Nursing Diagnosis: Sepsis Care Plan – A Comprehensive Guide for Nurses

Sepsis, a life-threatening condition arising from the body’s dysregulated response to infection, demands prompt recognition and aggressive management. Characterized by a systemic inflammatory response, sepsis can rapidly progress to septic shock, leading to organ failure and death if not addressed swiftly. This guide provides a comprehensive overview of sepsis within the nursing process framework, emphasizing crucial nursing assessments, interventions, and meticulously crafted care plans to enhance patient outcomes.

Nursing Process

Nurses across all healthcare settings play a pivotal role in sepsis management, particularly those in critical care units where most sepsis patients are treated. However, the ability to recognize early signs of sepsis is a fundamental skill for all nurses, as timely intervention is paramount to patient survival. Beyond recognition and immediate response, preventative measures are equally important. Meticulous infection control practices, including rigorous hand hygiene, consistent adherence to personal protective equipment (PPE) protocols, diligent wound care, and the application of sterile or aseptic techniques, are essential nursing responsibilities in mitigating the risk of sepsis.

Nursing Assessment

The cornerstone of effective nursing care is a thorough nursing assessment. This systematic process involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to form a holistic understanding of the patient’s condition. In the context of sepsis, both subjective and objective data are critical for accurate diagnosis and tailored care.

Review of Health History

1. Identify General Sepsis Symptoms: Early recognition of sepsis hinges on identifying its often subtle and varied symptoms. Nurses should be vigilant for:

• Temperature Instability: Elevated (hyperthermia, >100.4°F or >38°C) or decreased (hypothermia, <96.8°F or <36°C) body temperature.
• Chills: Shivering, often associated with fever.
• Mental Status Changes: Confusion, disorientation, lethargy, or agitation, indicating central nervous system involvement.
• Rapid Breathing (Tachypnea): Increased respiratory rate as the body attempts to compensate for metabolic acidosis and oxygen demand.
• Skin Changes: Flushed skin due to vasodilation or cool, clammy skin indicative of poor perfusion.
• Hypotension: Low blood pressure, a critical sign of progressing sepsis and potential shock.

2. Determine the Source of Infection: Sepsis originates from an infection. Identifying the primary site is crucial for targeted treatment. Common sources include infections of the:

• Lungs (Pneumonia): Respiratory infections are a leading cause of sepsis.
• Urinary System (Kidney, Bladder, Urinary Tract Infections – UTIs): UTIs, especially in catheterized patients, can escalate to sepsis.
• Gastrointestinal System: Abdominal infections, peritonitis, and bowel perforations can trigger sepsis.
• Blood (Bacteremia): Direct bloodstream infections.
• Invasive Devices: Catheter-related bloodstream infections (CRBSIs) from central lines and urinary catheters are significant risks.
• Skin and Soft Tissues (Burns, Wounds, Cellulitis): Compromised skin integrity provides entry points for pathogens.

3. Recognize Sepsis Risk Factors: Certain patient populations are at increased risk for developing sepsis. Nurses should identify these factors:

• Age Extremes: Infants and older adults (over 65 years) have less robust immune systems.
• Compromised Immune System (Immunocompromised): Conditions like HIV/AIDS, cancer, and immunosuppressive medications weaken defenses.
• Pre-existing Chronic Conditions (Comorbidities): Diabetes mellitus, chronic kidney disease, and COPD increase susceptibility.
• Prolonged Hospitalizations: Extended hospital stays increase exposure to healthcare-associated infections.
• Invasive Lines and Catheters: Central venous catheters and urinary catheters provide direct access to the bloodstream and urinary tract.
• Recent Antibiotic Use: Antibiotic use within the past 90 days, especially prolonged or unsupervised, can lead to antibiotic-resistant infections.
• Immunosuppressant Medications: Corticosteroids and other immunosuppressants suppress the immune response.

4. Review Medical History for Predisposing Conditions: A thorough medical history can reveal conditions that elevate sepsis risk:

• Existing, Undiagnosed, or Untreated Infections: Any infection, if not promptly and effectively managed, can progress to sepsis.
• Immunocompromising Conditions: Cancer, HIV, autoimmune diseases inherently increase infection risk.
• Chronic Diseases: Diabetes, COPD, heart failure, and other chronic illnesses impair immune function and overall health.
• Recent Surgical Procedures: Post-operative infections are a known sepsis trigger.
• Implanted Devices: Pacemakers, ports, prosthetic joints can become sites of infection.
• Organ Transplant Complications: Transplant recipients are immunosuppressed to prevent rejection, increasing infection vulnerability.

