Sepsis is when an infection, usually bacterial in nature, enters the bloodstream causing a systemic infection with an extreme immune response. Sepsis is life-threatening and requires early intervention to prevent septic shock which can lead to organ failure and death.
Sepsis often develops very quickly and has a high mortality rate if not recognized and aggressively treated. Infants and adults over age 65 are at the highest risk for developing sepsis along with those who have weakened immune systems or chronic conditions.
The Nursing Process
Most patients with sepsis are treated in the ICU but nurses in other units and specialties must be able to recognize and assess for signs of sepsis as a delay in treatment can be fatal. Nurses must also take care to prevent infection and sepsis with strict hand washing, PPE adherence, wound care, and sterile or aseptic techniques.
Nursing Care Plans Related to Sepsis
Risk For Infection Care Plan
Sepsis is a systemic infection and requires close monitoring of vital signs with prompt intervention. Nurses must recognize patients at risk for developing sepsis and prevent a worsening of their condition.
Nursing Diagnosis: Risk For Infection
Related to:
- Immunosuppression
- Multiple chronic comorbidities
- Compromised skin or tissue integrity
- Malnutrition
- Untreated/worsening infections (UTIs, cellulitis, pneumonia)
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will remain free of infection with vital signs and white blood count within normal limits
- Patient will display improvement in wound healing with no signs of infection such as redness, drainage, or odor
- Patient will identify interventions they can apply to prevent or reduce their risk of infection
Risk For Infection Assessment
1. Note signs and symptoms of sepsis.
Signs of sepsis are fever, tachycardia, tachypnea, chills, and an altered mental status. The nurse should monitor for abnormal vital signs and intervene to prevent sepsis.
2. Monitor lab work.
Lab tests indicative of sepsis include an elevated white blood count, C-reactive protein, and lactate levels.
3. Obtain specimens for culture.
To determine the source of the infection, the nurse may need to obtain blood for culture, urine specimens, and sputum samples.
Risk For Infection Interventions
1. Administer antiinfectives.
Prophylactic IV antibiotics may be administered to prevent infection. Broad-spectrum antibiotics may be used to kill the most common types of pathogens until a specific type of organism is identified through culture and sensitivity testing.
2. Hand hygiene.
Proper hand hygiene is the best intervention to prevent infection. Nurses must be vigilant about handwashing and patients should also be instructed when to perform hand hygiene and use hand sanitizer.
3. Discontinue unnecessary invasive lines.
IV lines, urinary catheters, vascular access devices, NG tubes, PEG tubes, drains, and mechanical ventilation are all possible sources that can lead to bloodstream infections. Lines should be assessed regularly for necessity and discontinued when they are no longer needed.
4. Promote skin integrity.
Patients often have decreased mobility while in the hospital which places them at risk for skin breakdown. Incontinence, poor nutrition and hydration, and any open wounds increase the risk of infection. Promote skin integrity by turning the patient every 2 hours, assisting with ambulation, and inspecting the skin every shift to monitor for impending or worsening skin breakdown.
Risk For Deficient Fluid Volume Care Plan
Sepsis worsening into septic shock causes a shift of fluids out of the intravascular space leading to hypotension requiring fluid resuscitation.
Nursing Diagnosis: Risk For Deficient Fluid Volume
Related to:
- Vasodilation
- Membrane permeability
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcome:
- Patient will maintain an adequate circulatory volume as evidenced by vital signs and urinary output within normal limits
Risk For Deficient Fluid Volume Assessment
1. Monitor for signs of fluid loss.
Septic shock will result in a rapid drop in blood pressure as the fluid shifts out of the intravascular space. The patient will display tachycardia, fever, and signs of dehydration such as poor skin turgor and dry mucous membranes.
2. Assess intake and output and weight.
Closely monitor intake (PO, IV) against urine output to check for imbalances.
3. Monitor for edema.
Fluid shifting into the interstitial space will cause edema in the tissues. The nurse can also monitor for general weight gain as this may also indicate third spacing.
4. Review lab values.
Changes in hemoglobin and hematocrit can point to a low fluid volume. Kidney failure will result in abnormal BUN and creatinine levels. Urine testing with a high specific gravity indicates dehydration and kidney damage.
