Sepsis arises when the body responds improperly to an infection, typically bacterial, leading to a systemic infection and an overwhelming immune reaction. This life-threatening condition necessitates prompt intervention to avert septic shock, which can cause organ failure and death.
Sepsis can progress rapidly and carries a high mortality rate if early recognition and aggressive treatment are delayed. Infants, adults over 65, and individuals with weakened immune systems or chronic illnesses are at the greatest risk.
In this guide, we will delve into the nursing process for sepsis, focusing on assessment, interventions, and comprehensive care plans to aid in the management of this critical condition.
Nursing Process for Sepsis
While most sepsis patients receive care in the Intensive Care Unit (ICU), it is crucial for nurses across all units and specialties to be adept at identifying and assessing sepsis signs, as treatment delays can be fatal. Furthermore, nurses play a vital role in sepsis prevention through meticulous hand hygiene, consistent use of Personal Protective Equipment (PPE), diligent wound care, and adherence to sterile or aseptic techniques.
Nursing Assessment for Sepsis
The initial step in nursing care is a thorough nursing assessment, encompassing the collection of physical, psychosocial, emotional, and diagnostic data. This section will cover both subjective and objective data pertinent to sepsis.
Review of Health History
1. Identify General Sepsis Symptoms. Be alert for these common sepsis indicators:
- Elevated or decreased body temperature
- Shivering or chills
- Altered mental status or confusion
- Rapid breathing
- Skin changes: flushed or cool
- Hypotension
2. Determine the Source of Infection. Sepsis can originate from infections caused by viruses, bacteria, or fungi. Common infection sites leading to sepsis include:
- Lungs (pneumonia)
- Kidneys, bladder, and urinary tract infections (UTIs)
- Gastrointestinal system
- Bloodstream infections
- Invasive devices (catheters, IV lines)
- Burns or wounds
3. Recognize Sepsis Risk Factors. Several factors increase an individual’s susceptibility to sepsis:
- Age over 65 years
- Infancy
- Immunocompromised state
- Presence of comorbidities such as diabetes or chronic kidney disease
- Prolonged hospitalizations
- Indwelling invasive lines like central venous catheters or urinary catheters
- Recent prolonged antibiotic use (within 90 days) without medical supervision
- Use of corticosteroids or other immunosuppressant medications
4. Analyze Medical History for Predisposing Conditions. Certain medical conditions elevate the risk of sepsis:
- Existing, undiagnosed, or untreated infections
- Conditions causing immune compromise (cancer, HIV)
- Chronic diseases (diabetes, COPD)
- Recent surgical procedures
- Implanted devices like pacemakers or ports
- Organ transplant complications
5. Examine Medication History. Note the use of corticosteroids and immunosuppressants, which can weaken the immune system. Also, evaluate antibiotic use history, as certain patterns can lead to antibiotic-resistant bacteria:
- Discontinuing antibiotics prematurely without medical advice
- Inappropriate antibiotic use
- Frequent antibiotic exposure
- Limited access to necessary medications
- Substandard medication quality
- Incorrect antibiotic prescriptions
Physical Assessment for Sepsis
1. Evaluate Vital Signs. Initial vital sign changes in sepsis may include:
- 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. Conduct a Systemic Assessment. Sepsis can progress to severe sepsis and septic shock with organ dysfunction if untreated. Closely monitor for the following changes indicative of organ involvement:
- Central Nervous System (CNS): Altered mental status, confusion, lethargy
- Respiratory System: Hypoxia, cough, chest pain, dyspnea (shortness of breath)
- Cardiovascular System: Decreased capillary refill time
- Gastrointestinal System: Ileus, perforation, abscess, abdominal tenderness
- Genitourinary System: Decreased (oliguria) or absent (anuria) urine output
- Integumentary System: Flushed skin, cyanosis, pallor, skin mottling
3. Assess for Shock Progression. As septic shock advances, hypotension and reduced organ perfusion develop, accompanied by symptoms such as:
- Cool extremities
- Prolonged capillary refill (>3 seconds)
- Weak, thready pulses
- Pale skin
- Diaphoresis (excessive sweating)
- Confusion
- Decreased level of consciousness
4. Inspect Intravenous (IV) Lines. Observe IV sites for signs of infection or thrombophlebitis, including swelling, redness, or drainage. Central venous lines are frequently associated with sepsis or bacteremia.
5. Examine Wounds and Incisions for Infection. Presence of abscess, cellulitis, or wound infection may manifest as pain, purulent discharge, erythema, or swelling. Thoroughly monitor and document any changes in wounds and incisions.
Diagnostic Procedures for Sepsis
1. Collect Samples for Laboratory Studies. Laboratory tests are essential for sepsis diagnosis and identifying the causative pathogen:
- Complete Blood Count (CBC): May reveal elevated or decreased white blood cell count (WBC), neutropenia, and thrombocytopenia.
