NANDA Nursing Diagnosis for Sepsis: A Comprehensive Guide for Nurses

Sepsis, a life-threatening condition arising from the body’s dysregulated response to infection, demands prompt recognition and aggressive intervention. As a critical concern in healthcare, especially within Intensive Care Units (ICUs), sepsis necessitates vigilant nursing care across all specialties. Early detection and immediate action are paramount to avert septic shock, a severe phase that can precipitate organ failure and mortality. Nurses are at the forefront of this battle, playing a crucial role in early assessment, prevention, and comprehensive management of sepsis.

This guide delves into the essential aspects of nursing care for sepsis, focusing on the application of NANDA nursing diagnoses to formulate effective care plans. We will explore the nursing process in sepsis management, encompassing assessment, key nursing diagnoses, interventions, and expected outcomes, all centered around the critical need for timely and effective care to improve patient outcomes.

Understanding the Nursing Process in Sepsis Management

The nursing process is a systematic approach to patient care, and it is particularly vital in the management of sepsis. It involves assessment, diagnosis, planning, implementation, and evaluation. For sepsis, this process is continuous and dynamic, requiring constant monitoring and adaptation to the patient’s rapidly changing condition.

Nurses in all healthcare settings must be adept at recognizing the subtle and overt signs of sepsis. Prevention is also a cornerstone of nursing care, emphasizing strict adherence to hand hygiene, appropriate use of Personal Protective Equipment (PPE), meticulous wound care, and sterile techniques to minimize infection risks and subsequent sepsis development.

Comprehensive Nursing Assessment for Sepsis

The initial step in providing effective nursing care is a thorough nursing assessment. This involves collecting subjective and objective data to understand the patient’s condition comprehensively. In sepsis, this assessment is crucial for early identification and intervention.

Review of Health History: Identifying Risk Factors and Symptoms

A detailed review of the patient’s health history is the first step in sepsis assessment. This includes noting general symptoms, identifying potential causes, recognizing risk factors, reviewing medical history, and scrutinizing medication lists.

1. Recognizing General Sepsis Symptoms: Early sepsis often presents with nonspecific symptoms. Nurses should be alert to:

• Fluctuations in body temperature: both increased (hyperthermia) and decreased (hypothermia).
• Chills and rigors.
• Altered mental status, ranging from confusion to lethargy.
• Tachypnea or rapid breathing.
• Skin changes: flushed or cool, clammy skin.
• Hypotension, a late but critical sign.

2. Identifying Potential Sources of Infection: Sepsis is triggered by an infection. Determining the primary site of infection is crucial for targeted treatment. Common sources include:

• Pulmonary infections: Pneumonia is a frequent precursor to sepsis.
• Urinary tract infections (UTIs): Infections of the kidneys, bladder, and urinary system.
• Gastrointestinal infections: Infections within the digestive system.
• Bloodstream infections: Bacteremia or septicemia.
• Infections related to invasive devices: Catheter-related infections.
• Wound and burn infections: Compromised skin integrity as entry points for pathogens.

3. Identifying Sepsis Risk Factors: Certain patient populations are at higher risk of developing sepsis. These risk factors include:

• Age extremes: Infants and adults over 65 years are most vulnerable.
• Compromised immune systems: Conditions like HIV, cancer, or immunosuppressive therapies increase susceptibility.
• Pre-existing comorbidities: Chronic conditions such as diabetes mellitus and chronic kidney disease.
• Prolonged hospital stays: Increased exposure to nosocomial infections.
• Invasive lines: Central venous catheters and urinary catheters provide potential entry points for infection.
• Recent antibiotic use: Prolonged or inappropriate antibiotic use can lead to antibiotic-resistant infections.
• Use of corticosteroids and immunosuppressants: These medications can suppress the immune response.