Risk For Deficient Fluid Volume Interventions
1. Administer IV fluids.
Crystalloids (normal saline, lactated Ringers) are the initial choice for fluid resuscitation as they are readily available and cost-effective. Colloids (albumin, fresh frozen plasma) may also be necessary to administer as they will remain in the intravascular space better than crystalloids due to their larger molecule size.
2. Administer vasopressors.
Vasopressors (dopamine, norepinephrine) should also be used with fluids or when septic shock is persistent despite fluid resuscitation. Vasopressors restore and maintain blood pressure.
3. Monitor circulatory function.
Monitoring the heart rate and rhythm is essential to ensure organ function. The mean arterial pressure (MAP) is an important indication of perfusion. Respiratory function should be monitored through pulse oximetry and kidney function should be monitored through output measurement and lab values.
Hyperthermia Care Plan
An elevated body temperature is a normal and protective process in response to inflammation and infection. When body temperature is extremely elevated and prolonged it can cause serious damage and increase the risk of mortality.
Nursing Diagnosis: Hyperthermia
Related to:
- Dehydration
- Increased metabolic rate
- Inflammatory process
As evidenced by:
- Increased body temperature higher than normal range
- Flushed skin, warm to touch
- Tachypnea
- Tachycardia
- Confusion
- Seizures
Expected Outcomes:
- Patient will maintain body temperature within normal limits
- Underlying causes (infection) will be treated to prevent worsening hyperthermia
Hyperthermia Assessment
1. Assess temperature rectally.
Rectal thermometers are most accurate for monitoring core temperature.
2. Assess neurological status.
Hyperthermia that is not controlled can cause brain damage. An altered LOC, confusion, and seizures are symptoms of deterioration.
Hyperthermia Interventions
1. Provide a cool environment.
Keep the room temperature cooler, remove extra linens, and remove heavy or restrictive clothing.
2. Apply a cooling blanket.
A cooling blanket will reduce surface temperature. These should be monitored closely so as not to induce shivering, which will have an inverse effect.
3. Administer antipyretics.
Administer acetaminophen or other antipyretics to reduce fever.
4. Provide cool rags or a tepid bath.
Place cool rags around the groin or axillae which are areas of high blood flow, and provide tepid baths to increase heat loss by evaporation.
References and Sources
- Avila, A. A., Kinberg, E. C., Sherwin, N. K., & Taylor, R. D. (2016). The Use of Fluids in Sepsis. Cureus, 8(3), e528. https://doi.org/10.7759/cureus.528
- Curry, M. (n.d.). Nursing Interventions for Sepsis: Fluid Management. Nursing CE Central. Retrieved February 21, 2022, from https://nursingcecentral.com/lessons/fluid-resuscitation-in-sepsis-how-much-and-what-kind/#coursetop
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Friedman, B. (2020, July 1). Measuring Mean Arterial Pressure: Choosing the Most Accurate Method. Clinical View. Retrieved February 21, 2022, from https://clinicalview.gehealthcare.com/white-paper/measuring-mean-arterial-pressure-choosing-most-accurate-method
- Kalil, A., & Pinsky, M. R. (2020, October 7). Septic Shock: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved February 21, 2022, from https://emedicine.medscape.com/article/168402-overview#a1
- Peter Axelrod, External Cooling in the Management of Fever, Clinical Infectious Diseases, Volume 31, Issue Supplement_5, October 2000, Pages S224–S229, https://doi.org/10.1086/317516
- Scheeren, T.W.L., Bakker, J., De Backer, D. et al. Current use of vasopressors in septic shock. Ann. Intensive Care 9, 20 (2019). https://doi.org/10.1186/s13613-019-0498-7
- Septicemia. (n.d.). Johns Hopkins Medicine. Retrieved February 21, 2022, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/septicemia
- Treatment. (2021, March 25). Sepsis Alliance. Retrieved February 21, 2022, from https://www.sepsis.org/sepsis-basics/treatment/
- Urine specific gravity test – San Francisco. (2019, July 4). UCSF Health. Retrieved February 21, 2022, from https://www.ucsfhealth.org/medical-tests/urine-specific-gravity-test
