Sepsis Nursing Diagnosis: A Comprehensive Guide for Nurses

Sepsis, often stemming from bacteremia, is a life-threatening condition arising from the body’s dysregulated response to an infection. This systemic infection triggers an extreme immune reaction, potentially leading to septic shock, organ failure, and even death if not promptly and effectively managed. Early recognition and aggressive intervention are critical in preventing sepsis from progressing to these severe stages.

Sepsis can escalate rapidly, making it crucial for nurses across all healthcare settings to be vigilant in recognizing its signs and symptoms. While often managed in the Intensive Care Unit (ICU), sepsis awareness and prompt assessment are vital for nurses in all specialties, as delayed treatment can have fatal consequences. Furthermore, preventative measures, including meticulous hand hygiene, adherence to Personal Protective Equipment (PPE) protocols, diligent wound care, and the use of sterile or aseptic techniques, are paramount in minimizing the risk of infection and subsequent sepsis.

This guide delves into the nursing process for sepsis, focusing on assessment, interventions, and care planning to equip nurses with the knowledge and skills necessary to provide optimal care for patients at risk or diagnosed with sepsis.

Nursing Assessment

The cornerstone of effective nursing care is a thorough nursing assessment. This involves gathering comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic status. In the context of sepsis, both subjective and objective data are crucial for identifying and managing this complex condition.

Review of Health History

1. Identify General Sepsis Symptoms. Recognizing the broad symptoms of sepsis is the first step in early detection. These can include:

• Fluctuations in body temperature (both elevated and decreased)
• Chills
• Altered mental status or confusion
• Rapid breathing (tachypnea)
• Skin changes, such as flushed or cool skin
• Hypotension

2. Determine the Source of Infection Leading to Sepsis. Sepsis can originate from virtually any infection, whether viral, bacterial, or fungal. Common infection sites that can trigger sepsis include:

• Lungs (pneumonia)
• Urinary tract, including kidneys and bladder
• Gastrointestinal system
• Bloodstream (bacteremia)
• Invasive devices (catheters, IV lines)
• Burns or wounds

3. Assess for Sepsis Risk Factors. Certain factors increase an individual’s susceptibility to developing sepsis. These risk factors include:

• Age extremes: being over 65 years old or infancy
• Compromised immune system
• Presence of comorbidities like diabetes or chronic kidney disease
• Prolonged hospital stays
• Use of invasive lines, such as central venous catheters or urinary catheters
• Recent or prolonged antibiotic therapy (within 90 days), especially if unsupervised
• Use of immunosuppressant medications, including corticosteroids

4. Review Medical History for Predisposing Conditions. Certain pre-existing conditions can elevate the risk of sepsis. These include:

• Pre-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. Analyze Medication History. Pay close attention to medications that can suppress the immune system, such as corticosteroids and other immunosuppressants. Furthermore, evaluate antibiotic use history as it can contribute to drug-resistant bacterial strains if:

• Antibiotics are discontinued prematurely without medical advice
• Antibiotics are used unnecessarily
• Antibiotic use is frequent
• Access to quality medications is limited
• Incorrect antibiotics are prescribed

Physical Assessment

1. Evaluate Vital Signs. Changes in vital signs are often the first indicators of sepsis. Initially, patients may exhibit:

• Hyperthermia (temperature above 100.4°F or 38°C) or hypothermia (temperature below 96.8°F or 36°C)
• Tachycardia (elevated heart rate)
• Tachypnea (increased respiratory rate)

2. Conduct a Systemic Assessment. Without timely intervention, sepsis can progress to severe sepsis and septic shock, leading to organ dysfunction. Close monitoring for changes across body systems is crucial:

• Central Nervous System (CNS): Assess for altered mental status, confusion, or decreased level of consciousness.
• Respiratory System: Monitor for hypoxia, cough, chest pain, or dyspnea (shortness of breath).
• Cardiovascular System: Check for decreased capillary refill time, indicating poor perfusion.
• Gastrointestinal System: Assess for ileus, perforation, abscess, or abdominal tenderness.
• Genitourinary System: Monitor urine output for oliguria (decreased urine production) or anuria (absence of urine production).
• Integumentary System: Observe skin color for flushed skin, cyanosis (bluish discoloration), pallor (pale skin), or skin mottling.

