Last updated on May 15th, 2022 at 11:41 am
Septic Shock Nursing Care Plans Diagnosis and Interventions
Septic Shock NCLEX Review and Nursing Care Plans
Septic shock is a fatal condition that develops once sepsis becomes severe. It is characterized by a drop in blood pressure following infection, changes in mentation, and organ failure.
Furthermore, this condition might develop as a result of untreated bacteremia. Septic shock must be recognized and treated promptly to avoid irreversible damage or death.
Signs and Symptoms of Septic Shock
Early signs of septic shock may be misdiagnosed as a cold or a fever. For this reason, it is always necessary to consult a health care expert or a physician for an accurate diagnosis.
Common symptoms of septic shock include:
- Tachycardia
- Rash
- Flushed skin
- Intense body pain
- Pyrexia
- Nausea
- Vomiting
- Hypotension
- Vascular leakage
- Edema
- Fatigue
- Headache
- Dizziness
Late-stage clinical features of septic shock include:
- Oliguria
- Jaundice
- Pulmonary edema
- Hypoglycemia
- Gastrointestinal hemorrhage
- Cold clammy skin
- Changes in sensorium
- Weak pulse
Types of Septic Shock
- Warm Shock. This type is characterized by having signs and symptoms of tachycardia, bounding pulses, and peripheral vasodilation. Adults are likely to experience warm shock.
- Cold Shock. This type is characterized by increased heart rate and peripheral vasoconstriction as a compensatory response. Tachycardia, oliguria, impaired mental status, and cold extremities are some of the symptoms. It affects children far more frequently than adults.
Causes of Septic Shock
Septic shock results from untreated bacteremia or infection infiltrating the body and attacking the tissues, and as a result, the body’s inflammatory responses are activated. Also, it is more likely to occur if sepsis remains undiagnosed and untreated.
Septic shock can be caused by a variety of infections, including, but not limited to:
- Appendicitis
- Bacteremia
- Pyelonephritis
- Methicillin-resistant staphylococcus aureus
- Mesenteric ischemia
- Respiratory infections (e.g., pneumonia)
- Reproductive system infections
- Abdominal or digestive system infections
- Kidney infections (e.g., urinary tract infections)
Other causes include:
- Immunosuppression. The most significant risk factors for sepsis and septic shock include transplants, malignancies, and immunosuppression since patients have a weakened immune system. A deficit in compensating mechanisms allows bacteria to permeate the body’s tissues more easily, increasing their likelihood of septic shock.
- Malnutrition. Malnutrition can weaken the body’s defense. For instance, protein-calorie deficits can affect immunoglobulin production and cortisol, thereby decreasing systemic response. Additionally, it prolongs the body’s recovery time following injury.
- Age and Gender. The incidence of sepsis increases with age. However, there are susceptible groups that are more prone to infections. Women, elderly patients, and children are more likely to contract sepsis and develop shock due to their weak immune systems. Women are significantly more susceptible to infection due to toxic shock syndrome, which is frequently caused by bacteria introduced via tampons. Moreover, they are also prone to genitourinary infections.
- Use of invasive interventions and devices, such as catheterization. Needlestick contamination can also introduce infection in the bloodstream. Biopsies, catheters, and surgical procedures increase infection risk or compromise the septic patient.
- Comorbidities. Patients with septic shock typically have underlying diseases that increase their susceptibility to infection. These comorbidities include Diabetes mellitus, liver cirrhosis, chronic obstructive pulmonary disease, and acquired immunodeficiency syndrome (AIDS).
Risk Factors of Septic Shock
- Prolonged hospitalization
- Age (Infancy and older age)
- Comorbidities, underlying chronic illness
- Use of immunosuppressive medications
- Use of invasive devices
- Invasive procedures (e.g., surgery)
- Malnutrition
- Poor aseptic technique
Diagnosis of Septic Shock
- Differential diagnosis. The presence of other conditions and infections can assist with diagnosis. For instance, the existence of malignancies can encompass this condition.