5. Medication Review and Antibiotic History: Medication lists provide critical information about immune status and potential antibiotic resistance:

• Corticosteroids and Immunosuppressants: These medications directly suppress the immune system, increasing infection and sepsis risk.
• Antibiotic Use History: Assess for recent, frequent, or inappropriate antibiotic use. Factors contributing to antibiotic resistance include:
  • Premature antibiotic discontinuation: Stopping antibiotics before completing the prescribed course.
  • Unnecessary antibiotic use (for viral infections): Overuse drives resistance.
  • Frequent antibiotic use: Repeated exposure selects for resistant bacteria.
  • Limited access to medications or poor quality drugs: Inadequate treatment promotes resistance.
  • Incorrect prescribing: Inappropriate antibiotic selection or dosing.

Physical Assessment

1. Vital Signs Monitoring: Vital sign changes are often the earliest indicators of sepsis. Closely assess for:

• Hyperthermia or Hypothermia: Temperature outside the normal range.
• Tachycardia: Heart rate above 100 bpm, often significantly elevated.
• Tachypnea: Respiratory rate above 20 breaths per minute.

2. Systemic Assessment for Organ Dysfunction: Sepsis can rapidly progress to severe sepsis and septic shock, marked by organ dysfunction. Systematic assessment is vital:

• Central Nervous System (CNS): Assess for altered mental status, confusion, lethargy, restlessness, or decreased Glasgow Coma Scale (GCS) score.
• Respiratory System: Monitor for hypoxia (SpO2 <90%), cough, chest pain, dyspnea (shortness of breath), increased respiratory effort, and adventitious breath sounds.
• Cardiovascular System: Evaluate capillary refill time (delayed >3 seconds), peripheral pulses (weak or thready), and blood pressure (hypotension).
• Gastrointestinal System: Assess for ileus (absent bowel sounds, abdominal distention), abdominal pain, tenderness, perforation (rigid abdomen), abscess formation, diarrhea, or vomiting.
• Genitourinary System: Monitor urine output for oliguria (decreased urine production, <0.5 mL/kg/hour) or anuria (absent urine production), indicating kidney dysfunction.
• Integumentary System: Observe skin color for flushed appearance (early sepsis), cyanosis (bluish discoloration, late sign of poor oxygenation), pallor (pale skin, poor perfusion), and mottling (patchy discoloration, indicative of shock).

3. Assess for Progression to Septic Shock: Septic shock represents the most severe stage of sepsis, characterized by profound hypotension and organ hypoperfusion. Signs include:

• Cool Extremities: Cold and clammy skin, especially in the extremities.
• Delayed Capillary Refill: Capillary refill time significantly prolonged (>3 seconds).
• Thready Pulses: Weak and rapid peripheral pulses.
• Pale Skin: Generalized pallor.
• Diaphoresis: Excessive sweating, often cold and clammy.
• Confusion and Decreased Level of Consciousness: Worsening mental status changes.

4. Intravenous (IV) Line Assessment: IV lines, particularly central lines, are potential infection sources. Inspect IV sites for:

• Swelling (Edema): Localized swelling around the insertion site.
• Redness (Erythema): Inflammation and infection.
• Drainage: Purulent or non-purulent discharge from the site.
• Pain or Tenderness: Discomfort upon palpation.
• Thrombophlebitis: Inflammation of the vein, often with a palpable cord.

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

• Abscess Formation: Localized collection of pus.
• Cellulitis: Spreading skin infection characterized by redness, warmth, pain, and swelling.
• Wound Infection: Purulent discharge, erythema, increased pain, swelling, and delayed healing. Document and monitor wound changes meticulously.

Alt Text: A registered nurse carefully examines a patient’s surgical wound for signs of infection, demonstrating meticulous wound assessment in sepsis care.

