Nursing Care Plan for Sepsis

Jump to Sections

1. Sepsis Pathophysiology
2. Symptoms & Signs of Sepsis
3. Nursing Diagnosis
4. Nursing Interventions
5. Nursing Actions & Care Note for Sepsis
6. Sepsis NCLEX Question
7. Stages of Septic Shock

Sepsis Pathophysiology

Sepsis is the body’s response to infection, and occurs when an infectious agent such as a virus or bacteria spreads throughout the body. The term “sepsis” is often used interchangeably with “septicemia,” which refers to blood poisoning.

Sepsis is also considered a systemic inflammatory response syndrome that results from an infection. 

Sepsis can trigger a “cytokine storm” – cytokines are chemical messengers that help regulate the immune system’s response to infection. When cytokines get out of control, they cause the body’s immune system to attack itself, making it difficult for a client’s organs to function normally.

Sepsis is a serious condition that can lead to organ failure and death if not treated quickly. If these symptoms persist for more than six hours without improvement, or if they worsen after seventy-two hours, it is likely that the client is becoming septic and requires emergency treatment.

Remember: Sepsis is life-threatening.

Risk Factors

• Pneumonia
• Being an infant or elderly
• Pregnancy
• Chronic illness or immuno-compromised clients 
• Catheter or tracheostomy insertion

Rationale:

Premature infants are extremely susceptible to sepsis, due to an underdeveloped immune system. Children also can become septic because manifestations (signs and symptoms) look different in children vs. adults. Children have less cardiac reserve than adults and may present differently.

Older adult clients are more susceptible to contracting infectious pathogens due to their declining immune system. In addition, other age-related changes and co-morbidities (chronic health problems, e.g., diabetes, cardiovascular disease, etc)  impact the resistance to pathogens. 

The elderly often present with different manifestations (signs and symptoms) than other populations which makes it more difficult to diagnose sepsis.

Clients who are immunocompromised or have comorbidities (chronic illness) do not have the ability to fight infection as do healthy individuals. 

Women in the third trimester of pregnancy tend to have a decreased immune system, thus increasing the risk for infection and sepsis.

Fluid replacement therapy directly affects sepsis factors (adequate urine output, changes in mental state, and stability of vital signs).

Causes

• Infection
• Foreign material in the body
• Bacterial overgrowth in the small intestine
• Fungal infections
• Prolonged IV or Foley Catheter use

Subjective (Client May Report)

• Pain
• Difficulty breathing
• Burning with urination
• Frequent cough
• Green mucus

Objective

• Increased or decreased temperature > than 100.4℉ (38 ℃)  or < 96.8 ℉ (36 ℃)
• Respiratory distress (rate over 20 bpm)
• Decreased urinary output
• Hypotension
• Increased or decreased  white blood cell count (WBC) > 12,000 cells/mm3 or < 4,000 cells/mm3 
• Decreased platelet count
• Edema
• Hyperglycemia
• Increased lactic acid or creatinine

Symptoms & Signs of Sepsis

• Fever
• Disorientation
• Shortness of breath
• Low blood pressure 
• Fatigue
• Chills
• Low urine output 
• Chest pain
• Confusion
• Low blood oxygen levels 

Nursing Diagnosis for Sepsis

When diagnosing a client with (possible) sepsis, look for signs of infection (e.g., fever, chills) AND either evidence of systemic inflammation or hypoperfusion.

Assessment 

The client has three or more of the following clinical criteria: 

1. Temperature over 100.4F or below 96.8F 
2. Heart rate over 90 beats per minute
3. Respiratory rate over 20 breaths per minute 
4. White blood cell count over 12,000 cells/mm3 
5. Platelet count less 100 000 cells/mm3 
6. Creatinine increase over 0.3 mg/dL in first 24 hours after presentation
7. Hypotension (systolic blood pressure less than 90 mm Hg)

Nursing Interventions for Sepsis

Sepsis is a complex condition involving inflammation and dysfunction of the immune system. Nursing interventions for sepsis are focused on monitoring and managing the client’s response to infection. 

However, it’s important to recognize that sepsis can result in morbidity and mortality in clients even if they receive appropriate treatment. Early detection and treatment of sepsis is key.

When blood is infected with bacteria, the body recruits white blood cells to fight them off. However, this process can be prolonged or excessive, which leads to an inflammatory response that can damage tissues and organs throughout the body.

Assessment

For signs and symptoms of sepsis, monitor the client for changes in condition (after assessment).

Cardiac Function

• Decreased cardiac output

Respiratory function

• Decreased delivery and use of oxygen 
• Fatigued respiratory muscles 

Neurologic and Sensory Functions

• Confusion
• Lack of energy
• Changes in personality
• Delirium
• Seizures

Visual Appearance & Labs

• WBC count (CBC)
• O2 to tissues lowered by lactate
  • This could result in: pale blue skin, lips, tongue or nail beds of the fingers
• Kidney performance (BMP)
• Change in level of consciousness (LOC)
• Positive blood cultures
• Acidosis detected by ABG

Nursing Actions & Care Note for Sepsis

Nurses are the first point of contact for clients with sepsis, and their actions can greatly impact a client’s recovery.