- Culture and sensitivity. Bacterial assays can reveal the presence of gram-positive and negative bacteria in the body. A positive culture can indicate the presence of an infection, which is one of the criteria used to diagnose SS.
- Lactate levels. An increase in lactate levels usually indicates an imbalance between the oxygen requirement and the oxygen supply. It is a good indicator of SS prognosis, and repeated testing provides a more reliable estimate of organ failure severity or fatality rate.
- Imaging tests such as X-rays, MRI, and CT scans can help identify progressing adult respiratory distress syndrome. Moreover, radiographic imaging will reveal pulmonary edema and alveolar infiltrates, which may cause dyspnea, cyanosis, and respiratory difficulties.
- Coagulation studies. Due to comorbidities such as cancer, the coagulation system may be implicated. Investigations of the coagulation proteins will help mitigate impaired fibrinolysis and fibrin deposition.
Treatment of Septic Shock
- Oxygen therapy. Supplemental oxygen is needed to stabilize the airway and promote perfusion.
- Antibiotic therapy. Antimicrobial treatment is needed to treat underlying infections. Antibiotics with a broad-spectrum activity may be required to combat bacterial and fungal infections actively.
- Intravenous fluids. Fluid therapy is indicated for patients with SS to address volume deficits, inadequate tissue perfusion, and myocardial dysfunction. Treatment for SS focuses on managing blood volume and ensuring adequate perfusion of tissues and tissues in the body. Setting up a liquid treatment system with added vasoactive medications is helpful for that purpose.
- Nutrition lines. The goal of metabolic support should be to avoid malnutrition, restore metabolic conditions, regulate inflammation, and lower morbidity and mortality rates. Nutrient and energy requirements must be met to minimize the risk of infection and promote recovery.
- Medications. Some drugs and medications promote oxygen delivery and lactate uptake.
- Glucose control. This treatment is typically used with diabetic patients since uncontrolled blood sugar can raise the risk and predisposition to numerous infections, such as cellulitis.
Septic Shock Nursing Diagnosis
Nursing Care Plan for Septic Shock 1
Risk for Infection
Nursing Diagnosis: Risk for infection related to a compromised immune system, secondary to septic shock.
Desired Outcomes:
- The patient will recover in a timely manner.
- The patient will adhere to appropriate aseptic and sanitation practices.
| Septic Shock Nursing Interventions | Rationale |
| Review significant sources of infection such as open wounds, burns, invasive catheters, and cellulitis. | This information will assist in determining the kind of infection, and the relevant intervention and therapy needed. |
| Discuss the importance of hand hygiene before and after each activity. Instruct the patient on the proper steps in handwashing. | Methicillin-resistant staphylococcus aureus (otherwise known as MRSA) transmission can occur through interaction with healthcare personnel who are unable to wash their hands between patient encounters. Hand hygiene is the number one preventive measure for cross-contamination and breaking the chain of infection to reduce the risk of illness. |
| Assess the patient’s level of pain and be alert to visible signs of septic shock (e.g., changes in skin color, hypotension, increased temperature, reduced urine output, pressure in the area of cellulitis) | Early detection allows for more effective therapy and fewer complications. During the early stages of shock, the skin tends to become heated, pink, and dry due to venous pooling in the peripheral veins. As the condition worsens, the BP drops, and the extremities may become cold. Tension and pain in the cellulitis area may signify the onset of necrotizing fasciitis due to Group A streptococcal infection (GABH). |
| Assess the site of care (e.g., IV sites, wounds, invasive devices, parenteral nutrition lines) for signs of infection. | May reveal the portal of entry and type of pathogenic organism. Central-venous catheter-related bloodstream infections (CRBSIs) are a significant source of life-threatening nosocomial infection. Indwelling catheters account for most nosocomial infections associated with Staphylococcus aureus bacteremia. If standard practices are followed, bacteremia, fungemia, and hemodialysis can be avoided. |
