Sepsis occurs when the body responds improperly to an infection, often bacterial, leading to a systemic infection and an extreme immune reaction. This life-threatening condition necessitates immediate medical attention to avert septic shock, which can result in organ failure and death.
Sepsis can progress rapidly and carries a high mortality rate if not promptly identified and treated aggressively. Infants, adults over 65, and individuals with compromised immune systems or chronic illnesses are at the highest risk of developing sepsis.
This article provides a comprehensive overview of sepsis within the nursing process framework, focusing on nursing assessments, interventions, and NANDA nursing diagnoses relevant to sepsis management.
Nursing Process
Patients with sepsis are typically managed in the Intensive Care Unit (ICU). However, nurses across all specialties must be adept at recognizing and assessing sepsis signs, as treatment delays can be fatal. Prevention is also crucial; nurses play a vital role in preventing infections and sepsis through rigorous hand hygiene, adherence to Personal Protective Equipment (PPE) protocols, meticulous wound care, and the application of sterile or aseptic techniques.
Nursing Assessment
The initial phase of nursing care involves a thorough nursing assessment to gather physical, psychosocial, emotional, and diagnostic data. This section will detail both subjective and objective data pertinent to sepsis.
Review of Health History
1. Document General Sepsis Symptoms. Common sepsis symptoms include:
- Elevated or decreased body temperature
- Chills
- Changes in mental status
- Rapid breathing (tachypnea)
- Skin that is flushed or cool to the touch
- Hypotension (low blood pressure)
2. Identify Potential Sources 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
- Gastrointestinal system
- Bloodstream infections
- Invasive devices (e.g., catheters)
- Burns or wounds
3. Recognize Sepsis Risk Factors. Factors that elevate sepsis risk include:
- Age over 65 years
- Infancy
- Weakened immune system
- Co-existing health conditions (comorbidities) like diabetes or kidney disease
- Prolonged hospital stays
- Indwelling invasive lines such as central venous catheters or urinary catheters
- Recent prolonged antibiotic use without medical supervision within the past 90 days
- Use of corticosteroids or other immunosuppressant medications
4. Analyze Medical History for Predisposing Conditions. Note conditions that increase sepsis susceptibility:
- Active infection
- Undiagnosed infection
- Untreated infection
- Immunocompromised states (e.g., cancer or HIV)
- Chronic illnesses (e.g., diabetes or COPD)
- Recent surgical procedures
- Implanted medical devices like pacemakers or ports
- Organ transplant complications
5. Review Medication History. Document the use of corticosteroids and other immunosuppressants that can weaken the immune system. Also, assess recent antibiotic use, as certain factors can contribute to antibiotic-resistant bacteria:
- Stopping antibiotics prematurely without medical advice
- Inappropriate antibiotic use
- Frequent antibiotic use
- Limited access to necessary medications
- Poor quality of available medications
- Incorrect antibiotic prescriptions
Physical Assessment
1. Evaluate Vital Signs. Initial vital sign changes in sepsis may include:
- Hyperthermia (>100.4°F or 38°C) or hypothermia (<96.8°F or 36°C)
- Tachycardia (elevated heart rate)
- Tachypnea (increased respiratory rate)
2. Conduct a Systemic Assessment. Without intervention, sepsis can progress to severe sepsis and septic shock with organ dysfunction. Closely monitor for the following:
- Central Nervous System (CNS): Altered mental status
- Respiratory System: Hypoxia, cough, chest pain, dyspnea (shortness of breath)
- Cardiovascular System: Delayed capillary refill
- Gastrointestinal System: Ileus, perforation, abscess, abdominal tenderness
- Genitourinary System: Decreased urine output (oliguria) or no urine output (anuria)
- Integumentary System: Flushed skin, cyanosis, pallor, skin mottling
3. Assess for Shock Progression. As septic shock develops, hypotension and reduced organ perfusion occur. Patients may exhibit:
- 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. Check IV sites for signs of infection or thrombophlebitis, such as swelling, redness, or drainage. Central venous lines are frequent sources of sepsis or bacteremia.
5. Examine Wounds and Incisions. Note any signs of infection in wounds or surgical incisions. Abscesses, cellulitis, or wound infections often present with pain, purulent discharge, erythema, or swelling. Document and monitor any changes in wounds and incisions meticulously.
Alt text: Nurse carefully inspecting an IV insertion site for redness, swelling, and drainage as part of sepsis nursing assessment.
