Central Line Placement with CVP and ScvO2 monitoring.
· Document interventions on “Severe Sepsis Initial Actions Checklist”.
RN’s SignatureDate :
Time :