Table 2 Clinical nursing pathway form of sepsis shock cluster treatment

Indicators to be completed

^aVital signs monitoring

^aEvaluate the condition and implement emergency medical orders, such as endotracheal intubation

^aTwo fluid routes were established with indwelling needle ≤ 22G, and central venous access was established with doctors

^aInvasive blood pressure monitoring by puncturing artery

^aCollect all kinds of samples, especially blood gas, and measure the concentration of lactic acid

^aIndwelling catheter to observe urine volume

^aBlood culture before antibiotic treatment

^aThe patients were treated with broad-spectrum antibiotics

^aPatients with hypotension or lactic acid ≥ 4 mmol/L were given 30 ml/kg crystal solution according to the doctor’s advice

^aThe project is not completed within 1 h, especially

^bMeasurement of lactic acid concentration

^bBlood culture was performed before antibiotic treatment

^bGive broad-spectrum antimicrobial therapy

^bLow blood pressure or lactic acid ≥ 4 mmol/L was given 30 ml/kg crystalloid solution for target resuscitation

^aThe color, character and quantity of gastric juice were observed by indwelling gastric tube

^aBlood glucose measurement

^aMethods to prevent DVT, such as pneumatic therapy, subcutaneous injection of low molecular weight heparin, etc

^aTreatment and nursing of primary disease

^aObservation and nursing of sedation and analgesia

^aCluster nursing of ^aCRBSI

Cluster nursing of VAP

^aCluster nursing of CAUTI

^aProject not completed within 3 h

^aGive pressor

^aMeasure CVP

^aMeasure ScvO₂

^aRepeated measurement of lactic acid level