Diagnostic Procedures
1. Collect Samples for Laboratory Tests. Laboratory studies are crucial for sepsis diagnosis and identifying the causative pathogen:
- Complete Blood Count (CBC): May show elevated or decreased white blood cell (WBC) count, 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 sepsis-causing organism.
- Urinalysis and Urine Culture: Further investigate urinary tract infections as a sepsis source.
- Biomarkers: Procalcitonin and presepsin can aid in early sepsis diagnosis.
- Lactate Levels: Levels >2 mmol/L suggest poor organ perfusion. Levels >4 mmol/L are indicative of septic shock.
- C-Reactive Protein (CRP): Typically elevated in sepsis.
- International Normalized Ratio (INR) and Partial Thromboplastin Time (PTT): Elevated results may indicate coagulation abnormalities.
2. Prepare Patient for Imaging Studies. Imaging can help identify the infection source. Common imaging modalities include:
- Chest X-ray
- Chest Computed Tomography (CT) scan
- Abdominal Ultrasound
- Abdominal CT scan or Magnetic Resonance Imaging (MRI)
- Site-specific soft tissue imaging (ultrasound, CT scan, or MRI)
- Contrast-enhanced CT scan or MRI of the brain/neck
3. Anticipate Invasive Diagnostic Procedures. In suspected sepsis cases, consider:
- Thoracentesis
- Paracentesis
- Drainage of fluid collections and abscesses
- Bronchoscopy with lavage, washing, or other invasive sample collection
Alt text: Healthcare provider labeling blood culture vials, highlighting the importance of laboratory diagnostics in sepsis identification.
Nursing Interventions
Nursing interventions are vital for patient recovery from sepsis. This section outlines key nursing interventions for sepsis management.
1. Prepare for Hospital Admission. Patients with sepsis require intensive care in an ICU setting due to the rapid progression of the condition and the need for aggressive medical treatment.
2. Initiate Antibiotic Therapy as Prescribed. Prompt antibiotic administration is crucial. Broad-spectrum antibiotics are typically started initially. Once pathogen identification from blood cultures is available, antibiotic therapy may be narrowed to target the specific causative agent.
3. Commence Fluid Volume Resuscitation. In the acute phase of sepsis, 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 Ordered. Vasopressors, which constrict blood vessels to raise blood pressure, may be necessary if hypotension persists despite fluid resuscitation.
5. Implement Appropriate Positioning. Semi-Fowler’s or high-Fowler’s position is advised to reduce pneumonia risk. Prone positioning may be recommended for sepsis-induced Acute Respiratory Distress Syndrome (ARDS).
6. Initiate Invasive Hemodynamic Monitoring. Invasive arterial monitoring allows for accurate and continuous blood pressure and hemodynamic assessment.
7. Provide Oxygen or Prepare for Mechanical Ventilation. Hypoxic patients require supplemental oxygen. Respiratory failure may necessitate intubation and mechanical ventilation.
8. Administer Insulin as Needed. Sepsis can cause elevated blood glucose levels even in non-diabetic patients. Insulin 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 control the source of infection.
10. Remove Intravascular Devices if Suspected Source. Prompt removal of intravascular access devices that may be contributing to sepsis is recommended.
11. Enforce Strict Hygiene Practices. Hand hygiene is paramount in infection prevention. Strict hygiene protocols are essential for sepsis patients to limit bacterial growth. This includes bed baths and aseptic cleaning of catheters and IV hubs according to hospital guidelines. Regular disinfection of all equipment is also necessary.
12. Implement Transmission-Based Precautions. Septic isolation and transmission-based precautions are vital to prevent cross-transmission to other patients, healthcare workers, and visitors. Protective isolation may be used for immunocompromised patients to minimize exposure to infectious agents. Visitor restrictions may be implemented.
13. Utilize Personal Protective Equipment (PPE). PPE protects both healthcare providers and patients. Gowns and gloves should be donned before room entry. Masks and eye protection are needed to protect against droplets and airborne microorganisms.
14. Initiate Enteral Nutrition. Early enteral or parenteral nutrition is recommended to address micronutrient deficiencies and provide protein for patients unable to maintain adequate oral intake within three days.
Alt text: ICU nurse discussing sepsis patient’s treatment plan with a physician, emphasizing collaborative care in sepsis management.