Diagnostic Procedures

1. Laboratory Studies: Laboratory tests are crucial for diagnosing sepsis, identifying the causative pathogen, and assessing organ function:

• Complete Blood Count (CBC): May reveal leukocytosis (elevated white blood cell count, WBC) or leukopenia (decreased WBC), neutropenia (low neutrophil count), and thrombocytopenia (low platelet count).
• Kidney Function Tests (Renal Panel): Elevated creatinine and blood urea nitrogen (BUN) indicate impaired kidney function and poor perfusion.
• Blood Cultures and Site-Specific Cultures: Cultures from blood, wounds, sputum, urine, or other suspected infection sites are essential to identify the causative organism and guide antibiotic therapy.
• Urinalysis and Urine Culture: Investigate urinary tract infections as a sepsis source.
• Biomarkers: Procalcitonin (PCT) and presepsin are biomarkers that are elevated in sepsis and aid in early diagnosis.
• Lactate Levels: Elevated lactate (>2 mmol/L) indicates anaerobic metabolism and poor tissue perfusion. Levels >4 mmol/L are strongly suggestive of septic shock.
• C-Reactive Protein (CRP): An inflammatory marker, typically elevated in sepsis.
• Coagulation Studies (INR, PTT): Elevated International Normalized Ratio (INR) and Partial Thromboplastin Time (PTT) indicate coagulation abnormalities and disseminated intravascular coagulation (DIC), a serious complication of sepsis.

2. Imaging Scans: Imaging studies help locate the source of infection and assess organ damage:

• Chest X-ray: Detects pneumonia or other lung infections.
• Chest CT Scan: More detailed imaging of the lungs and mediastinum.
• Abdominal Ultrasonography: Initial assessment of abdominal organs, particularly useful for gallbladder and liver.
• Abdominal CT Scan or MRI: Detailed abdominal imaging to identify abscesses, peritonitis, or other intra-abdominal infections.
• Site-Specific Soft Tissue Imaging (Ultrasound, CT, MRI): Evaluates localized infections like cellulitis or abscesses.
• Contrast-Enhanced CT or MRI of Brain/Neck: Investigates central nervous system infections or neck infections.

3. Invasive Diagnostic Procedures: Invasive procedures may be necessary to obtain samples for diagnosis or drainage of infection:

• Thoracentesis: Pleural fluid aspiration for analysis in cases of suspected empyema or pleural effusion.
• Paracentesis: Ascitic fluid aspiration for analysis in suspected peritonitis or abdominal infection.
• Fluid Accumulation and Abscess Drainage: Drainage of abscesses or other fluid collections for culture and source control.
• Bronchoscopy with Lavage/Washing: Bronchoalveolar lavage (BAL) or bronchial washings to obtain respiratory samples for culture and diagnosis, particularly in ventilator-associated pneumonia (VAP).

Nursing Interventions

Effective nursing interventions are crucial for patient recovery from sepsis. These interventions are multifaceted and aimed at addressing the underlying infection, supporting organ function, and preventing complications.

1. Hospital Admission and ICU Preparation: Patients with sepsis require immediate hospitalization and intensive care unit (ICU) admission due to the potential for rapid deterioration and the need for aggressive medical management.

2. Antibiotic Therapy Initiation: Prompt antibiotic administration is the cornerstone of sepsis treatment.

• Broad-Spectrum Antibiotics: Start with broad-spectrum antibiotics immediately after obtaining blood cultures to cover a wide range of potential pathogens.
• Narrow-Spectrum Antibiotics: Once culture results identify the specific causative pathogen, antibiotics may be narrowed to target the specific organism, minimizing antibiotic resistance development.

3. Fluid Volume Resuscitation: Aggressive fluid resuscitation is essential to address hypovolemia and improve tissue perfusion.

• Crystalloid Fluids: Administer at least 30 mL/kg of crystalloid fluids (e.g., normal saline, lactated Ringer’s) within the first three hours of sepsis recognition.
• Perfusion Pressure Goals: Fluid resuscitation aims to maintain adequate perfusion pressure and hemodynamic stability.

4. Vasopressor Administration: Vasopressors are used to raise blood pressure when fluid resuscitation alone is insufficient.

• Vasopressor Medications: Administer vasopressors (e.g., norepinephrine, dopamine) as prescribed if blood pressure remains low despite adequate fluid administration. Vasopressors constrict blood vessels, increasing systemic vascular resistance and blood pressure.

