Sepsis, a life-threatening condition, arises when the body’s response to an infection spirals out of control, triggering widespread inflammation and potential organ dysfunction. Often stemming from bacterial infections, sepsis can rapidly progress to septic shock, a critical stage characterized by organ failure and a high risk of mortality. Early recognition and aggressive intervention are paramount to improving patient outcomes.
Individuals at the extremes of age—infants and adults over 65—face heightened sepsis vulnerability, as do those with compromised immune systems or pre-existing chronic illnesses. Nurses, regardless of their unit or specialty, play a crucial role in sepsis management. While intensive care units (ICUs) are often the primary setting for sepsis treatment, vigilance in recognizing sepsis signs and symptoms across all healthcare settings is essential, as treatment delays can have fatal consequences. Furthermore, nurses are pivotal in sepsis prevention through meticulous infection control practices, including stringent hand hygiene, consistent use of personal protective equipment (PPE), diligent wound care, and adherence to sterile and aseptic techniques.
Nursing Assessment for Sepsis
The cornerstone of effective nursing care is a thorough nursing assessment. This process involves gathering comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic status. In the context of sepsis, both subjective and objective data points are critical for accurate evaluation and timely intervention.
Review of Health History in Sepsis Assessment
1. Identify General Sepsis Symptoms: Begin by noting any generalized symptoms that may indicate sepsis. These can be varied but commonly include:
- Fluctuations in body temperature: Elevated (hyperthermia) or decreased (hypothermia)
- Chills and rigors
- Altered mental status, ranging from confusion to lethargy
- Rapid respiratory rate (tachypnea)
- Skin changes: Flushed appearance or cool, clammy skin
- Drop in blood pressure (hypotension)
2. Determine Potential Sources of Infection: Sepsis is invariably triggered by an infection. Explore potential sources, considering that various pathogens, including bacteria, viruses, and fungi, can initiate the septic cascade. Common infection sites leading to sepsis include:
- Lungs (pneumonia)
- Urinary tract (kidney, bladder, urinary system infections)
- Gastrointestinal system
- Bloodstream infections
- Infections related to invasive devices (catheters, lines)
- Skin and soft tissue infections (burns, wounds)
3. Evaluate Sepsis Risk Factors: Certain factors predispose individuals to a higher risk of developing sepsis. Assess for the presence of these risk factors:
- Advanced age (over 65 years)
- Infancy
- Immunocompromised state (due to illness or medications)
- Presence of comorbidities (e.g., diabetes mellitus, chronic kidney disease)
- Prolonged hospitalizations
- Indwelling invasive lines (central venous catheters, urinary catheters)
- Recent or prolonged antibiotic use (within the past 90 days), especially if unsupervised
- Use of immunosuppressant medications, such as corticosteroids
4. Analyze Medical History for Predisposing Conditions: Delve into the patient’s medical history to identify conditions that may increase sepsis susceptibility:
- Pre-existing, undiagnosed, or untreated infections
- Conditions causing immune compromise (e.g., cancer, HIV infection)
- Chronic diseases (e.g., diabetes, COPD)
- Recent surgical procedures
- Implanted medical devices (pacemakers, ports)
- Organ transplant complications
5. Medication Review and Antibiotic History: Scrutinize the patient’s medication list, paying particular attention to corticosteroids and other immunosuppressants that can weaken the immune system. Furthermore, assess for a history of antibiotic use. Factors related to antibiotic use can contribute to the development of drug-resistant bacteria, increasing sepsis risk:
- Premature discontinuation of antibiotics without medical guidance
- Inappropriate or unnecessary antibiotic use
- Frequent antibiotic exposure
- Limited access to necessary medications
- Substandard medication quality
- Inappropriate antibiotic prescribing practices
Physical Assessment in Sepsis Detection
1. Monitor Vital Signs Critically: Vital sign abnormalities are often the first indicators of sepsis. Initially, patients may exhibit:
- Elevated body temperature (hyperthermia > 100.4°F or 38°C) or low body temperature (hypothermia < 96.8°F or 36°C)
- Rapid heart rate (tachycardia)
- Increased respiratory rate (tachypnea)
2. Conduct Systemic Assessment for Organ Dysfunction: Sepsis can rapidly progress to severe sepsis and septic shock, leading to organ dysfunction. Vigilantly monitor for changes across various body systems:
- Central Nervous System (CNS): Altered mental status, confusion, decreased level of consciousness.