4. Reviewing Medical History for Predisposing Conditions: Certain medical conditions significantly elevate sepsis risk:

• Existing, undiagnosed, or untreated infections: Any infection can progress to sepsis if not managed promptly.
• Immunocompromising conditions: Cancer, HIV, and autoimmune disorders weaken the body’s defenses.
• Chronic diseases: Diabetes and COPD can impair immune function and increase infection risk.
• Recent surgical procedures: Postoperative infections are a known sepsis trigger.
• Implanted devices: Pacemakers and ports can become sites of infection.
• Organ transplant complications: Immunosuppression and surgical risks are factors.

5. Medication Review: Antibiotic and Immunosuppressant Use: Medication history is vital, especially noting:

• Corticosteroid and immunosuppressant use: These medications can mask early sepsis signs and impair immune response.
• Antibiotic history: Assess for recent, frequent, or incomplete antibiotic courses, which can contribute to antibiotic resistance. Factors leading to drug-resistant bacteria include:
  • Premature discontinuation of antibiotics without medical advice.
  • Unnecessary antibiotic use, contributing to resistance.
  • Frequent antibiotic exposure.
  • Limited access to appropriate medications.
  • Substandard quality of medications.
  • Incorrect antibiotic prescribing practices.

Physical Assessment: Recognizing Clinical Manifestations

A thorough physical assessment is crucial for detecting sepsis progression. Nurses must monitor vital signs and conduct a systemic assessment to identify early indicators of deterioration.

1. Vital Signs Assessment: Initial vital sign changes in sepsis include:

• Temperature dysregulation: Hyperthermia (temperature >100.4°F or 38°C) or hypothermia (temperature <96.8°F or 36°C).
• Tachycardia: Elevated heart rate.
• Tachypnea: Increased respiratory rate.

2. Systemic Assessment for Organ Dysfunction: Sepsis can rapidly progress to severe sepsis and septic shock, leading to organ dysfunction. Close monitoring for the following is essential:

• Central Nervous System (CNS): Altered mental status, confusion, decreased level of consciousness.
• Respiratory System: Hypoxia, cough, chest pain, dyspnea.
• Cardiovascular System: Decreased capillary refill time, hypotension.
• Gastrointestinal System: Ileus, perforation, abscess, abdominal tenderness.
• Genitourinary System: Oliguria (decreased urine production) or anuria (absent urine production).
• Integumentary System: Flushed skin, cyanosis, pallor, skin mottling.

3. Assessing for Progression to Septic Shock: Septic shock is characterized by profound hypotension and organ hypoperfusion. Signs include:

• Cool extremities.
• Prolonged capillary refill (>3 seconds).
• Thready, weak peripheral pulses.
• Pale, clammy skin.
• Diaphoresis (excessive sweating).
• Confusion and disorientation.
• Decreased level of consciousness, progressing to unresponsiveness.

4. Intravenous (IV) Line Assessment: IV sites are potential sources of infection. Assess for:

• Signs of local infection: swelling, redness, pain, drainage at the insertion site.
• Thrombophlebitis: inflammation of the vein.
• Central venous lines are particularly associated with sepsis and bacteremia.

5. Wound and Incision Assessment: Monitor wounds and surgical incisions for signs of infection:

• Abscess formation.
• Cellulitis: spreading skin infection.
• Wound infection: pain, purulent discharge, erythema, swelling.
• Document all changes in wound appearance meticulously.

Diagnostic Procedures: Confirming Sepsis and Identifying Causative Agents

Diagnostic procedures are crucial for confirming sepsis, identifying the causative pathogen, and assessing the severity of organ dysfunction.