| Monitor the patient’s laboratory values (e.g., WBC counts). | An infection’s spread is often assessed by measuring the white blood cell count (WBC). Septic shock can cause leukocytosis or leukopenia in patients depending on the severity. The absolute neutrophil count must be determined if the WBC count is exceedingly low. Similarly, an initial increase in band cells suggests the body’s attempt to establish an immune response to the infection. |
| Ensure that aseptic techniques are observed and followed during invasive procedures, changing a dressing, administering care, or suctioning. | To prevent nosocomial infection. |
| Use gloves and personal protective equipment (PPE) when handling a patient. | One of the most critical aspects of care is infection control when a patient is in septic shock. Infection-induced organ failure and circulatory abnormalities significantly raise mortality. |
| If possible, limit the use of invasive devices (e.g., insertion of catheters) | To minimize the risk of infection and the number of available points of entry for opportunistic pathogens. |
| Specify the dangers of exposure to infectious diseases and their complications. | These precautions aim to minimize the risk of secondary bacterial, fungal, or viral infection. |
Nursing Care Plan for Septic Shock 2
Risk for Impaired Gas Exchange
Nursing Diagnosis: Risk for Impaired Gas Exchange related to regulatory dysfunction, secondary to septic shock.
Desired Outcome: The patient will demonstrate normal respiration as evidenced by normal arterial blood gases, respiratory rate, and normal breath sounds
| Septic Shock Nursing Interventions | Rationale |
| Measure the patient’s depth and rate of breathing. Take note of any respiratory or auxiliary muscle tension. | Hypoxia and stress all contribute to breathing difficulties. Patients with compromised compensatory mechanisms may indicate the need for ventilatory support to address dyspnea. |
| Auscultate for abnormal breath sounds (e.g., presence of stridor, crackles, and wheezes) | Breathing problems and aberrant respiratory noises are signs of atelectasis and interstitial edema. Both of these factors contribute to the development of septic shock. |
| Assess for changes in the level of consciousness and sensorium changes (e.g., lethargy, confusion, personality changes, stupor, and coma) | These are symptoms of hypoxia. Disorientation is another symptom that patients with septic shock experience. Hypoxemia and reduced perfusion all affect cerebral function. |
| Assess the patient’s arterial blood gases (ABGs) and pulse oximetry. | Hypoxemia (PaO2 80 mm hg) occurs due to the body’s increased oxygen needs during a fever. Since septic shock results in organ malfunction, the body’s metabolic systems cannot utilize available oxygen more efficiently. Additional factors include reduced ventilation and pulmonary abnormalities such as atelectasis and interstitial edema. As the septic condition worsens, metabolic acidosis develops due to lactic acid build-up from anaerobic metabolism. |
| Monitor the patient’s chest x-rays. | Septic shock can be investigated with bedside chest x-rays and clinical examination. Radiographic changes indicate the progression or remission of pulmonary complications such as edema. |
| Instruct the patient on deep breathing and coughing techniques. Ask him/her for a return demonstration. | Deep breathing and coughing are essential techniques to aid respiratory effort and promote oxygenation. It also helps prevent atelectasis and pulmonary edema. |
| Administer blood products as indicated. | To increase oxygen supply. Insufficient tissue perfusion and decreased oxygen supply have been linked to organ failure in sepsis. It signifies that the tissue requires more oxygen than normal circulation can supply. A lack of oxygen delivery necessitates the use of packed red blood cells (pRBCs) as a therapy option. |
| Administer supplemental oxygen as prescribed. | This measure helps keep the mucosa of the mouth and nose from drying out. Oxygen supplementation is essential in treating hypoxemia, respiratory failure, and the treatment of acidosis. |
Nursing Care Plan for Septic Shock 3
Deficient Fluid Volume
Nursing Diagnosis: Deficient Fluid Volume related to increased urinary output, as evidenced by weight loss, dry skin, insufficient fluid intake, and imbalance in intake and output ratio
Desired Outcomes:
- The patient’s urine-specific gravity will be within the normal range, as evidenced by increased fluid intake.