- Respiratory System: Hypoxia, cough, chest pain, shortness of breath (dyspnea).
- Cardiovascular System: Decreased capillary refill time, indicating poor peripheral perfusion.
- Gastrointestinal System: Ileus (decreased bowel motility), potential bowel perforation, abscess formation, abdominal tenderness.
- Genitourinary System: Reduced urine output (oliguria) or complete absence of urine production (anuria), signifying kidney dysfunction.
- Integumentary System: Skin changes such as flushed skin, cyanosis (bluish discoloration), pallor (pale skin), or skin mottling (patchy discoloration).
3. Assess for Progression to Septic Shock: As sepsis advances to septic shock, hypotension becomes pronounced, and organ perfusion deteriorates. Monitor for these signs indicative of shock:
- Cool extremities
- Prolonged capillary refill time (> 3 seconds)
- Weak, thready peripheral pulses
- Pale skin
- Excessive sweating (diaphoresis)
- Confusion
- Decreased level of consciousness
4. Inspect Intravenous (IV) Lines for Infection: Carefully examine IV insertion sites for signs of localized infection or thrombophlebitis. Look for swelling, redness, drainage, or pain at the site. Central venous lines are particularly associated with an increased risk of sepsis and bloodstream infections (bacteremia).
5. Evaluate Wounds and Incisions for Infection: Assess any wounds or surgical incisions for signs of infection. Abscess formation, cellulitis, or wound infections can manifest as pain, purulent discharge, erythema (redness), and swelling. Meticulously monitor and document any changes observed in wounds and incisions.
Diagnostic Procedures for Sepsis
1. Obtain Samples for Laboratory Studies: Laboratory tests are crucial for confirming sepsis and identifying the causative pathogen. Anticipate the need to collect samples for the following:
- Complete Blood Count (CBC): May reveal elevated or decreased white blood cell (WBC) count, neutropenia (low neutrophil count), and thrombocytopenia (low platelet count).
- Kidney Function Tests: Assess renal function, as sepsis can impair kidney perfusion.
- Blood and Site-Specific Cultures: Cultures from blood, wounds, sputum, or urine are essential to identify the specific organism causing the infection and guide antibiotic therapy.
- Urinalysis and Urine Culture: Further investigate urinary tract infections as a potential sepsis source.
- Biomarkers: Emerging biomarkers like procalcitonin and presepsin can aid in early sepsis diagnosis.
- Lactate Levels: Elevated lactate levels (> 2 mmol/L) correlate with poor organ perfusion. Levels exceeding 4 mmol/L are strongly indicative of septic shock.
- C-Reactive Protein (CRP): Expect elevated CRP levels, as it is an inflammatory marker.
- Coagulation Studies (INR and PTT): Prolonged INR and PTT values may indicate coagulation abnormalities associated with sepsis-induced coagulopathy.
2. Prepare Patient for Imaging Scans: Imaging studies can help pinpoint the source of infection and assess for organ involvement. Potential imaging modalities include:
- Chest X-ray: To evaluate for pneumonia or other lung infections.
- Chest Computed Tomography (CT) Scan: Provides more detailed lung imaging.
- Abdominal Ultrasonography: Initial assessment for abdominal infections or fluid collections.
- Abdominal CT Scan or Magnetic Resonance Imaging (MRI): Offers comprehensive abdominal imaging.
- Site-Specific Soft Tissue Imaging (Ultrasound, CT, MRI): To investigate localized infections.
- Contrast-Enhanced CT or MRI of the Brain/Neck: In cases of suspected central nervous system infection or neck source.
3. Anticipate Invasive Diagnostic Procedures: In certain situations, invasive procedures may be necessary to obtain diagnostic samples or drain infections:
- Thoracentesis: Fluid aspiration from the pleural space (around the lungs).
- Paracentesis: Fluid aspiration from the peritoneal cavity (abdomen).
- Drainage of Fluid Accumulations or Abscesses: To obtain samples and relieve infection.
- Bronchoscopy with Lavage, Washing, or Biopsy: To sample respiratory secretions or tissue in suspected lung infections.