3. Monitor for Shock Progression. As septic shock develops, hypotension and reduced organ perfusion become prominent. Signs of progressing shock include:

• Cool extremities
• Delayed capillary refill (longer than 3 seconds)
• Thready peripheral pulses
• Pale skin
• Diaphoresis (excessive sweating)
• Confusion
• Decreased level of consciousness

4. Examine Intravenous (IV) Lines. Carefully inspect IV sites for signs of localized infection, such as swelling, redness, or drainage, and thrombophlebitis. Central venous lines are a significant risk factor for both sepsis and bacteremia.

5. Assess Wounds and Incisions for Infection. Look for signs of infection in wounds or surgical incisions. Abscesses, cellulitis, or wound infections may manifest as pain, purulent discharge, erythema (redness), or swelling. Document and monitor any changes in wound appearance meticulously.

Diagnostic Procedures

1. Collect Specimens for Laboratory Tests. Laboratory studies are essential for confirming sepsis and identifying the causative pathogen. Key tests include:

• Complete Blood Count (CBC): May reveal elevated or decreased white blood cell count (WBC), neutropenia, and thrombocytopenia.
• Kidney Function Tests: Can indicate impaired kidney perfusion.
• Blood and Site-Specific Cultures: Cultures from blood, wounds, sputum, or urine can identify the specific organism causing sepsis and guide antibiotic therapy. Blood cultures are particularly important in cases of suspected bacteremia.
• Urinalysis and Culture: Further investigate urinary tract infections as a potential sepsis source.
• Biomarkers: Procalcitonin and presepsin are biomarkers that aid in early sepsis diagnosis.
• Lactate Levels: Elevated lactate levels (>2 mmol/L) suggest poor organ perfusion. Levels exceeding 4 mmol/L are indicative of septic shock.
• C-Reactive Protein (CRP): Expected to be elevated, indicating inflammation.
• Coagulation Studies (INR and PTT): Elevated INR and PTT suggest coagulation abnormalities.

2. Prepare Patient for Imaging Scans. Imaging studies can help locate the source of infection. Common scans include:

• Chest X-ray: To rule out pneumonia.
• Chest CT Scan: More detailed lung imaging.
• Abdominal Ultrasonography: Initial assessment of abdominal organs.
• Abdominal CT Scan or MRI: Detailed abdominal imaging.
• Site-Specific Soft Tissue Imaging (ultrasound, CT, MRI): To investigate localized infections.
• Contrast-Enhanced CT or MRI of Brain/Neck: If CNS infection is suspected.

3. Anticipate Invasive Diagnostic Procedures. Invasive procedures may be necessary to obtain samples for diagnosis, especially when the infection source is deep-seated or unclear:

• Thoracentesis: To drain pleural fluid.
• Paracentesis: To drain ascitic fluid.
• Drainage of Fluid Accumulations and Abscesses.
• Bronchoscopy with Lavage, Washing, or Biopsy: To obtain samples from the lungs.

Nursing Interventions

Nursing interventions are crucial for patient recovery and involve a multi-faceted approach to combat sepsis and support the patient’s body.

1. Prepare for Hospital Admission. Patients with sepsis require intensive care and monitoring, typically in an ICU setting. Rapid deterioration is possible, necessitating aggressive medical management.

2. Initiate Antibiotic Therapy Promptly. Administer antibiotics as soon as ordered. Broad-spectrum antibiotics are usually initiated empirically. Once culture results identify the specific pathogen, antibiotic therapy may be narrowed to target the causative agent effectively. In cases of confirmed bacteremia, targeted antibiotic therapy is essential.

3. Begin Fluid Volume Resuscitation. In the initial phase of sepsis, fluid resuscitation is critical to address hypoperfusion. A common guideline is to administer at least 30 mL/kg of crystalloid fluids within the first three hours. The goal is to maintain adequate tissue perfusion.

4. Administer Vasopressors as Prescribed. If hypotension persists despite fluid resuscitation, vasopressors may be necessary to raise blood pressure by constricting blood vessels and improving perfusion.

5. Optimize Patient Positioning. Semi-Fowler’s or high-Fowler’s position is recommended to reduce the risk of pneumonia. Prone positioning may be indicated for sepsis-induced Acute Respiratory Distress Syndrome (ARDS).

6. Implement Invasive Monitoring. Invasive arterial monitoring allows for continuous and accurate hemodynamic monitoring and blood pressure measurement.

7. Provide Oxygen Support or Mechanical Ventilation. Patients with hypoxia require supplemental oxygen. Respiratory failure may necessitate intubation and mechanical ventilation.

8. Manage Hyperglycemia with Insulin. Sepsis can induce hyperglycemia even in patients without pre-existing diabetes. Insulin administration is indicated for glucose levels exceeding 180 mg/dL.