- The patient will successfully identify risk factors for fluid deficiency and take steps to remedy the situation.
- No indications of dehydration will be present in the patient.
| Septic Shock Nursing Interventions | Rationale |
| Assess the patient’s urinary output and monitor his/her intake and output (I&O) ratio. Correspond with weight measurements and document trends. | Septic shock treatment focuses mostly on managing blood volume and ensuring adequate tissue perfusion. Vasodilation-induced hypovolemia is indicated by a decrease in urine output and an increase in the specific gravity of the urine. Fluid loss is indicated when the amount of urine output exceeds the amount of fluid consumed. As a result, weight loss is proportional to insufficient intake or fluid volume loss. |
| Examine the patient’s vital signs, skin condition (e.g., loss of turgor, dry mucous membrane), and increased thirst | This measure assesses fluid imbalances and trends of dehydration (e.g., hypovolemia and third spacing of fluid). Septic shock commonly presents with hypotension and oliguria. When this happens, loss of fluid volume is expected. Dehydration that is severe enough to impair the amount of blood and bodily fluids can result in shock. At the same time, tissue edema can develop when fluid shifts from the vascular compartment to the interstitial space. |
| Review laboratory findings such as hematocrit, RBC count, creatinine, changes in blood viscosity, and blood urea nitrogen. | Increased hematocrit and decreased urine osmolality indicate fluid imbalance and dehydration. Whereas the BUN and creatinine ratio can signal kidney failure. |
| Ensure that the patient is receiving adequate hydration. | Hydration is necessary for temperature regulation, infection prevention, and lubrication. Moreover, it will help increase oral moisture and help prevent electrolyte imbalances. |
| Administer intravenous fluids for weak or bedridden patients as indicated. | This measure helps ensure that fluid requirements are met. Since cellular dysfunction becomes more severe as the disease advances, hydration is an effective treatment for severe sepsis. Fluid therapy is most effective early in the course of severe sepsis because as the condition worsens, there is greater dysfunction at the cellular level. Hypovolemia and vasodilation may necessitate large amounts of fluid volume to compensate for fluid losses due to increased capillary permeability. |
Nursing Care Plan for Septic Shock 4
Hyperthermia
Nursing Diagnosis: Hyperthermia related to a compromised compensatory system, secondary to septic shock, as evidenced by flushed skin, malaise, fatigue, headache, pain, loss of appetite, tachypnea, and tachycardia.
Desired Outcomes:
- The patient’s body temperature will be within normal range.
- The patient will recognize and manage the risk factors for hyperthermia.
| Septic Shock Nursing Interventions | Rationale |
| Assess for any signs and symptoms of hyperthermia. Examine concerns of excessive heat or sweating. | Hyperthermia is characterized by flushed cheeks, a rash, respiratory distress, irritation, and malaise. Early detection of pyrexia aids in mitigating immune system dysfunction and cardiovascular congestion. |
| Examine changes in consciousness and mental status | Many patients with septic shock are found to have severe hyperthermia. Septic shock and hyperthermia might be indicated by increasing disorientation, changes in the level of consciousness, and abnormal conduct. |
| Check the patient’s temperature and monitor for chills and profuse diaphoresis. | A temperature above 38.0 degrees Celcius indicates the onset of an acute infectious illness. A persistent fever that lasts longer than 24 hours and fluctuates daily (remittent fever) may indicate pulmonary infections. On the other hand, intermittent fever may signal tuberculosis, septic episodes, or septic endocarditis. Vasodilation occurs during the early stages of septic shock, resulting in flushed and warm skin. |
| Assess whether clothing or bedcovers are too warm for the environment or planned activity. | In sepsis, the immune response to the infection is most frequently manifested by fever (increased body temperature). Septic shock frequently results in hemodynamic alterations, which might result in heatstroke. As a result, temperatures should be lowered as quickly as possible until they are within the typical range of 36-38 degrees Celsius. |
| Review laboratory results for culture and sensitivity. | Positive culture findings may suggest bloodstream infection. Septicemia can only be effectively treated when the pathogen causing the infection has been identified. Antibiotics can be administered based on the source and susceptibility of the pathogen. |