Nursing Interventions for Sepsis
Effective nursing interventions and comprehensive care are crucial for patient recovery from sepsis. The following interventions are essential components of sepsis management:
1. Prepare for Hospital Admission and ICU Transfer: Patients with sepsis require intensive monitoring and specialized care, typically in a hospital intensive care unit (ICU). Sepsis can deteriorate rapidly, necessitating aggressive medical and nursing management.
2. Initiate Antibiotic Therapy Promptly: Administer antibiotics as prescribed, as early initiation of antimicrobial therapy is critical in sepsis. Broad-spectrum antibiotics are usually started empirically to cover a wide range of potential pathogens. Once culture results identify the specific causative organism, antibiotic therapy may be narrowed to a more targeted, narrow-spectrum antibiotic.
3. Implement Fluid Volume Resuscitation: Fluid resuscitation is a cornerstone of early sepsis management. In the initial phase, a bolus of at least 30 mL/kg of crystalloid intravenous fluids is generally recommended within the first three hours. The goal of fluid resuscitation is to restore and maintain adequate tissue perfusion.
4. Administer Vasopressors as Prescribed: Vasopressors are medications that constrict blood vessels, thereby raising blood pressure. If hypotension persists despite adequate fluid resuscitation, vasopressors may be necessary to maintain blood pressure and organ perfusion.
5. Optimize Patient Positioning: Positioning can aid respiratory function. Semi-Fowler’s or high-Fowler’s positions are often recommended to reduce the risk of aspiration pneumonia. In sepsis-induced acute respiratory distress syndrome (ARDS), prone positioning (patient lying face down) may be employed to improve oxygenation.
6. Initiate Invasive Hemodynamic Monitoring: Invasive arterial monitoring may be necessary to continuously and accurately monitor hemodynamics and blood pressure in critically ill sepsis patients.
7. Provide Oxygen Therapy and Prepare for Mechanical Ventilation: Patients with hypoxia (low blood oxygen levels) require supplemental oxygen. Those with respiratory failure may necessitate endotracheal intubation and mechanical ventilation to support breathing.
8. Administer Insulin for Hyperglycemia: Sepsis can induce a rise in blood glucose levels, even in patients without pre-existing diabetes. Insulin administration may be required to manage hyperglycemia, typically targeting glucose levels below 180 mg/dL.
9. Prepare for Potential Surgical Intervention: In some cases, surgical intervention may be necessary to remove localized sources of infection, such as infected or necrotic tissue.
10. Remove Potentially Infected Intravascular Devices: Prompt removal of intravascular access devices (e.g., central lines, catheters) that are suspected as the source of sepsis is generally recommended to eliminate the infection source.
11. Emphasize Strict Hygiene Practices: Maintaining meticulous hygiene is paramount to prevent further infection and cross-contamination. This includes rigorous hand hygiene for healthcare providers, patients, and visitors. Provide bed baths and perform aseptic cleaning of catheters and IV hubs according to facility guidelines. Ensure regular disinfection of patient care equipment.
12. Implement Appropriate Isolation Precautions: To minimize the risk of cross-transmission of infection between patients, healthcare workers, and visitors, implement septic isolation and transmission-based precautions as indicated. Protective isolation may be necessary for patients with compromised immune systems to shield them from potential pathogens. Visitor restrictions may be implemented as part of infection control measures.
13. Utilize Personal Protective Equipment (PPE): Consistent and correct use of PPE is essential to protect both healthcare workers and patients from infection transmission. Don gowns and gloves before entering the patient’s room. Use face masks and eye protection (safety goggles or face shields) to protect against droplets and airborne microorganisms.
14. Initiate Enteral Nutrition Support: Early initiation of enteral (feeding through a tube into the gastrointestinal tract) or parenteral (intravenous feeding) nutrition is recommended to address micronutrient deficiencies and provide adequate protein intake, particularly for patients who are unable to maintain sufficient oral intake for more than three days.
Nursing Care Plans for Sepsis
Once nursing diagnoses are identified for a patient with sepsis, nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term goals of care. Here are examples of nursing care plans for common nursing diagnoses associated with sepsis:
Decreased Cardiac Output related to Sepsis
Severe sepsis and hypoperfusion significantly impact cardiovascular function and circulation.