1. Laboratory Studies: Blood and other bodily fluid samples are essential for diagnosis:

• Complete Blood Count (CBC): May reveal leukocytosis (elevated WBC count) or leukopenia (decreased WBC count), neutropenia, and thrombocytopenia.
• Kidney Function Tests: Elevated creatinine and BUN indicate impaired kidney perfusion.
• Blood and Site-Specific Cultures: Cultures from blood, urine, sputum, wounds, and IV sites identify the causative organism.
• Urinalysis and Culture: Further evaluate urinary tract infections.
• Biomarkers: Procalcitonin (PCT) and presepsin are elevated in sepsis and aid in early diagnosis.
• Lactate Levels: Serum lactate >2 mmol/L indicates tissue hypoperfusion; levels >4 mmol/L suggest septic shock.
• C-Reactive Protein (CRP): Elevated CRP is a marker of inflammation.
• Coagulation Studies (INR and PTT): Elevated INR and PTT indicate coagulopathy, a complication of sepsis.

2. Imaging Scans: Imaging helps identify the source of infection and assess organ damage:

• Chest X-ray: Detects pneumonia.
• Chest CT Scan: More detailed lung imaging.
• Abdominal Ultrasonography: Evaluates abdominal organs for infection or abscesses.
• Abdominal CT Scan or MRI: Detailed abdominal imaging.
• Site-Specific Soft Tissue Imaging (Ultrasound, CT, MRI): Evaluates localized infections.
• Contrast-Enhanced CT or MRI of Brain/Neck: Rule out CNS infections.

3. Invasive Diagnostic Procedures: Invasive procedures may be necessary in complex cases:

• Thoracentesis: Pleural fluid aspiration for culture and analysis.
• Paracentesis: Ascitic fluid aspiration for culture and analysis.
• Drainage of Fluid Accumulations and Abscesses: Obtaining samples and therapeutic drainage.
• Bronchoscopy with Lavage, Washing, or Biopsy: Lower respiratory tract sample collection.

Essential Nursing Interventions for Sepsis

Nursing interventions are critical for supporting the patient through sepsis and promoting recovery. These interventions are multifaceted, addressing immediate life-threatening issues and preventing further complications.

1. Hospital Admission and ICU Preparation: Sepsis necessitates intensive care. Prepare the patient for:

• Transfer to the Intensive Care Unit (ICU) for continuous monitoring and advanced support.
• Explain the need for ICU care to the patient and family, emphasizing the severity of sepsis.

2. Antibiotic Therapy: Timely Administration: Prompt antibiotic administration is a cornerstone of sepsis treatment:

• Initiate broad-spectrum antibiotics immediately, as ordered, ideally within one hour of sepsis recognition.
• Obtain blood cultures before starting antibiotics, if possible, without delaying antibiotic administration.
• Once pathogen identification is available from cultures, antibiotics may be narrowed to target the specific causative organism.

3. Fluid Resuscitation: Restoring Intravascular Volume: Aggressive fluid resuscitation is vital in early sepsis:

• Initiate fluid resuscitation with crystalloid solutions (e.g., normal saline, lactated Ringer’s) at a rate of at least 30 mL/kg within the first three hours.
• Monitor hemodynamic response to fluid boluses closely.
• The goal is to restore and maintain adequate perfusion pressure and tissue oxygenation.

4. Vasopressor Administration: Supporting Blood Pressure: Vasopressors are used to maintain blood pressure when fluid resuscitation is insufficient:

• Administer vasopressors (e.g., norepinephrine) as prescribed if hypotension persists despite adequate fluid resuscitation.
• Titrate vasopressors to maintain a target Mean Arterial Pressure (MAP), typically ≥65 mmHg.

5. Patient Positioning: Optimizing Respiratory Function: Positioning can aid respiratory function:

• Semi-Fowler’s or High-Fowler’s position promotes lung expansion and reduces pneumonia risk.
• Prone positioning may be indicated for patients with sepsis-induced ARDS to improve oxygenation.

6. Invasive Hemodynamic Monitoring: Invasive monitoring provides real-time data:

• Arterial line insertion allows for continuous blood pressure monitoring and arterial blood gas sampling.
• Central venous catheter insertion may be necessary for CVP monitoring and vasoactive medication administration.