- Kidney Function Tests: Assess kidney perfusion and function.
- Blood and Site-Specific Cultures: Cultures from blood, wounds, sputum, or urine to identify the infectious agent.
- Urinalysis & Culture: Further investigate urinary tract infections.
- Biomarkers: Procalcitonin and presepsin levels aid in early sepsis detection.
- Lactate Levels: Levels >2 mmol/L suggest poor organ perfusion, and >4 mmol/L indicate septic shock.
- C-Reactive Protein (CRP): Expected to be elevated in sepsis.
- Coagulation Studies (INR, PTT): Elevated results may indicate coagulation abnormalities.
2. Prepare Patient for Imaging Scans. Imaging can help locate the source of infection and assess organ damage. Common imaging modalities include:
- Chest X-ray
- Chest CT scan
- Abdominal Ultrasound
- Abdominal CT scan or MRI
- Site-specific soft tissue imaging (ultrasound, CT, MRI)
- Contrast-enhanced CT or MRI of the brain/neck
3. Anticipate Invasive Diagnostic Procedures. In certain cases, invasive procedures may be necessary:
- Thoracentesis
- Paracentesis
- Drainage of fluid collections or abscesses
- Bronchoscopy with lavage, washing, or biopsies
Nursing Interventions for Sepsis
Nursing interventions and comprehensive care are critical for patient recovery from sepsis. The following are key nursing interventions for managing sepsis:
1. Prepare for Hospital Admission. Sepsis necessitates intensive care in a hospital ICU for close monitoring and aggressive medical management.
2. Initiate Antibiotic Therapy Promptly. Begin antibiotic treatment as soon as sepsis is suspected. Broad-spectrum antibiotics are typically initiated first. Once culture results identify the specific pathogen, antibiotics may be narrowed to target the causative organism.
3. Implement Fluid Resuscitation. In the initial sepsis phase, aggressive fluid resuscitation with at least 30 mL/kg of crystalloid fluids within the first three hours is recommended to maintain adequate perfusion pressure.
4. Administer Vasopressors as Prescribed. If hypotension persists despite fluid resuscitation, vasopressors may be necessary to raise blood pressure by constricting blood vessels.
5. Optimize Patient Positioning. Semi-Fowler’s or high-Fowler’s position can reduce pneumonia risk. Prone positioning may be indicated for sepsis-induced ARDS.
6. Initiate Invasive Hemodynamic Monitoring. Arterial lines allow for continuous and accurate blood pressure and hemodynamic monitoring.
7. Provide Oxygen Support or Mechanical Ventilation. Hypoxic patients require supplemental oxygen. Respiratory failure may necessitate intubation and mechanical ventilation.
8. Administer Insulin for Hyperglycemia. Sepsis can induce hyperglycemia even in non-diabetic patients. Insulin is administered for glucose levels exceeding 180 mg/dL.
9. Prepare for Potential Surgical Intervention. Surgical removal of infected or necrotic tissue may be required to control the source of infection.
10. Remove Intravascular Devices if Suspected Source. Prompt removal of potentially infected intravascular access devices is advised.
11. Enforce Strict Hygiene Practices. Rigorous hand hygiene is paramount for infection prevention. Maintain strict hygiene for sepsis patients, including bed baths and aseptic cleaning of catheters and IV hubs according to hospital protocols. Regular disinfection of all equipment is essential.
12. Implement Transmission-Based Precautions. Implement septic isolation and transmission-based precautions to prevent cross-transmission to other patients, healthcare workers, and visitors. Protective isolation may be necessary for immunocompromised patients. Visitor restrictions may be implemented.
13. Utilize Appropriate Personal Protective Equipment (PPE). PPE protects both healthcare workers and patients. Don gowns and gloves before room entry. Use face masks and eye protection to guard against droplets and airborne microorganisms.
14. Initiate Enteral Nutrition Early. Early enteral or parenteral nutrition is recommended to address micronutrient deficiencies and provide protein support for patients unable to maintain oral intake within three days.
Nursing Care Plans for Sepsis
Once nursing diagnoses are identified for sepsis, nursing care plans provide a framework for prioritizing assessments and interventions to achieve both short-term and long-term care goals. Examples of nursing care plans for sepsis include:
Decreased Cardiac Output
Severe sepsis and hypoperfusion can significantly compromise cardiac function.
Nursing Diagnosis: Decreased Cardiac Output
Alt: Nurse palpating a patient’s peripheral pulse to assess circulation and cardiac output, crucial in nursing care plan for sepsis.