| Encourage the patient to take adequate fluid intake. | Mild hyperthermia is treatable with self-care methods such as increased water consumption. By urging patients to drink water and using a fan, the body’s evaporative cooling function can be augmented. |
| Provide cooling measures such as hypothermia therapy, ice packs, cool water baths, cooling blankets, and tepid sponge baths. | Cold applications to the skin (e.g., spraying, sponging, or using a fan) minimize body heat and reduce fever, especially when the temperature rises above 39.9°C–40°C and convulsions or brain injury are possible. |
| Administer antibiotics as prescribed | Antibiotics should be administered to address the underlying sepsis resulting in the patient’s hyperthermia. |
Nursing Care Plan for Septic Shock 5
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to a lack of information on the condition, secondary to septic shock, as evidenced by verbalized concerns about disease, frequent requests for information, information misinterpretation, difficulty following guidelines, and difficulty performing tests
Desired Outcomes:
- The patient will demonstrate knowledge of the illness, its associated risk factors, treatment regimen, and symptom control.
- The patient will exhibit less anxiety and fear over the management of the illness.
| Septic Shock Nursing Interventions | Rationale |
| Assess the patient’s readiness and ability to learn | Healthcare practitioners can use this assessment to ensure that patients are receiving the information they require |
| Teach the patient and significant other(s) about the risk factors, mode of transmission, and portal of entry of pathogens. Review significant indications of septic shock. | Awareness of infectious vectors helps the patient and healthcare providers develop and implement preventive measures. The patient and SOs must notice indications of sepsis and promptly notify the healthcare provider. |
| Examine the disease’s pathophysiology and prognosis. | Educating the patient about the condition and what to expect in terms of treatment gives them the information they need to make well-informed decisions. |
| Educate the patient about the signs and symptoms that warrant medical attention (e.g., high fever, increased heart rate, fatigue, changes in urinary output, syncope). | Infections can be treated before they become life-threatening if detected earlier. |
| Stress the importance of maintaining personal hygiene and sanitation. Educate the patient on proper aseptic and food preservation techniques. Ascertain that exposure to gravely ill individuals is kept to a minimum. | The risk of infection is reduced by maintaining good personal hygiene and a clean environment. Preventing contact/exposure to sick individuals reduces the likelihood of acquiring communicable diseases, which can worsen a patient’s condition or result in death. |
| Discuss the significance of a nutritious diet. | It is necessary to consistently meet the patient’s nutritional requirements to achieve proper healing, immune system strengthening, and overall well-being. Protein-rich diets can assist patients with sepsis or septic shock regain some of their muscle mass. |
| Suggest the use of pads instead of tampons as indicated. | Tampon use can also contribute to the spread of bacteria. Toxic shock syndrome is usually caused by Staphylococcus aureus bacterial toxins, although group A streptococcus bacterial toxins can also cause it. Women are more likely to suffer from toxic shock syndrome (TSS) due to tampon use. The bacteria’s toxin can cause shock, organ failure, and even death. |
| Inform the patient about pharmacological therapy, possible side effects, and the importance of adhering to the prescribed regimen. | Treatment and preventative outcomes are improved when patients have access to relevant information, lowering the risk of recurrence and mortality. Additionally, this will enable them to engage in activities that benefit their health. |
| Emphasize the importance of vaccinations and antibiotics. | Individuals at increased risk of infection (e.g., elderly, chronically unwell individuals, predisposition to cardiovascular diseases, immunosuppression) benefit from preemptive vaccination and antibiotic therapy. Immunization against Streptococcus pneumoniae reduces the risk of sepsis following splenectomy. |
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. (2022). 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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