Sepsis Nursing Diagnosis and Nursing Care Plans

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Sepsis Nursing Care Plans Diagnosis and Interventions

Sepsis NCLEX Review and Nursing Care Plans

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.

Nursing Diagnosis for Sepsis

Nursing Care Plan 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.

Nursing Interventions for SepsisRationales
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.

Nursing Care Plan for Sepsis 2

 Nursing Diagnosis: Risk for Septic Shock

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

Nursing Interventions for SepsisRationales
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.

Nursing Care Plan for Sepsis 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.

Nursing Interventions for SepsisRationales
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.

Nursing Care Plan for Sepsis 4

Risk for Impaired Gas Exchange

Nursing Diagnosis: Risk for Impaired Gas Exchange related to altered blood circulation, alveolar-capillary membrane changes- increased capillary permeability resulting in pulmonary congestion.

Desired Outcomes:

  • The patient will have improved oxygenation as shown by improved ABG results, as evidenced by a normal respiratory rate, oxygen saturation within the target range, and clear breath sounds.
  • The patient will sustain a sufficient circulatory volume.
  • The patient will report reduced incidents of dyspnea, fatigue, and weakness.
Nursing Interventions for SepsisRationale
Assess the client’s vital signs at least every 4 hours, specifically the respiratory rate, and depth.  Observe breathing patterns and the use of accessory muscles.Hypoxemia is often manifested by rapid, shallow respiration, stress, and circulating endotoxins. The client must be closely observed for any sign of ineffective compensatory mechanism, these include  Hypoventilation and dyspnea. If any of these will persist, ventilation support might be required. 
Monitor client’s breath sounds through Auscultation. Take note of the following: Stridor,  crackles, wheezes, and areas of decreased or absent ventilation. Abnormal breathing sounds and respiratory distress are common signs of atelectasis or a condition in which the lungs or part of its lobe has collapsed. It is a result of deflation or filling of fluid within the alveoli.
Check if there are changes in the sensory function of the client. It includes confusion, lack of energy, changes in personality, stupor, delirium, and coma Decrease supply of oxygen to the blood, poor cellular perfusion will lead to  hypoxia or insufficient oxygen supply in the brain. Once this occurs, it will affect the normal function of the brain.
Monitor the client for any presence of bluish or gray discoloration around the mount. This condition is called circumoral cyanosis   Circumoral cyanosis may imply an insufficient supply of oxygen to the brain.
Observe the client for cough and purulent production of sputum. Respiratory Infection commonly occurs by aspiration of an oropharyngeal organism or spread from other sites. Once the pathogens entered the Respiratory tract, microorganisms may produce mucus. By coughing, this mucus is expelled out of the body.
Encourage pulmonary drainage by repositioning the client frequently. Other helpful methods are coughing, deep-breathing exercises, suction, pursed-lip breathing as required.  Pulmonary hygiene is an important part of the treatment plan to help to clear airways of mucus and secretion. These techniques ensure a sufficient supply of oxygen to the lungs and effective function of the respiratory system.
Support the client’s airway. Placing the client in a comfortable position with the head of the bed elevated at 30 to 45 degrees as tolerated. If tolerated, the client may be encouraged to sit in an upright sitting position. Elevating the patient’s head of the bed promotes lung expansion and minimizes aspiration.
Close monitoring of Arterial blood gas and oxygen saturationSignificant changes in the level of Arterial blood gas may denote something is not working well in the body’s oxygenation, An ABG result of increasing PaCO2 and decreasing Pao2 are evident signs of hypoxemia
Obtain a series of chest x-rays as requested.A chest x-ray is one of the diagnostic tools that provide images if there’s progression or resolution of pulmonary complications, which includes infiltrates and edema.
Transfusion of red blood cells, as required.To improve oxygen supply to the blood, administering red blood cells may be required. It also helps to treat sepsis-induced hypoperfusion, or if the client’s hematocrit level falls below 30%.
Oxygen supply via nasal cannula, mask, or high-flow rebreathing mask as needed.Oxygenation plays a major role in treating Hypoxemia, stopping the progress of acidosis, and preventing respiratory complications.
Administer medication as ordered.Pharmacological therapy works directly to support oxygen supply, reduce respiratory distress, and strengthen the body’s immune response.

Nursing Care Plan for Sepsis 5

Risk for Deficient Fluid Volume

Nursing Diagnosis: Risk for Deficient Fluid Volume Marked increase in vascular compartment, massive vasodilation.

Desired Outcome: The client will demonstrate adequate circulatory volume as shown by stable vital signs within the client’s normal range, good skin turgor, normal capillary refill, good quality of palpable peripheral pulses, and adequate urinary output.