Nursing Care Plans for Sepsis
Once nursing diagnoses are identified for sepsis, nursing care plans guide the prioritization of assessments and interventions to achieve short-term and long-term care goals. Examples of nursing care plans for sepsis are detailed below, using NANDA nursing diagnoses.
Decreased Cardiac Output
Severe sepsis and hypoperfusion can significantly impair circulation, leading to the NANDA nursing diagnosis: Decreased Cardiac Output.
Related Factors:
- Altered hemodynamic parameters
- Impaired cardiac contractility
- Impaired myocardial circulation
- Loss of vascular tone
- Hypovolemia
As Evidenced By:
- Tachycardia
- Elevated or decreased Central venous pressure (CVP)
- Altered Mean arterial pressure (MAP)
- Cyanosis
- Pallor
- Prolonged capillary refill time
- Hypotension
- Oliguria
- Alteration in level of consciousness
- Cold, clammy skin
- Decreased peripheral pulses
- Cardiac dysrhythmias
- Presence of murmurs
Expected Outcomes:
- The patient will demonstrate adequate cardiac output, indicated by:
- Vital signs within normal limits:
- Blood pressure: 90/60 mmHg to 120/80 mmHg
- Pulse rate: 60 to 100 bpm
- Central venous pressure 8-12 mmHg
- Mean arterial pressure 65-90 mmHg
- Urine output: 0.5 to 1.5 mL/kg/hour
- Absence of adverse cardiac findings:
- Adynamic precordium
- Absence of cardiac dysrhythmias
- Absence of murmurs
- Vital signs within normal limits:
Nursing Assessments:
1. Assess for signs and symptoms of 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, Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP)). CVP reflects right heart filling pressures, while PADP and PCWP provide insights into left-sided fluid volumes.
3. Monitor laboratory data. Sepsis-induced cardiomyopathy may be indicated by:
- Elevated cardiac markers:
- Increased plasma troponins I or T can suggest 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 an early indicator of septic cardiomyopathy.
Nursing Interventions:
1. Administer fluid resuscitation as prescribed. Adequate fluid therapy is crucial to address tissue hypoperfusion and hypovolemia resulting from vasodilation, fluid loss, and capillary leakage in sepsis. Use caution to avoid fluid overload in patients with cardiomyopathy.
2. Administer medications as prescribed.
- Antibiotics: Broad-spectrum antibiotics should be given immediately after blood cultures are obtained.
- Vasopressors: To counteract vasodilation and improve blood pressure and perfusion.
3. Anticipate adjunctive therapies if needed. Mechanical circulatory support like Intra-aortic balloon pump (IABP), ventricular assist devices, or Extracorporeal Membrane Oxygenation (ECMO) may be necessary if primary therapies fail to maintain cardiac output.
4. Optimize oxygen delivery. Ensure adequate oxygenation via high-flow oxygen or mechanical ventilation to support cardiac function and tissue perfusion.
Hyperthermia
Elevated body temperature (Hyperthermia), a NANDA nursing diagnosis, is a common response to infection and inflammation in sepsis.
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.
- The underlying cause of hyperthermia (infection) will be treated.
Nursing Assessments:
1. Assess temperature rectally for accuracy. Rectal temperature measurement is the most accurate method for core body temperature monitoring.
2. Assess neurological status. Uncontrolled hyperthermia can lead to neurological damage. Altered level of consciousness, confusion, and seizures indicate neurological deterioration.
Nursing Interventions:
1. Provide a cool environment. Adjust room temperature, reduce linens, and remove restrictive clothing to promote heat loss.
2. Apply a cooling blanket. Use a cooling blanket to reduce surface temperature, monitoring closely to prevent shivering.
3. Administer antipyretics. Administer acetaminophen or other antipyretics as prescribed to reduce fever.
4. Provide cool compresses or tepid baths. Apply cool compresses to areas with high blood flow like the groin and axillae and provide tepid baths to enhance evaporative heat loss.
Ineffective Protection
Patients with sepsis are at risk for Ineffective Protection, a NANDA nursing diagnosis, due to compromised immune defenses.
Related Factors:
- Infectious process
- Immunosuppression
- Abnormal blood profiles
- Poor nutrition
- Medication regimen
- Older age
As Evidenced By:
- Changes in level of consciousness
- Insomnia
- Immobility
- Poor ability to handle stress
- Open wound/pressure ulcer
Expected Outcomes:
- Patient will remain free from new infections.
- Patient will verbalize appropriate food choices to meet nutritional needs.