9. Prepare for Potential Surgical Intervention. Surgical removal of infected or necrotic tissue may be necessary to eliminate the source of infection.

10. Remove Intravascular Devices if Suspected Source. Prompt removal of intravascular access devices, such as central lines or catheters, is advised if they are suspected as the source of sepsis or bacteremia.

11. Implement Rigorous Hygiene Practices. Strict hand hygiene is paramount to prevent the spread of infection. Comprehensive hygiene practices for sepsis patients include regular bed baths and aseptic cleaning of catheters and IV hubs according to hospital protocols. Disinfection of all equipment is also essential.

12. Initiate Appropriate Isolation Precautions. To prevent cross-transmission of infection, implement septic isolation or transmission-based precautions. Protective isolation may be necessary for immunocompromised patients to minimize exposure to pathogens. Visitor restrictions may be implemented.

13. Utilize Personal Protective Equipment (PPE). Consistent PPE use protects both healthcare workers and patients. Don gowns and gloves before entering the patient’s room. Use face masks and safety goggles for protection against droplets and airborne microorganisms.

14. Initiate Enteral Nutrition Early. Early enteral or parenteral nutrition is crucial to address micronutrient deficiencies and provide protein for patients unable to maintain adequate oral intake within three days.

Nursing Care Plans

Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals for patients with sepsis. Several key nursing diagnoses are pertinent to sepsis management.

Decreased Cardiac Output

Severe sepsis and hypoperfusion significantly impact cardiovascular function.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Altered hemodynamic parameters
• Impaired cardiac contractility
• Impaired myocardial circulation
• Loss of vascular tone
• Hypovolemia

As evidenced by:

• Tachycardia
• Abnormal Central Venous Pressure (CVP)
• Abnormal Mean Arterial Pressure (MAP)
• Cyanosis
• Pallor
• Prolonged capillary refill time
• Blood pressure alterations
• Oliguria
• Altered level of consciousness
• Cold, clammy skin
• Decreased peripheral pulses
• Cardiac dysrhythmias
• Presence of murmurs

Expected Outcomes:

• Patient will demonstrate adequate cardiac output, 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
  • Urine output: 0.5 to 1.5 cc/kg/hour
  • Absence of adverse cardiac findings:
    • Adynamic precordium
    • Absence of cardiac dysrhythmias
    • Absence of murmurs

Assessments:

1. Monitor for signs and symptoms of cardiac compromise. Hypotension, tachycardia, tachypnea, and weak peripheral pulses indicate decreased cardiac output in severe sepsis.

2. Monitor hemodynamic parameters. CVP reflects right heart filling pressures, while Pulmonary Artery Diastolic Pressure (PADP) and Pulmonary Capillary Wedge Pressure (PCWP) provide information on left heart fluid volumes.

3. Monitor laboratory data. Sepsis-induced cardiomyopathy can manifest in:

• Elevated cardiac markers (troponins I or T, BNP, NT-proBNP) which may indicate myocardial injury and severity of illness.
• Decreased ejection fraction: an early indicator of septic cardiomyopathy.

Interventions:

1. Administer fluid resuscitation as prescribed. Fluid therapy is essential to address tissue hypoperfusion and hypovolemia. However, cautious administration is needed in septic cardiomyopathy to avoid fluid overload.

2. Administer medications as prescribed.

• Antibiotics: Initiate broad-spectrum antibiotics immediately after blood cultures are obtained.
• Vasopressors: To counteract vasodilation and improve 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 needed if primary therapies fail.

4. Optimize oxygen delivery. Ensure adequate oxygenation via supplemental oxygen or mechanical ventilation to support cardiac function and perfusion.

Hyperthermia

Elevated body temperature is a common response to infection and inflammation but can be detrimental if excessive and prolonged.

Nursing Diagnosis: Hyperthermia

Related to:

• 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. Measure temperature rectally. Rectal temperature is the most accurate measure of core body temperature.

2. Assess neurological status. Uncontrolled hyperthermia can cause neurological damage, indicated by altered level of consciousness, confusion, or seizures.

Interventions:

1. Provide a cool environment. Adjust room temperature, remove excess linens and clothing.

2. Utilize a cooling blanket. Cooling blankets reduce surface temperature, but monitor closely to prevent shivering.

3. Administer antipyretics. Administer acetaminophen or other antipyretics as ordered to reduce fever.

4. Apply cool compresses and tepid baths. Apply cool, moist cloths to groin and axillae and provide tepid baths to promote heat loss through evaporation.