7. Oxygen Therapy and Mechanical Ventilation: Respiratory support is often needed:

• Administer supplemental oxygen to maintain adequate oxygen saturation.
• Prepare for possible intubation and mechanical ventilation for patients with respiratory failure or severe hypoxia.

8. Insulin Administration: Managing Hyperglycemia: Stress-induced hyperglycemia is common in sepsis:

• Monitor blood glucose levels regularly.
• Administer insulin as per protocol for blood glucose levels >180 mg/dL.
• Maintain tight glycemic control to improve outcomes.

9. Surgical Intervention: Source Control: Surgery may be required to remove the source of infection:

• Prepare the patient for possible surgical procedures to drain abscesses or remove infected/necrotic tissue.
• Source control is crucial in improving sepsis outcomes.

10. Removal of Intravascular Devices: Devices can be sources of infection:

• Promptly remove any intravascular access devices (e.g., central lines, peripheral IVs) suspected as the source of sepsis, if clinically appropriate and safe.
• Consider replacing devices at different sites if continued access is needed.

11. Hygiene Practices: Preventing Secondary Infections: Strict hygiene is essential:

• Implement rigorous hand hygiene practices for all healthcare providers, patients, and visitors.
• Provide daily bed baths and meticulous aseptic care of catheters and IV sites according to hospital protocols.
• Ensure regular disinfection of all patient care equipment.

12. Isolation and Transmission-Based Precautions: Preventing infection spread is crucial:

• Implement septic isolation and transmission-based precautions to minimize cross-transmission.
• Protective isolation may be indicated for immunocompromised patients to prevent exposure to pathogens.
• Restrict visitors if necessary to minimize infection risks.

13. Personal Protective Equipment (PPE): Protecting Healthcare Workers and Patients: PPE is essential for infection control:

• Ensure healthcare workers consistently use appropriate PPE, including gowns, gloves, masks, and eye protection, when entering the patient’s room.

14. Enteral Nutrition: Providing Nutritional Support: Early nutritional support is vital:

• Initiate enteral nutrition (preferred) or parenteral nutrition early in the course of sepsis for patients unable to take oral nutrition within three days.
• Provide adequate calories and protein to meet metabolic demands and support immune function.

NANDA Nursing Care Plans for Sepsis: Addressing Key Diagnoses

NANDA nursing diagnoses provide a standardized framework for identifying patient problems and guiding nursing care. In sepsis, several key nursing diagnoses are frequently relevant. These include:

1. Decreased Cardiac Output

Severe sepsis and hypoperfusion significantly impact cardiovascular function, leading to decreased cardiac output.

Nursing Diagnosis: Decreased Cardiac Output

Related Factors:

• Altered hemodynamic parameters (e.g., decreased preload, increased afterload)
• Impaired cardiac contractility (sepsis-induced cardiomyopathy)
• Impaired myocardial circulation
• Loss of vascular tone (vasodilation)
• Hypovolemia (relative and absolute)

As Evidenced By:

• Tachycardia
• Hypotension
• Elevated or decreased Central Venous Pressure (CVP)
• Decreased Mean Arterial Pressure (MAP)
• Cyanosis and pallor
• Prolonged capillary refill time
• Oliguria
• Altered level of consciousness
• Cold, clammy skin
• Diminished peripheral pulses
• Cardiac dysrhythmias
• Presence of murmurs

Expected Outcomes:

• Patient will demonstrate adequate cardiac output, evidenced by:
  • Vital signs within normal limits:
    • Blood pressure: Systolic 90-120 mmHg, Diastolic 60-80 mmHg
    • Heart rate: 60-100 bpm
    • CVP: 8-12 mmHg
    • MAP: 65-90 mmHg
  • Urine output: 0.5-1.5 mL/kg/hour
  • Absence of cardiac dysrhythmias and murmurs
  • Alert and oriented mental status
  • Warm and dry skin with normal color

Nursing Assessments:

1. Monitor for signs and symptoms of decreased cardiac output: Hypotension, tachycardia, tachypnea, weak peripheral pulses, altered mental status.
2. Hemodynamic monitoring: Assess CVP, Pulmonary Artery Diastolic Pressure (PADP), and Pulmonary Capillary Wedge Pressure (PCWP) to evaluate fluid status and cardiac function.
3. Laboratory data monitoring:
   • Cardiac markers: Troponin I or T, BNP, NT-proBNP – elevated levels indicate myocardial injury or dysfunction.
   • Ejection fraction: Decreased left ventricular ejection fraction indicates septic cardiomyopathy.