- Patient will demonstrate measures to enhance immune system protection.
Nursing Assessments:
1. Monitor for signs of sepsis. Promptly report changes in mental status, hypotension, fever, tachycardia, chills, and flushed skin as potential sepsis indicators.
2. Monitor WBC and differential count. Leukocytosis or leukopenia may be present in sepsis. Increased immature band forms can also indicate infection. Differential count analysis can suggest the type of infecting organism.
3. Monitor risk factors for ineffective protection. Assess for factors that increase infection risk, such as immunosuppression from diseases like cancer, autoimmune disorders, HIV, and their treatments (chemotherapy, immunosuppressants), immobility, malnutrition, and wounds.
Nursing Interventions:
1. Encourage rest. Adequate sleep is essential for cellular repair and immune function.
2. Minimize invasive procedures. Limit catheterizations, injections, and rectal/vaginal procedures to reduce pathogen introduction. Use aseptic techniques when invasive lines are necessary.
3. Promote a high protein, nutrient-rich diet. Protein supports tissue repair and immune response. Consider appetite stimulants or dietitian consultation if needed.
4. Educate patient and family on infection control measures. Emphasize hand hygiene as a primary measure to prevent infection transmission.
Risk for Deficient Fluid Volume
Sepsis can lead to septic shock, causing fluid shifts out of the intravascular space and resulting in the NANDA nursing diagnosis: Risk for Deficient Fluid Volume.
Related Factors:
- 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, as evidenced by stable vital signs and urine output within normal limits.
Nursing Assessments:
1. Monitor for signs of fluid loss. Septic shock can cause a rapid decrease in blood pressure due to fluid shifts. Assess for tachycardia, fever, poor skin turgor, and dry mucous membranes.
2. Assess intake and output and daily weight. Monitor fluid balance and weight changes to detect imbalances.
3. Monitor for edema. Fluid shifting into interstitial spaces can cause edema. Monitor for peripheral edema and weight gain.
4. Review lab values. Changes in hemoglobin and hematocrit can indicate fluid volume status. Monitor BUN and creatinine for kidney function and urine specific gravity for hydration status and kidney function.
Nursing Interventions:
1. Administer IV fluids. Crystalloids (normal saline, lactated Ringers) are typically the initial fluids for resuscitation. Colloids (albumin, fresh frozen plasma) may be used to maintain intravascular volume.
2. Administer vasopressors as needed. Vasopressors (dopamine, norepinephrine) may be necessary in conjunction with fluids to maintain blood pressure in septic shock.
3. Monitor circulatory function. Continuously monitor heart rate, rhythm, MAP, respiratory rate, pulse oximetry, urine output, and relevant lab values to assess perfusion and organ function.
Risk for Infection
Sepsis itself is a systemic infection, and managing the Risk for Infection, another NANDA nursing diagnosis, is critical to prevent further complications.
Related Factors:
- Immunosuppression
- Multiple chronic comorbidities
- Compromised skin or tissue integrity
- Malnutrition
- Untreated/worsening infections (Urinary Tract 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 count within normal limits.
- Patient will show improvement in wound healing without infection signs.
- Patient will identify infection prevention measures they can implement.
Nursing Assessments:
1. Monitor for signs and symptoms of sepsis. Be vigilant for fever, tachycardia, tachypnea, chills, and altered mental status as indicators of potential sepsis or worsening infection.
2. Monitor laboratory work. Track WBC count, CRP, and lactate levels as indicators of infection and sepsis severity.
3. Obtain specimens for culture. Collect blood, urine, sputum, or wound specimens for culture to identify the source of infection.
Nursing Interventions:
1. Administer anti-infectives as prescribed. Prophylactic antibiotics or broad-spectrum antibiotics may be used initially until specific pathogens are identified.
2. Emphasize hand hygiene. Reinforce handwashing protocols for healthcare providers, patients, and visitors as the most effective infection prevention strategy.
3. Discontinue unnecessary invasive lines. Regularly assess the necessity of IV lines, urinary catheters, and other invasive devices and remove them when no longer needed to reduce infection risk.
4. Promote skin integrity. Implement measures to prevent skin breakdown, such as frequent repositioning, pressure ulcer prevention strategies, and ensuring adequate nutrition and hydration to maintain skin health and reduce infection risk.
Alt text: Nurse demonstrating proper handwashing technique to a patient, highlighting hand hygiene as a key measure in sepsis prevention and infection control.