5. Patient Positioning: Positioning can optimize respiratory function.

• Semi-Fowler’s or High-Fowler’s Position: Elevating the head of the bed reduces the risk of aspiration pneumonia and improves lung expansion.
• Prone Positioning: In sepsis-induced acute respiratory distress syndrome (ARDS), prone positioning can improve oxygenation by improving ventilation-perfusion matching.

6. Invasive Hemodynamic Monitoring: Invasive arterial monitoring provides continuous and accurate blood pressure and hemodynamic data, crucial for guiding fluid and vasopressor therapy.

7. Oxygen Therapy and Mechanical Ventilation: Respiratory support is often necessary in sepsis.

• Supplemental Oxygen: Administer oxygen to patients with hypoxia to maintain adequate SpO2 levels.
• Mechanical Ventilation: Prepare for intubation and mechanical ventilation for patients with respiratory failure, severe hypoxia, or declining respiratory status.

8. Insulin Administration for Hyperglycemia Management: Sepsis often induces hyperglycemia, even in non-diabetic patients.

• Insulin Therapy: Administer insulin as prescribed to maintain blood glucose levels within target range (typically <180 mg/dL). Tight glycemic control may not always be beneficial and can increase hypoglycemia risk.

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

• Infected or Necrotic Tissue Removal: Surgical debridement or drainage of abscesses may be necessary to remove infected tissues and control the source of sepsis.

10. Intravascular Device Removal: Prompt removal of potentially infected intravascular devices is crucial.

• Catheter Removal: Remove central lines, peripheral IV catheters, and urinary catheters if they are suspected as the source of sepsis, or if they are no longer essential.

11. Hygiene Practices: Strict hygiene practices are essential to prevent secondary infections and cross-contamination.

• Hand Hygiene: Emphasize and practice meticulous hand hygiene before and after patient contact, and after contact with potentially contaminated materials.
• Aseptic Technique: Use aseptic technique for catheter care, IV line maintenance, and wound care.
• Equipment Disinfection: Regularly disinfect patient care equipment according to facility guidelines.
• Bed Baths and Perineal Care: Maintain patient hygiene through regular bed baths and perineal care.

12. Infection Control Precautions: Implement appropriate infection control precautions to prevent transmission.

• Standard Precautions: Utilize standard precautions for all patient interactions.
• Transmission-Based Precautions: Implement contact, droplet, or airborne precautions as indicated by the suspected or confirmed pathogen.
• Protective Isolation: Consider protective isolation for severely immunocompromised patients to minimize exposure to pathogens.

13. Personal Protective Equipment (PPE): Consistent PPE use protects healthcare workers and patients.

• Gowns and Gloves: Don gowns and gloves before entering the patient’s room to prevent direct contact transmission.
• Masks and Eye Protection: Use face masks and eye protection (goggles or face shields) to protect against droplet and airborne transmission, especially during procedures with potential splash or splatter.

14. Enteral or Parenteral Nutrition: Nutritional support is important in sepsis management.

• Early Enteral Nutrition: Initiate enteral nutrition (tube feeding) as early as possible to provide nutrients and support gut function, ideally within 24-48 hours, if the patient can tolerate it.
• Parenteral Nutrition: If enteral nutrition is contraindicated or not tolerated, parenteral nutrition (IV nutrition) may be necessary to meet nutritional needs.

Nursing Care Plans

Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term goals of care for sepsis patients. Here are examples of nursing care plans for common nursing diagnoses associated with sepsis:

Decreased Cardiac Output

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

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Altered hemodynamic parameters (hypotension, decreased systemic vascular resistance)
• Impaired cardiac contractility (sepsis-induced myocardial dysfunction)
• Impaired myocardial circulation
• Loss of vascular tone (vasodilation)
• Hypovolemia (fluid shifts, capillary leak)

As evidenced by:

• Tachycardia
• Changes in Central Venous Pressure (CVP), Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP)
• Decreased Mean Arterial Pressure (MAP)
• Cyanosis, Pallor
• Prolonged capillary refill time (>3 seconds)
• Hypotension (Systolic BP <90 mmHg or MAP <65 mmHg)
• Oliguria (urine output <0.5 mL/kg/hour)
• Altered level of consciousness, confusion, restlessness
• Cold, clammy skin
• Decreased peripheral pulses (weak, thready)
• Cardiac dysrhythmias
• Presence of murmurs (new murmurs may indicate septic cardiomyopathy)