Nursing Interventions:

1. Administer fluid resuscitation: Aggressive fluid therapy to address hypovolemia and improve preload. Monitor for fluid overload, especially in patients with cardiac dysfunction.
2. Administer medications as prescribed:
   • Antibiotics: Timely administration of broad-spectrum antibiotics.
   • Vasopressors: To increase blood pressure and systemic vascular resistance.
3. Anticipate adjunctive therapies: Mechanical circulatory support (Intra-Aortic Balloon Pump (IABP), Ventricular Assist Devices (VADs), ECMO) may be necessary in severe septic cardiomyopathy.
4. Optimize oxygen delivery: Ensure adequate oxygenation via supplemental oxygen or mechanical ventilation to support cardiac function and tissue perfusion.

2. Hyperthermia

Hyperthermia is a common physiological response to infection and inflammation in sepsis.

Nursing Diagnosis: Hyperthermia

Related Factors:

• Dehydration
• Increased metabolic rate associated with infection
• Inflammatory process

As Evidenced By:

• Elevated body temperature above normal range
• Flushed, warm skin
• Tachypnea
• Tachycardia
• Confusion
• Seizures (in severe cases)

Expected Outcomes:

• Patient will maintain body temperature within normal limits (36°C to 38°C or 96.8°F to 100.4°F).
• Underlying infection will be effectively treated, preventing persistent hyperthermia.

Nursing Assessments:

1. Accurate temperature measurement: Rectal temperature is the most accurate for core temperature.
2. Neurological status assessment: Monitor for altered level of consciousness, confusion, and seizures, which can indicate hyperthermia-related CNS effects.

Nursing Interventions:

1. Environmental control: Maintain a cool room temperature, remove excess clothing and bed linens.
2. Cooling measures: Apply cooling blankets, monitor closely to prevent shivering, which can increase body temperature.
3. Antipyretic administration: Administer acetaminophen or other prescribed antipyretics.
4. Physical cooling: Apply cool, damp cloths to groin and axillae; provide tepid sponge baths to promote evaporative cooling.

3. Ineffective Protection

Sepsis compromises the body’s protective mechanisms, increasing vulnerability to further infection and complications.

Nursing Diagnosis: Ineffective Protection

Related Factors:

• Infectious process
• Immunosuppression
• Abnormal blood profiles (e.g., leukopenia)
• Poor nutritional status
• Medication regimen (immunosuppressants)
• Older age

As Evidenced By:

• Changes in level of consciousness
• Insomnia or sleep disturbances
• Immobility
• Poor stress management
• Presence of open wounds or pressure ulcers

Expected Outcomes:

• Patient will remain free from secondary infections.
• Patient will demonstrate behaviors to enhance immune system protection.
• Patient will verbalize understanding of nutritional needs to support immune function.

Nursing Assessments:

1. Monitor for signs of sepsis progression or secondary infections: Changes in mental status, persistent hypotension, fever spikes, new sites of infection.
2. Monitor WBC and differential count: Leukocytosis or leukopenia, changes in neutrophil counts, indicate immune response status.
3. Risk factor assessment: Identify and monitor factors compromising protection, such as immunosuppression, malnutrition, and presence of wounds.