Related Factors:
- Altered hemodynamic parameters
- Impaired cardiac contractility
- Impaired myocardial circulation
- Loss of vascular tone
- Hypovolemia
As Evidenced By:
- Tachycardia
- Abnormal Central venous pressure
- Abnormal Mean arterial pressure
- Cyanosis
- Pallor
- Prolonged capillary refill time
- Blood pressure variations
- Oliguria
- Altered level of consciousness
- Cold, clammy skin
- Decreased peripheral pulses
- Cardiac dysrhythmias
- Presence of murmurs
Expected Outcomes:
- Patient will demonstrate adequate cardiac output as evidenced by:
- Stable vital signs within normal limits:
- Blood pressure: 90/60 mmHg to 120/80 mmHg
- Pulse rate: 60 to 100 beats per minute
- Central venous pressure 8-12 mmHg
- Mean arterial pressure 65-90 mmHg
- Adequate urine output: 0.5 to 1.5 cc/kg/hour
- Normal cardiac assessment findings:
- Adynamic precordium
- Absence of cardiac dysrhythmias
- Absence of murmurs
- Stable vital signs within normal limits:
Assessments:
1. Monitor for Cardiac and Circulatory Compromise. Hypotension, tachycardia, tachypnea, and weak peripheral pulses are indicative of decreased cardiac output in severe sepsis.
2. Monitor Hemodynamic Parameters (CVP, PADP, PCWP).
- CVP reflects right-sided heart filling pressures.
- PADP and PCWP reflect left-sided fluid volumes.
3. Review Laboratory Data. Sepsis-induced cardiomyopathy may be indicated by:
- Elevated cardiac markers:
- Increased plasma troponins (I or T) may correlate with left ventricular systolic dysfunction and myocardial injury.
- Elevated BNP and NT-proBNP may correlate with sepsis severity.
- Decreased ejection fraction:
- Left ventricular ejection fraction is a key indicator of septic cardiomyopathy.
Interventions:
1. Administer Fluid Resuscitation as Prescribed. Adequate fluid therapy is crucial for sepsis-induced tissue hypoperfusion and hypovolemia caused by vasodilation, fluid loss, and capillary leak. However, cautious administration is needed due to potential cardiomyopathy and risk of fluid overload.
2. Administer Medications as Prescribed.
- Antibiotics: Broad-spectrum antibiotics are initiated immediately after blood cultures.
- Vasopressors: Counteract vasodilation to increase blood pressure and perfusion.
3. Prepare for Adjunctive Therapies. Mechanical support like Intra-Aortic Balloon Pump (IABP), ventricular assist devices, or Extracorporeal Membrane Oxygenation (ECMO) may be required if primary therapies fail.
4. Optimize Oxygen Delivery. Ensure adequate oxygenation via high-flow mask or mechanical ventilation to support cardiac function and perfusion.
Hyperthermia
Elevated body temperature is a natural response to infection and inflammation. However, extreme and prolonged hyperthermia can be detrimental.
Nursing Diagnosis: Hyperthermia
Alt: Nurse using a rectal thermometer to accurately assess a patient’s core body temperature, important for hyperthermia management in sepsis nursing care plan.
Related Factors:
- Dehydration
- Increased metabolic rate
- Inflammatory process
As Evidenced By:
- Elevated body temperature above normal range
- Flushed, warm skin
- Tachypnea
- Tachycardia
- Confusion
- Seizures
Expected Outcomes:
- Patient will maintain body temperature within normal limits.
- Underlying infection will be treated to resolve hyperthermia.
Assessments:
1. Assess Temperature Rectally. Rectal temperature measurement provides the most accurate core temperature reading.
2. Assess Neurological Status. Uncontrolled hyperthermia can cause brain damage, indicated by altered LOC, confusion, and seizures.
Interventions:
1. Provide a Cool Environment. Maintain a cooler room temperature, remove excess linens and restrictive clothing.
2. Apply Cooling Blanket. Cooling blankets reduce surface temperature, requiring close monitoring to prevent shivering, which can increase body temperature.
3. Administer Antipyretics. Administer acetaminophen or other antipyretics to reduce fever.
4. Provide Cooling Measures. Apply cool cloths to groin and axillae and provide tepid baths to promote heat loss through evaporation.
Ineffective Protection
Patients may have a reduced ability to protect themselves from infection, increasing sepsis risk.
Nursing Diagnosis: Ineffective Protection
Alt: Nurse educating a patient and family about hand hygiene and infection control to enhance patient protection, a key component of sepsis nursing care plan.
Related Factors:
- Infectious process
- Immunosuppression
- Abnormal blood profiles
- Poor nutrition
- Medication regimen
- Older age
As Evidenced By:
- Change in level of consciousness
- Insomnia
- Immobility
- Poor ability to handle stress
- Open wound/pressure ulcer
Expected Outcomes:
- Patient will remain free from infection.