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Vital signs within normal limits:
    • Blood pressure: Systolic 90-120 mmHg, Diastolic 60-80 mmHg (or patient’s baseline)
    • Pulse rate: 60-100 beats per minute, regular rhythm
    • Central venous pressure (CVP) 8-12 mmHg
    • Mean arterial pressure (MAP) 65-90 mmHg
  • Urine output: 0.5-1.5 mL/kg/hour
  • Absence of cardiac dysrhythmias
  • Absence of new murmurs
  • Improved level of consciousness

Assessments:

1. Assess for signs and symptoms of cardiac and circulatory compromise. Hypotension, tachycardia, tachypnea, and weak peripheral pulses are key indicators of decreased cardiac output in sepsis.

2. Monitor hemodynamic parameters (CVP, PADP, PCWP).

   • CVP reflects right ventricular preload and overall fluid volume status.
   • PADP and PCWP provide information about left ventricular preload and left-sided heart function.

3. Monitor laboratory data, including cardiac markers. Sepsis-induced cardiomyopathy can lead to:

   • Elevated cardiac troponins (Troponin I or T): Indicate myocardial injury. Elevated troponins in sepsis correlate with left ventricular dysfunction and increased mortality.
   • Elevated BNP and NT-proBNP: Brain natriuretic peptide (BNP) and N-terminal pro-BNP are elevated in heart failure and can be elevated in septic cardiomyopathy, correlating with disease severity.
   • Decreased ejection fraction (Ejection Fraction <50%): Left ventricular ejection fraction (LVEF) may be reduced in septic cardiomyopathy, indicating impaired systolic function.

Interventions:

1. Administer fluid resuscitation as prescribed. Aggressive fluid therapy is crucial to address hypovolemia and improve preload. However, caution is needed in septic cardiomyopathy as excessive fluid can worsen cardiac function. Monitor closely for signs of fluid overload.

2. Administer medications as prescribed:

   • Antibiotics: Administer broad-spectrum antibiotics immediately after obtaining blood cultures.
   • Vasopressors: Administer vasopressors (e.g., norepinephrine) to increase blood pressure and systemic vascular resistance. Titrate vasopressors to maintain MAP ≥65 mmHg.

3. Anticipate adjunctive therapies as indicated. For severe septic cardiomyopathy, mechanical circulatory support may be needed.

   • Intra-aortic balloon pump (IABP): Provides counterpulsation to augment coronary perfusion and reduce afterload.
   • Percutaneous ventricular assist devices (pVADs): Support left ventricular function.
   • Extracorporeal membrane oxygenation (ECMO): Provides temporary cardiopulmonary support in refractory septic shock and severe cardiomyopathy.

4. Optimize oxygen delivery. Ensure adequate oxygenation to support myocardial function and tissue perfusion. Administer supplemental oxygen via nasal cannula, high-flow nasal cannula, or mechanical ventilation as needed to maintain SpO2 >90%.

Hyperthermia

Hyperthermia is a common manifestation of sepsis, reflecting the body’s inflammatory response to infection.

Nursing Diagnosis: Hyperthermia

Related to:

• Dehydration
• Increased metabolic rate (hypermetabolism associated with sepsis)
• Inflammatory process (systemic inflammatory response syndrome – SIRS)

As evidenced by:

• Increased body temperature above normal range (>100.4°F or >38°C)
• Flushed skin, warm to touch
• Tachypnea
• Tachycardia
• Confusion, irritability
• Seizures (in severe hyperthermia)

Expected Outcomes:

• Patient will maintain body temperature within normal limits (97.6°F-100.4°F or 36.4°C-38°C) within 24-48 hours.
• Underlying cause of hyperthermia (infection) will be identified and treated.

Assessments:

1. Assess temperature rectally or via bladder catheter if available. Rectal temperature is considered the most accurate for core body temperature measurement. Bladder catheters with temperature probes provide continuous core temperature monitoring.

2. Assess neurological status. Uncontrolled hyperthermia can lead to neurological damage. Monitor for altered level of consciousness (LOC), confusion, irritability, delirium, and seizures.

Interventions:

1. Provide a cool environment. Reduce room temperature, remove unnecessary blankets and clothing to promote heat dissipation.

