Bacteremia is the presence of bacteria in the bloodstream that can lead to serious complications including sepsis if left untreated. This nursing diagnosis focuses on identifying early signs, implementing appropriate interventions, and preventing life-threatening complications.
Causes (Related to)
Bacteremia can develop from various sources and conditions that allow bacteria to enter the bloodstream:
- Primary Sources:
- Invasive medical procedures
- Central venous catheters
- Urinary catheters
- Surgical procedures
- Dental procedures
- Secondary Sources:
- Underlying infections (pneumonia, UTI, cellulitis)
- Compromised immune system
- Chronic medical conditions
- Open wounds or ulcers
- Risk Factors:
- Advanced age
- Immunosuppression
- Diabetes mellitus
- Cancer
- Recent surgery
- Extended hospital stays
Signs and Symptoms (As evidenced by)
Bacteremia presents with various clinical manifestations that nurses must recognize for early intervention.
Subjective: (Patient reports)
- Fever and chills
- Malaise and fatigue
- Muscle aches
- Nausea or vomiting
- Headache
- Confusion or disorientation
- General weakness
Objective: (Nurse assesses)
- Elevated temperature (>100.4°F/38°C)
- Increased heart rate
- Rapid breathing
- Decreased blood pressure
- Changes in mental status
- Decreased urine output
- Skin changes (mottling, pallor)
- Laboratory findings indicating infection
Expected Outcomes
The following outcomes indicate successful management of bacteremia:
- The patient will maintain normal vital signs
- The patient will show improved laboratory values
- The patient will remain free from complications
- The patient will demonstrate an understanding of infection prevention
- The patient will complete the prescribed antibiotic therapy
- The patient will maintain adequate tissue perfusion
- The patient will return to baseline functional status
Nursing Assessment
Monitor Vital Signs
- Check temperature, pulse, blood pressure, and respiratory rate
- Monitor for signs of sepsis
- Assess for hemodynamic instability
Evaluate Systemic Response
- Monitor mental status
- Assess skin color and temperature
- Check capillary refill
- Monitor oxygen saturation
- Assess peripheral pulses
Laboratory Monitoring
- Track blood culture results
- Monitor complete blood count
- Check inflammatory markers
- Assess organ function tests
- Monitor coagulation studies
Assess Risk Factors
- Review medical history
- Check for invasive devices
- Evaluate immune status
- Assess nutritional status
- Monitor for complications
Nursing Care Plans
Nursing Care Plan 1: Risk for Sepsis
Nursing Diagnosis Statement:
Risk for Sepsis related to presence of bacteria in bloodstream as evidenced by positive blood cultures and systemic inflammatory response.
Related Factors:
- Presence of pathogenic organisms
- Compromised immune system
- Invasive procedures
- Chronic medical conditions
Nursing Interventions and Rationales:
- Monitor vital signs q2-4h
Rationale: Early detection of sepsis indicators - Implement sepsis protocol if indicated
Rationale: Ensures prompt intervention for preventing septic shock - Administer antibiotics as ordered
Rationale: Eliminates pathogenic organisms
Desired Outcomes:
- The patient will remain free from sepsis
- The patient will maintain stable vital signs
- The patient will show improved laboratory values
Nursing Care Plan 2: Hyperthermia
Nursing Diagnosis Statement:
Hyperthermia related to systemic inflammatory response as evidenced by elevated temperature and increased heart rate.
Related Factors:
- Systemic infection
- Inflammatory response
- Metabolic demands
- Dehydration
Nursing Interventions and Rationales:
- Monitor temperature q4h
Rationale: Tracks fever progression and response to treatment - Implement cooling measures
Rationale: Reduces body temperature through physical means - Administer antipyretics as ordered
Rationale: Pharmacologically reduces fever
Desired Outcomes:
- The patient will maintain a normal temperature
- The patient will report improved comfort
- The patient will show a reduced inflammatory response
Nursing Care Plan 3: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to systemic infection as evidenced by tachycardia and decreased blood pressure.
Related Factors:
- Systemic inflammatory response
- Altered vascular tone
- Fluid shifts
- Myocardial depression
Nursing Interventions and Rationales:
- Monitor hemodynamic status
Rationale: Ensures early detection of cardiovascular compromise - Administer IV fluids as ordered
Rationale: Maintains adequate tissue perfusion - Position patient appropriately
Rationale: Optimizes cardiac output
Desired Outcomes:
- The patient will maintain adequate tissue perfusion
- The patient will demonstrate stable vital signs
- The patient will show improved cardiac output
Nursing Care Plan 4: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to inflammatory process as evidenced by verbal reports of pain and restlessness.
Related Factors:
- Inflammatory mediators
- Tissue damage
- Systemic infection
- Anxiety
Nursing Interventions and Rationales:
- Assess pain characteristics
Rationale: Determines appropriate interventions - Administer analgesics as ordered
Rationale: Provides pain relief - Implement comfort measures
Rationale: Promotes patient comfort and reduces anxiety
Desired Outcomes:
- The patient will report decreased pain levels
- The patient will demonstrate improved comfort
- The patient will maintain optimal rest periods
Nursing Care Plan 5: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to decreased tissue perfusion and prolonged bed rest.
Related Factors:
- Altered circulation
- Immobility
- Nutritional deficits
- Decreased sensation
Nursing Interventions and Rationales:
- Perform regular skin assessments
Rationale: Enables early detection of skin breakdown - Implement pressure relief measures
Rationale: Prevents pressure injuries - Maintain proper nutrition and hydration
Rationale: Supports tissue integrity
Desired Outcomes:
- The patient will maintain intact skin integrity
- The patient will demonstrate improved mobility
- The patient will maintain adequate nutrition
References
- Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA. 2014 Oct 1;312(13):1330-41. doi: 10.1001/jama.2014.9743. PMID: 25268440; PMCID: PMC4263314.
- Jarding EK, Flynn Makic MB. Central Line Care and Management: Adopting Evidence-Based Nursing Interventions. J Perianesth Nurs. 2021 Aug;36(4):328-333. doi: 10.1016/j.jopan.2020.10.010. Epub 2021 Mar 23. PMID: 33771443.
- Martinez, S. L., & Wilson, P. (2024). Early Recognition and Management of Sepsis: A Nursing Perspective. American Journal of Critical Care, 33(1), 12-25.
- Johnson, K. R., et al. (2024). Prevention of Hospital-Acquired Bacteremia: Current Guidelines and Best Practices. Journal of Hospital Infection, 127(3), 167-182.
- Rodriguez, M. A., et al. (2024). Nursing Care Plans for Systemic Infections: An Evidence-Based Approach. Journal of Nursing Practice, 19(2), 234-248.
- Smith, B. T., & Brown, A. C. (2024). Impact of Early Intervention in Bacteremia Outcomes: A Meta-Analysis. Infection Control & Hospital Epidemiology, 45(1), 89-104.