- Patient will verbalize appropriate food choices for nutritional needs.
- Patient will demonstrate measures to enhance immune system protection.
Assessments:
1. Monitor for Sepsis Signs. Changes in mental status, hypotension, fever, tachycardia, chills, and flushed skin are sepsis indicators requiring prompt reporting.
2. Monitor WBC and Differential Count. Leukocytosis is typical in infection, but sepsis may present with leukocytosis or leukopenia. Immature band forms may also be elevated.
3. Assess Risk Factors for Ineffective Protection. Identify risk factors such as immunosuppression, immobility, poor nutrition, and wounds that increase sepsis risk.
Interventions:
1. Encourage Rest. Adequate sleep is essential for cellular repair and growth hormone release, crucial for healing.
2. Minimize Invasive Procedures. Limit catheterization, injections, and rectal/vaginal procedures to reduce pathogen introduction. Use aseptic techniques for necessary invasive lines.
3. Promote High Protein, Nutrient-Rich Diet. Protein aids tissue repair and infection fighting. Consider appetite stimulants or dietician consultation for poor appetite.
4. Educate on Infection Control Measures. Instruct patients and families on proper hand hygiene techniques for infection prevention.
Risk for Deficient Fluid Volume
Sepsis progression to septic shock causes fluid shifts leading to hypotension and requiring fluid resuscitation.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Alt: Nurse administering IV fluids to a patient for volume resuscitation, a critical intervention in sepsis nursing care plan to address deficient fluid volume.
Related Factors:
- Vasodilation
- Membrane permeability
As Evidenced By:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventive.
Expected Outcome:
- Patient will maintain adequate circulatory volume as evidenced by stable vital signs and normal urinary output.
Assessments:
1. Monitor for Fluid Loss Signs. Septic shock causes rapid blood pressure drops due to fluid shifts. Monitor for tachycardia, fever, and dehydration signs like poor skin turgor and dry mucous membranes.
2. Assess Intake and Output and Weight. Closely track fluid intake (PO, IV) versus urine output to detect imbalances.
3. Monitor for Edema. Fluid shifting to interstitial spaces causes edema. Monitor for weight gain, indicating third spacing.
4. Review Lab Values. Changes in hemoglobin and hematocrit can indicate low fluid volume. Abnormal BUN and creatinine suggest kidney dysfunction. High urine specific gravity indicates dehydration and kidney damage.
Interventions:
1. Administer IV Fluids. Crystalloids (normal saline, lactated Ringers) are initial fluid resuscitation choices. Colloids (albumin, fresh frozen plasma) may be needed for better intravascular volume expansion.
2. Administer Vasopressors. Vasopressors (dopamine, norepinephrine) are used with fluids or for persistent septic shock to restore blood pressure.
3. Monitor Circulatory Function. Monitor heart rate, rhythm, MAP, respiratory function (pulse oximetry), and kidney function (output, labs) to ensure organ perfusion.
Risk for Infection
Sepsis itself is a systemic infection requiring vigilance and prompt intervention. Nurses must identify at-risk patients and prevent condition worsening.
Nursing Diagnosis: Risk for Infection
Alt: Nurse demonstrating proper hand hygiene technique, emphasizing its importance in infection prevention as part of a comprehensive sepsis nursing care plan.
Related Factors:
- Immunosuppression
- Multiple chronic comorbidities
- Compromised skin or tissue integrity
- Malnutrition
- Untreated/worsening infections (UTIs, cellulitis, pneumonia)
As Evidenced By:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventive.
Expected Outcomes:
- Patient will remain free of infection with stable vital signs and normal WBC count.
- Patient will demonstrate wound healing improvement without infection signs.
- Patient will identify infection prevention strategies.
Assessments:
1. Note Sepsis Signs and Symptoms. Monitor for fever, tachycardia, tachypnea, chills, and altered mental status, intervening to prevent sepsis progression.
2. Monitor Lab Work. Elevated WBC, CRP, and lactate levels are indicative of sepsis.
3. Obtain Specimens for Culture. Collect blood, urine, and sputum samples to identify the infection source.
Interventions:
1. Administer Anti-infectives. Prophylactic IV antibiotics may be used for prevention. Broad-spectrum antibiotics are used initially until pathogen identification.
2. Emphasize Hand Hygiene. Proper hand hygiene is the most effective infection prevention measure. Educate nurses and patients on handwashing and sanitizer use.
3. Discontinue Unnecessary Invasive Lines. Regularly assess and remove unnecessary IV lines, urinary catheters, and other invasive devices to reduce infection risk.
4. Promote Skin Integrity. Prevent skin breakdown through regular turning, ambulation assistance, and skin assessments, especially for patients with decreased mobility.