2. Apply a cooling blanket. Use a cooling blanket to reduce surface temperature. Monitor closely for shivering, which can paradoxically increase body temperature and metabolic demand.

3. Administer antipyretics as prescribed. Administer acetaminophen or ibuprofen to reduce fever. Follow prescribed dosage and frequency.

4. Provide cool compresses or tepid baths. Apply cool, damp cloths to groin, axillae, and forehead to promote heat loss through conduction and evaporation. Tepid sponge baths can also be used, avoiding cold water which can induce shivering. Do not use ice packs or alcohol rubs.

Ineffective Protection

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

Nursing Diagnosis: Ineffective Protection

Related to:

• Infectious process (sepsis)
• Immunosuppression (sepsis-induced or pre-existing)
• Abnormal blood profiles (leukopenia, neutropenia, thrombocytopenia)
• Poor nutritional status
• Medication regimen (immunosuppressants, chemotherapy)
• Older age

As evidenced by:

• Change in level of consciousness (lethargy, confusion)
• Insomnia, fatigue
• Immobility, weakness
• Poor ability to handle stress
• Open wounds, pressure ulcers, invasive devices

Expected Outcomes:

• Patient will remain free from secondary infections during hospitalization.
• Patient will verbalize understanding of infection prevention measures.
• Patient will demonstrate protective behaviors to enhance immune function.

Assessments:

1. Monitor for signs and symptoms of secondary infections. Sepsis patients are at high risk for hospital-acquired infections. Monitor for fever, new sites of infection (pneumonia, UTI, wound infection), changes in sputum, urine, or wound drainage.

2. Monitor WBC count and differential. Leukocytosis (elevated WBC) may indicate infection, but leukopenia (low WBC) or neutropenia (low neutrophil count) in sepsis suggests severe immune compromise. Monitor neutrophil count as a key indicator of infection risk. Assess differential count for bandemia (increased immature neutrophils – “left shift”), indicating acute infection.

3. Assess risk factors for ineffective protection. Identify and document patient-specific risk factors, including immunosuppression (HIV, cancer, transplant, autoimmune diseases, medications), age extremes, malnutrition, presence of invasive devices, and impaired skin integrity.

Interventions:

1. Encourage rest and sleep. Promote adequate rest and sleep to support immune function and cellular repair. Cluster nursing activities to minimize disruptions.

2. Minimize invasive procedures. Avoid unnecessary invasive procedures (catheterizations, injections). Use meticulous aseptic technique when invasive procedures are necessary. Remove invasive lines and catheters as soon as clinically appropriate.

3. Promote optimal nutrition. Encourage a high-protein, nutrient-rich diet to support immune function and tissue repair. Consult dietitian for nutritional assessment and support. Consider oral nutritional supplements or enteral/parenteral nutrition if needed.

4. Educate patient and family about infection control measures. Teach proper hand hygiene techniques. Educate on the importance of avoiding contact with sick individuals. Instruct family and visitors to adhere to hospital infection control policies.

Risk for Deficient Fluid Volume

Sepsis-induced vasodilation and capillary leak lead to fluid shifts out of the intravascular space, increasing the risk of deficient fluid volume and hypovolemic shock.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related to:

• Vasodilation (sepsis-induced systemic vasodilation)
• Increased membrane permeability (capillary leak syndrome)
• Third spacing of fluids

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 circulatory volume as evidenced by:
  • Stable vital signs (blood pressure, heart rate) within patient’s baseline.
  • Urinary output ≥0.5 mL/kg/hour.
  • Absence of signs of dehydration (dry mucous membranes, poor skin turgor).
  • Balanced fluid intake and output.

Assessments:

1. Monitor for signs of fluid loss and dehydration. Early signs of fluid volume deficit in sepsis include tachycardia, decreased blood pressure, increased respiratory rate, fever, dry mucous membranes, poor skin turgor, and decreased urine output.

2. Assess intake and output and daily weight. Strictly monitor fluid intake (oral, IV) and output (urine, drains, emesis, diarrhea). Monitor daily weight for trends in fluid balance. A sudden weight gain may indicate fluid retention, while weight loss may suggest dehydration.

3. Monitor for edema. Assess for peripheral edema (swelling in extremities) and pulmonary edema (crackles in lungs). Edema can be a sign of fluid shifts and third spacing, or fluid overload from aggressive resuscitation.