So let’s break down the nursing intervention and action:

The initial treatment for sepsis is the same for all clients, regardless of age or medical history. This includes taking a detailed history and performing a physical exam to evaluate the client’s overall health and determine if they are at risk for developing sepsis.

Perform

• A thorough assessment of the client’s airway, breathing, and circulation.

Provide

• IV fluids as prescribed to support sufficient urine output
• Oxygen to support 02 saturation of 93% or greater
• Medications as prescribed

Avoid

• Invasive procedures or blood draws

Administer

• Antibiotics as prescribed

Monitor

• Vital signs including:
  • Heart rate
  • Respiratory rate
  • Temperature
  • Blood pressure
  • Pulse oximetry
  • Urine output

Encourage

Nurses should encourage clients upon discharge or for home care to eat a healthy diet and maintain their normal fluid intake. They should be encouraged to take their temperature daily as well as keep track of how much water they consume each day.

Clients should also stay hydrated, avoid becoming overly fatigued and stressed, and try to get rest. Nurses need to encourage clients to follow their prescribed treatment plan and avoid any over-the-counter medications or remedies that may interfere with their treatment.

Goals and Outcomes

• Clear airway
• Reduced infection
• Reduced pain and discomfort

Sepsis NCLEX Question

An older adult client diagnosed with sepsis becomes angry at the unlicensed assistive personnel (UAP) and refuses oral care. The UAP reports this incident to the registered nurse (RN). 

Which response by the RN is appropriate?

Answer: “We will talk to the client about the issue together.”

Rationale: The angry client must be allowed to express concerns openly. It’s appropriate to approach the situation with an unbiased attitude of acceptance and openness.

Find our other Nursing Care Plans here.

Stages of Septic Shock

As sepsis progresses, it can escalate into septic shock, a life-threatening condition where the body’s response to infection leads to dangerously low blood pressure and inadequate blood flow to vital organs.

Understanding the stages of septic shock is crucial for timely intervention, as each phase presents different physiological changes that require specific nursing actions.

1. Early Sepsis – Low MAP

Initially, a client who is going into septic shock will first experience a decrease in mean arterial pressure (MAP).

Mean arterial pressure is referred to as the state in which a person has decreased blood perfusion around the body.

How does one get the mean arterial pressure?

First, add up two diastolic pressures; and then add the systolic pressure. Remember that the systolic pressure is the first number or the top number of your client’s blood pressure. Okay, so after adding two diastolic pressures and one systolic pressure, divide the sum by three. If the result is greater than 60, then you can breathe easy because your client will be fine. However, if the MAP is less than 60, it means that your client’s body is being suffocated from oxygen.

A drop in mean arterial pressure means that the infection has gone worse that it’s turning off some of the barrel receptors inside the body. Barrel receptors are the receptors in the blood vessels that help regulate the constriction of blood vessels.

On the other hand, massively widened vessels cause a decrease in resistance which will result in a decreased pressure; thus, creating low oxygen perfusion around the body.

2. Compensatory Stage

When your body is trying to compensate for any type of shock, not just septic shock, it will increase the heart rate and respiratory rate to get more oxygen since there is not enough blood perfusion.

3. Progressive Phase

The third phase of septic shock is the moment when the infection has become so severe that the body is compensating by igniting an inflammatory process. This inflammatory process is the body’s defense mechanism to fight off the infection. However, in septic shock, the inflammatory process has gone haywire, and it has become widespread and systemic.

The progressive stage is where the majority of clinical manifestations occur, mainly:

• Hypothermia – a temperature less than 97.
• Pneumonia – the alveoli are damaged and disrupt oxygen exchange.
• Decreased urinary output – glomeruli in the kidneys become inflamed. The dilated vessels cause reduced resistance and perfusion that the body compensates by holding on to volume; thus, decreasing urine output.
• High specific gravity – dark brown, thick, odorous, and very concentrated urine output.
• Bleeding – since the kidneys make erythropoietin, the inflammatory process will cause broken vessels

4. Refractory Stage

What happens when a client bleeds and how can it be stopped? Since this is a septic shock, the body will stop the bleeding by putting platelets on the affected areas to patch it up. However, there are occasions wherein a client develops disseminated intravascular coagulation (DIC) with septic shock.

The platelets will patch up the inflamed, bleeding organs in the body. The problem is, production of platelets inside the body is limited, and once they are used up, it will take a while for the body to regenerate the fibrin and fibrinogen – the receptors that help in blood clotting. 

Without platelets, the body will experience systemic bleeding that can cascade into DIC. Disseminated intravascular coagulation is severe bleeding that is hard to stop. This systemic bleeding leads to multiple organ dysfunction syndrome (MODS) that is basically multi-organ system failure, meaning all the body organs are shutting down.

Sources

https://alraziuni.edu.ye/uploads/pdf/Nursing-Care-Plans-Edition-9-Murr-Alice-Doenges-Marilynn-Moorehouse-Mary.pdf