Nursing Interventions:

1. Promote rest and sleep: Adequate sleep is crucial for immune function and cellular repair.
2. Minimize invasive procedures: Limit catheterizations, injections, and other invasive procedures to reduce infection risk. Use aseptic techniques meticulously when invasive procedures are necessary.
3. Nutritional support: Encourage a high-protein, nutrient-rich diet to support immune function and tissue repair. Consider nutritional supplements or dietary consultation if needed.
4. Patient and family education: Educate on infection control measures, particularly hand hygiene, and strategies to enhance immune system protection.

4. Risk for Deficient Fluid Volume

Septic shock is characterized by vasodilation and increased capillary permeability, leading to fluid shifts and potential hypovolemia.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related Factors:

• Vasodilation
• Increased membrane permeability
• Fluid shifts out of the intravascular space

As Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcome:

• Patient will maintain adequate fluid volume, evidenced by stable vital signs, adequate urine output, and balanced intake and output.

Nursing Assessments:

1. Monitor for signs of fluid loss and dehydration: Hypotension, tachycardia, decreased skin turgor, dry mucous membranes.
2. Intake and output monitoring: Strictly monitor fluid intake (oral, IV) and urine output. Assess daily weight.
3. Edema assessment: Monitor for edema, which can indicate fluid shifts into interstitial spaces.
4. Laboratory value review: Hemoglobin and hematocrit levels, BUN, creatinine, urine specific gravity to assess hydration status and kidney function.

Nursing Interventions:

1. Administer IV fluids: Crystalloids (normal saline, lactated Ringer’s) are the initial fluids of choice for resuscitation. Colloids may be considered in certain situations.
2. Administer vasopressors: Use vasopressors in conjunction with fluid resuscitation to maintain blood pressure and perfusion in septic shock.
3. Monitor circulatory function: Continuously monitor heart rate, blood pressure, MAP, pulse oximetry, and urine output as indicators of circulatory volume and organ perfusion.

5. Risk for Infection

While sepsis itself is an infection-related condition, patients remain at risk for secondary or worsening infections due to immunosuppression and invasive procedures.

Nursing Diagnosis: Risk for Infection

Related Factors:

• Immunosuppression
• Multiple chronic comorbidities
• Compromised skin or tissue integrity
• Malnutrition
• Untreated or worsening infections

As Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected Outcomes:

• Patient will remain free from new infections, with vital signs and WBC count within normal limits.
• Patient will demonstrate wound healing without signs of infection.
• Patient will identify and implement infection prevention measures.

Nursing Assessments:

1. Monitor for signs and symptoms of new or worsening infection: Fever, tachycardia, tachypnea, altered mental status, localized signs of infection (wound drainage, redness).
2. Monitor laboratory values: WBC count, CRP, lactate levels as indicators of infection.
3. Obtain specimens for culture: As needed, obtain blood, urine, sputum, wound cultures to identify potential new infections.

Nursing Interventions:

1. Administer anti-infectives: Prophylactic antibiotics may be indicated in specific situations. Administer broad-spectrum antibiotics promptly as ordered for suspected infections.
2. Implement hand hygiene: Emphasize and practice rigorous hand hygiene for all healthcare personnel, patients, and visitors.
3. Discontinue unnecessary invasive lines: Remove IV lines, urinary catheters, and other invasive devices as soon as clinically appropriate to reduce infection risk.
4. Promote skin integrity: Implement measures to prevent skin breakdown, such as frequent turning, pressure ulcer prevention strategies, and meticulous wound care.

Conclusion: Enhancing Sepsis Care Through NANDA Nursing Diagnoses

Utilizing NANDA nursing diagnoses in the care of patients with sepsis provides a structured and effective approach to address the complex and rapidly changing needs of these critically ill individuals. By focusing on key diagnoses such as Decreased Cardiac Output, Hyperthermia, Ineffective Protection, Risk for Deficient Fluid Volume, and Risk for Infection, nurses can develop targeted care plans, prioritize interventions, and ultimately contribute to improved patient outcomes in sepsis management. Early recognition, aggressive treatment, and vigilant nursing care remain the cornerstones of sepsis survival.

References

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