4. Review laboratory values. Monitor hemoglobin (Hgb) and hematocrit (Hct). Elevated Hct may indicate hemoconcentration due to dehydration. Monitor serum electrolytes (sodium, potassium) and renal function tests (BUN, creatinine). Elevated BUN and creatinine may indicate prerenal azotemia due to hypovolemia and kidney hypoperfusion. Urine specific gravity may be elevated in dehydration.

Interventions:

1. Administer IV fluids as prescribed. Initiate rapid IV fluid resuscitation with crystalloids (normal saline, lactated Ringer’s) as the initial fluid of choice. Colloids (albumin) may be considered in patients with persistent hypovolemia despite crystalloid administration, but are not routinely recommended as first-line therapy. Follow sepsis resuscitation protocols for fluid administration.

2. Administer vasopressors as prescribed. Vasopressors (norepinephrine, dopamine) may be needed to maintain blood pressure and tissue perfusion if fluid resuscitation alone is inadequate. Titrate vasopressors to maintain MAP ≥65 mmHg.

3. Monitor circulatory function closely. Continuously monitor heart rate, blood pressure, respiratory rate, SpO2, and level of consciousness. Assess peripheral pulses, capillary refill, and skin color and temperature. Monitor central venous pressure (CVP) if a central line is in place to guide fluid management. Monitor urine output hourly.

Risk for Infection

While sepsis itself is an infection, patients remain at risk for developing new or secondary infections during their illness and hospitalization.

Nursing Diagnosis: Risk for Infection

Related to:

• Immunosuppression (sepsis-induced immune dysfunction)
• Multiple chronic comorbidities
• Compromised skin or tissue integrity (invasive devices, wounds, pressure ulcers)
• Malnutrition
• Untreated or worsening infections (potential for superinfection or secondary infection)

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 or secondary infections during hospitalization.
• Patient will demonstrate understanding of infection prevention strategies.
• Patient will exhibit improvement in wound healing without signs of infection.

Assessments:

1. Monitor for signs and symptoms of new infections. Sepsis patients are vulnerable to secondary infections. Monitor for fever, chills, new cough or change in sputum, dysuria or change in urine characteristics, wound drainage or redness, localized pain, or any new signs of systemic infection.

2. Monitor laboratory work for indicators of infection. Monitor WBC count, differential, CRP, PCT, and other inflammatory markers. Obtain cultures (blood, urine, sputum, wound) as indicated if new infection is suspected.

3. Obtain specimens for culture if new infection is suspected. Culture blood, urine, sputum, wound drainage, or other relevant sites if signs of new infection develop to identify the causative pathogen and guide antibiotic therapy.

Interventions:

1. Administer anti-infectives as prescribed. Administer prescribed antibiotics promptly and ensure appropriate dosing and duration. Monitor for therapeutic effectiveness and adverse effects of antibiotics. Be vigilant about preventing antibiotic resistance by using antibiotics judiciously and according to guidelines.

2. Emphasize hand hygiene. Reinforce meticulous hand hygiene practices for healthcare providers, patient, and visitors. Ensure access to hand sanitizer and soap and water. Educate on proper handwashing technique and indications.

3. Discontinue unnecessary invasive lines and devices. Regularly assess the necessity of invasive lines (IV catheters, urinary catheters, central lines, drains, endotracheal tubes). Remove lines as soon as they are no longer clinically indicated to reduce infection risk.

4. Promote skin integrity. Implement measures to prevent skin breakdown and pressure ulcers. Turn and reposition patients at least every 2 hours. Use pressure-reducing support surfaces. Provide meticulous skin care and moisture management. Assess skin regularly for redness, breakdown, or signs of infection.

References

• Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., … & Moreno, R. (2013). Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine, 41(2), 580-637.
• Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., … & Angus, D. C. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 315(8), 801-810.
• Townsend-Gervis, M., & Fan, E. (2013). Sepsis-associated cardiomyopathy. Critical Care Clinics, 29(3), 407-420.
• Vincent, J. L., & De Backer, D. (2013). Circulatory shock. New England Journal of Medicine, 369(18), 1726-1734.
• Wong, H. R., &اندارایانی, V. (2017). Biomarkers in sepsis and septic shock. Current opinion in pediatrics, 29(3), 344-349.