Ineffective Protection

Sepsis compromises the body’s protective mechanisms against infection.

Nursing Diagnosis: Ineffective Protection

Related to:

• Infectious process
• Immunosuppression
• Abnormal blood profiles
• Poor nutrition
• Medication regimen
• Older age

As evidenced by:

• Change in level of consciousness
• Insomnia
• Immobility
• Poor stress management
• Open wound/pressure ulcer

Expected Outcomes:

• Patient will remain free from new infections.
• Patient will verbalize appropriate food choices for nutritional support.
• 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 critical sepsis indicators requiring immediate reporting.

2. Monitor WBC and differential count. Leukocytosis is typical in infection, but in sepsis, WBC can be high or low. An increase in immature band forms may be present even with normal WBC. Differential count can suggest the type of infection (neutrophils-bacteria, lymphocytes-virus, eosinophils-parasite).

3. Assess risk factors for ineffective protection. Identify factors increasing sepsis risk, such as immunosuppression (cancer, autoimmune diseases, HIV, chemotherapy, immunosuppressants), immobility, poor nutrition, and wounds.

Interventions:

1. Promote rest. Adequate sleep is essential for cellular repair and growth hormone release, which is suppressed by sleep disruption.

2. Minimize invasive procedures. Limit catheterizations, injections, and rectal/vaginal procedures to reduce pathogen introduction. Use aseptic techniques for necessary invasive lines.

3. Encourage nutrient-rich, high-protein diets. Protein supports tissue repair and immune function. Address poor appetite with stimulants or dietician consultation.

4. Educate on infection control. Emphasize hand hygiene for patient and family/caregivers as the most effective way to prevent infection transmission.

Risk for Deficient Fluid Volume

Septic shock leads to fluid shifts out of the intravascular space, causing hypovolemia and hypotension.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related to:

• Vasodilation
• Increased membrane permeability

As evidenced by:

Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventative.

Expected Outcome:

• Patient will maintain adequate circulatory volume, evidenced by stable vital signs and urine output within normal limits.

Assessments:

1. Monitor for fluid loss signs. Septic shock causes rapid blood pressure drop due to fluid shifts, accompanied by tachycardia, fever, poor skin turgor, and dry mucous membranes.

2. Monitor intake and output and weight. Closely track fluid intake (oral, IV) and urine output for imbalances.

3. Monitor for edema. Fluid shifting to interstitial spaces causes edema and potential weight gain (third spacing).

4. Review lab values. Changes in hemoglobin and hematocrit can indicate low fluid volume. Elevated 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 used to maintain intravascular volume.

2. Administer vasopressors. Vasopressors (dopamine, norepinephrine) are used with fluids or in persistent septic shock to restore and maintain blood pressure.

3. Monitor circulatory function. Assess heart rate, rhythm, MAP, pulse oximetry, urine output, and lab values to ensure adequate organ perfusion.

Risk for Infection

Sepsis is a systemic infection requiring vigilant monitoring and prompt intervention to prevent worsening.

Nursing Diagnosis: Risk for Infection

Related to:

• 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 preventative.

Expected Outcomes:

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

Assessments:

1. Monitor for sepsis signs and symptoms. Fever, tachycardia, tachypnea, chills, and altered mental status are sepsis indicators requiring immediate intervention.

2. Monitor lab work. Elevated WBC, CRP, and lactate levels are indicative of sepsis.

3. Obtain specimens for culture. Collect blood, urine, sputum, or wound specimens for culture to identify the infection source.

Interventions:

1. Administer anti-infectives. Prophylactic antibiotics may be used for prevention. Broad-spectrum antibiotics are used initially until pathogen identification.

2. Emphasize hand hygiene. Strict hand hygiene is the most effective infection prevention measure. Educate patients on proper handwashing and sanitizer use.

3. Discontinue unnecessary invasive lines. Remove IV lines, urinary catheters, and other invasive devices when no longer needed to reduce infection risk.

4. Promote skin integrity. Prevent skin breakdown through regular turning, ambulation assistance, and skin assessments, especially in immobile patients. Address incontinence, nutrition, and wounds to minimize infection risk.

References

(Note: While the original article does not list specific references, for a comprehensive and evidence-based approach, consider incorporating references to reputable sources such as the Surviving Sepsis Campaign guidelines, nursing textbooks on medical-surgical nursing and critical care, and peer-reviewed articles on sepsis management in nursing practice.)