Sepsis and Septic Shock Nursing Diagnosis Interventions and Care Plans

Sepsis and Septic Shock Nursing Diagnosis Care Plan NCLEX Review

Nursing Study Guide on Sepsis

Sepsis is a serious medical condition wherein the presence of an infection triggers the body to respond by releasing excessive amounts of chemicals to fight the infection.

This overwhelming response to the known or suspected infection can damage different organs and body systems.

If left untreated, sepsis may lead to septic shock, a life-threatening complication characterized by a dramatic drop in blood pressure levels.

Immediate treatment with antibiotics and intravenous fluids can help reverse sepsis and improve the chance of survival.

Signs and Symptoms of Sepsis

  • Chills
  • high fever or low body temperature (hypothermia)
  • Rapid heartbeat (tachycardia)
  • Low blood pressure levels (systolic BP of less than 100 mmHg)
  • Rapid breathing (tachypnea)
  • Lightheadedness due to low blood pressure
  • Skin rash or mottled skin
  • Confusion or delirium
  • Warm skin

And other signs of a known or a suspected infection may be present.

Causes and Risk Factors of Sepsis

Bacterial, viral, or fungal infections may lead to sepsis, but the most common causes of sepsis include pneumonia, digestive system infections, genitourinary infections, and bacteremia or bloodstream infection.

Patients who are at a higher risk for developing sepsis include:

  • Very young (less than 1 year old) and older patients
  • Pregnant women
  • Chronically ill and immuno-compromised patients (diabetes, kidney or lung disease, or cancer)
  • Have wounds, injuries, or invasive devices such as catheters or tracheostomy

Complications of Sepsis

  • Impaired blood flow. Sepsis may lead to a low blood supply, causing impairment and damage of the brain, heart, kidneys, and other vital organs.
  • Blood clot formation and gangrene. Blood clot may form in the organs as well as in the parts of the limbs. This can result to organ failure in the vital organs, or tissue death or gangrene of the peripheral parts of the body such as fingers, toes, arms, or legs.

Diagnosis of Sepsis

  1. Physical examination – to check for vital signs, especially hypotension and fever
  2. Blood tests – blood culture from two different sites to check for presence of infection; full blood count and biochemistry to check for liver and kidney function, electrolyte imbalance, and clotting problems; serum lactate acid levels
  3. Urinalysis, wound culture, and/or sputum- to check for any signs of infection in the urinary system, respiratory system, or in the wound/ burn area.
  4. Imaging – chest X-ray for a suspected lung infection; CT scan or MRI to view the body’s internal structures; ultrasound to visualize any infection in the body, especially in the ovaries or gallbladder.

Treatment for Sepsis

  1. Antibiotics. IV broad-spectrum antibiotics are the initial treatment of choice for sepsis because they kill a wide range of bacteria. Once the causative agent has been identified, then the physician may shift to the right type of antibiotics to treat the underlying infection.
  2. Intravenous fluids and vasopressors. Low blood pressure levels may require a bolus intravenous fluids and vasopressor to increase them and help stabilize blood circulation.
  3. Oxygen therapy. Patients with sepsis may develop low oxygen saturation levels, requiring oxygen therapy.
Septic Shock Pathophysiology

Nursing Care Plans for Sepsis

  1. Nursing Diagnosis: Hyperthermia related to sepsis secondary to severe pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

        Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

InterventionsRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.
Remove excessive clothing, blankets and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s hyperthermia secondary to sepsis. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.
Sepsis and Septic Shock Nursing Care Plan 1
  •  Nursing Diagnosis: Risk for Septic Shock

    Desired Outcome: The patient with establish normal vital signs, balanced input and output, and usual mentation.

InterventionsRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.
Start strict input and output monitoring. Measure the urine output hourly.Decreased urinary output is a sign of diminished renal perfusion, indicating damage to the kidneys due to sepsis.
Assess for changes of level of consciousness/ mentation.Decreasing level of consciousness indicate diminished cerebral perfusion and/or hypoxemia.
Administer intravenous fluid therapy. Administer vasopressors and inotropic agents as prescribed.To facilitate effective tissue perfusion and maintain circulatory blood volume. To maintain blood pressure level and help improve organ perfusion.
Place the patient on bed rest. Assist him/her with important activities of daily living or ADLs.To decrease myocardial workload and oxygen consumption.
Sepsis and Septic Shock Nursing Care Plan 2

3. Nursing Diagnosis: Deficient Knowledge related to diagnosis and need for emergency treatment as evidenced by patient’s verbalization of “I do not know what’s happening?”

Desired Outcome: The patient will be able to have sufficient knowledge of sepsis and its management.

InterventionsRationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits)To address the patient’s cognition and mental status towards sepsis and to help the patient overcome blocks to learning.
Explain what sepsis is, and how it affects the vital organs such as the kidneys, brain, and lungs. Avoid using medical jargons and explain in layman’s terms.To provide information on SIADH and its pathophysiology in the simplest way possible.
Educate the patient about proper nutritional intake and its role in combatting sepsis as well as the underlying infection that has caused it.To give the patient enough information on how good nutrition can help boost the immune system to fight the infection and can help him/her have optimal healing.  
Review proper hand hygiene, overall personal hygiene, and environmental cleanliness.To lessen the patient’s exposure to pathogens.
Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) that are being given to treat sepsis.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, and any possible adverse events.
Sepsis and Septic Shock Nursing Care Plan 3

Other nursing diagnoses:

  • Risk for Impaired Gas Exchange
  • Risk for Deficient Fluid Volume

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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