Nursing Interventions for SepsisRationale
Record client’s 24-hour intake and output and compare it with daily weight. Also, include cumulative intake and output imbalances (including insensible losses).  Weight must be taken daily and at the same time each day. Measure urinary output and its specific gravity. Measure all fluid losses in all ways, such as diaphoresis, wound drainage, and gastric losses.These measurements give functional data for comparison. A decrease in urine output with a high specific gravity indicates relative hypovolemia with vasodilation. Increase positive fluid balance with corresponding weight gain may suggest third spacing and excess fluid accumulation in the tissue, recommending a treatment to alter the fluid.
Check for signs of dehydration, such as dry, cracked mucous membranes, poor skin turgor, frequent thirstiness, and a decrease in urine output. Loss of extracellular fluid and third spacing of fluid are signs of dehydration.
Assess for dependent or peripheral edema in areas of sacrum, scrotum, back, and legs.Loss of fluid at the vascular compartment into the interstitial space produces tissue edema.
  Monitor vital signs, focusing on the Blood pressure and heart rate. Also, include Central venous pressure (CVP). Check if there’s an increase in temperature and episodes of orthostatic hypotension.The deficit in the volume of circulating fluid reduces Blood pressure and CVP, the heart will initiate a compensatory mechanism through an increase in the heart rate to improve cardiac output and increase systemic blood pressure. Central venous pressure measurements are beneficial in identifying the level of fluid deficit and how it responds to replacement therapy. In addition, a temperature rise promotes metabolism, thus, increasing fluid loss.
Palpate peripheral pulses. Assess skin color and capillary refillA collapse in circulation and shock is a result of insufficient organ perfusion to all body areas, contributed by a deficit in the extracellular fluid.
Monitor laboratory results as requested. Blood tests such as BUN/Cr ratio and electrolytes level could point out dehydration, dysfunction in kidney function, and failure. A low level of electrolytes may cause abnormalities in the heart rate, muscle spasms, and tiredness. These tests also help the healthcare team to see whether the treatment is effective or if another plan of action is can be considered.
Observe cardiac output, as identified.Functional parameters like level of cardiac output, cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively with the use of \thoracic electrical bioimpedance (TEB) technique. Cardiac output determination helps identify the therapeutic need and effectiveness. 
Administer Intravenous fluid as prescribed.Intravenous fluids are indicated to maintain the required fluid balance if oral intake is not possible. It replenishes fluid loss and corrects plasma protein concentration deficit. Fluid therapy is most effective if started immediately, even before the condition gets worst. There is a risk of greater dysfunction at the cellular level if not corrected immediately.
Watch out for reports of sudden sharp chest pain, bluish discoloration of the skin, difficulty breathing, restlessness, and anxiety.Increased concentration of plasma in the blood may result in the formation of systemic emboli.
Educate the client about the signs and symptoms and other significant information about dehydrationHaving enough knowledge about the condition and also what to expect allows the client and their family members to be driven
Observe if there are any changes in the client’s mental status.Fluid loss and dehydration can cause irritability, tiredness, confusion, and fatigue.

Nursing Care Plan for Sepsis 6

Risk for Infection

Nursing Diagnosis: Risk for Infection related to failure to recognize or treat infection early, and/or exercise proper preventive measures.

Desired Outcomes:

  • The client will be free of infection promptly on time, as shown by normal vital signs, negative fever, and normal white blood cell count.
  • The client will demonstrate the preventive measures against infection, such as proper handwashing techniques.
  • The client will show the ability how to recognize symptoms of infection and allow immediate treatment.
Nursing Interventions for SepsisRationale
Check all the possible sources of infection. This includes open wounds, burns, localized pain, the presence of contraptions such as catheters, Intravenous lines, and others.Sepsis is commonly caused by local infection, like in the respiratory tract, urinary tract, abdominal and soft tissues. In some situations, infection is acquired in the hospital is caused by the use of intravascular devices.
Assess for any signs and symptoms. Classic signs of infections include fever, redness, swelling, increased pain, colored discharge from the wound, injury, and others. Educate the client about these signs and symptoms.Oftentimes, fever is the first sign of infection. A temperature of 37.8 degrees and above may indicate infection. Signs and symptoms may vary depending on which body part is involved.  For any suspicious drainage, specimen culture may be needed. Monitor temperature every 4 hours. Acknowledging signs of infection earlier ensures prompt treatment and improves the patient’s recovery.
Closely monitor laboratory values such as blood tests, urine tests, the culture of microorganismsThese laboratory procedures are helpful to early recognize the existence of infection. For culture tests, it provides information on which type of microorganism causes the infection.
Take note of the patient’s list of medication, existing medical history, and immunization.Some medicines suppress the function of the immune system, making the body vulnerable to acquiring infection. Also, for people with incomplete immunization, may result in inadequate acquired immunity.
Practice regular and proper handwashing and encourage patients their family members to do the same.Hand washing is one of the universal precautions, it breaks the chain of infection and decreases the risk of introducing microorganisms into the body. According to existing guidelines, the recommended hand washing is for at least 15 seconds, covering the whole hands, including between fingers and fingertips.
When coughing and sneezing, remind the client to cover the mouth and nose. Wash their hands from time to time and wear masks appropriately.This preventive measure helps to stop the spread of infection. Making it a regular habit will reduce the chances of the increasing number of getting infected. 
Advised the client to eat a balanced diet, increased fluid intake if not contraindicated, have enough rest, and do regular physical activity.A well-balanced diet, which includes vitamins, minerals, and other dietary essentials builds a strong immune system and promotes faster wound healing. High Enough rest can reduce stress and boost immunity. Staying hydrated helps to loosen secretions and replenish fluid loss during fever. It also prevents urine concentration and induced frequent emptying of the bladder.
Educate the client about the risk factors of infection.With the increased number of having infections nowadays, awareness about the risk of infection improves care and increases cooperation among people.
Teach the client about the importance of complying with the treatment.The client must comply proactively with the designated treatment according to their needs. It promotes complete healing and recovery and prevents further complications.  
Advised the client to receive daily baths and routine oral care.Taking a bath daily removes the number of pathogens on the skin. Using moisturizing agents keeps the skin intact and prevents breakout. Routine oral care reduces the growth of bacteria in the mouth, preventing its entrance to the respiratory tract.

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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