Nursing Diagnosis: Decreased Cardiac Output
Related Factors:
- Altered hemodynamic parameters
- Impaired cardiac contractility
- Impaired myocardial circulation
- Loss of vascular tone
- Hypovolemia (decreased blood volume)
As Evidenced By:
- Tachycardia (rapid heart rate)
- Abnormal central venous pressure (CVP)
- Abnormal mean arterial pressure (MAP)
- Cyanosis (bluish skin discoloration)
- Pallor (pale skin)
- Prolonged capillary refill time
- Hypotension (low blood pressure)
- Oliguria (decreased urine output)
- Alteration in level of consciousness
- Cold, clammy skin
- Decreased peripheral pulses
- Cardiac dysrhythmias (irregular heart rhythms)
- Presence of heart murmurs
Expected Outcomes:
- The patient will demonstrate adequate cardiac output, as evidenced by:
- 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 (CVP): 8-12 mmHg
- Mean arterial pressure (MAP): 65-90 mmHg
- Urine output: 0.5 to 1.5 cc/kg/hour
- Absence of adverse cardiac findings:
- Adynamic precordium (normal chest wall movement with heartbeat)
- 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 severe sepsis and decreased cardiac output.
2. Monitor hemodynamic parameters (CVP, Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP)).
- CVP reflects right-sided heart filling pressures.
- PADP and PCWP provide insights into left-sided heart fluid volumes.
3. Monitor relevant laboratory data. Sepsis-induced cardiomyopathy (heart muscle dysfunction) may be indicated by:
- Elevated cardiac markers:
- Increased plasma troponins I or T may suggest left ventricular systolic dysfunction and myocardial injury.
- Elevated BNP and NT-proBNP may correlate with sepsis severity.
- Decreased ejection fraction (measured by echocardiogram):
- Left ventricular ejection fraction is an early indicator of septic cardiomyopathy.
Nursing Interventions:
1. Administer fluid resuscitation as prescribed. Adequate fluid therapy is essential to address sepsis-induced tissue hypoperfusion and hypovolemia caused by vasodilation, fluid loss, and capillary leak. Fluid administration increases preload, potentially improving stroke volume and cardiac output (Frank-Starling law). However, caution is needed as excessive fluid can be detrimental in cardiomyopathy.
2. Administer medications as prescribed.
- Antibiotics: Broad-spectrum antibiotics should be initiated promptly after blood cultures are obtained.
- Vasopressors: Counteract vasodilation, increasing blood pressure and perfusion.
3. Anticipate adjunctive therapies as indicated. Mechanical circulatory support (intra-aortic balloon pump (IABP), ventricular assist devices, extracorporeal membrane oxygenation (ECMO)) may be necessary if primary therapies fail to maintain cardiac output.
4. Optimize oxygen delivery. Ensure adequate oxygenation through supplemental oxygen or mechanical ventilation to support cardiac function and tissue perfusion.
Hyperthermia related to Sepsis
Elevated body temperature is a natural response to infection and inflammation. However, excessive and prolonged hyperthermia can be harmful.
Nursing Diagnosis: Hyperthermia
Related Factors:
- Dehydration
- Increased metabolic rate
- Inflammatory process
As Evidenced By:
- Elevated body temperature above normal range
- Flushed, warm skin
- Tachypnea (rapid breathing)
- Tachycardia (rapid heart rate)
- Confusion
- Seizures
Expected Outcomes:
- Patient will maintain body temperature within normal limits.
- The underlying cause of hyperthermia (infection) will be addressed.
Nursing Assessments:
1. Measure temperature rectally for accuracy. Rectal temperature measurement is considered the most accurate for core body temperature.
2. Assess neurological status. Uncontrolled hyperthermia can lead to brain damage. Changes in level of consciousness, confusion, and seizures are signs of neurological deterioration.
Nursing Interventions:
1. Create a cool environment. Adjust room temperature, remove excess linens and clothing.
2. Apply a cooling blanket. Cooling blankets reduce surface temperature, but monitor closely to prevent shivering, which can increase body temperature.
3. Administer antipyretic medications. Administer acetaminophen or other prescribed antipyretics to reduce fever.
4. Provide cool compresses or tepid baths. Apply cool compresses to areas with high blood flow (groin, axillae). Tepid baths promote heat loss through evaporation.
Ineffective Protection related to Sepsis
Sepsis impairs the body’s protective mechanisms against infection and systemic inflammatory response.
Nursing Diagnosis: Ineffective Protection
Related Factors:
- Infectious process
- Immunosuppression
- Abnormal blood profiles
- Poor nutritional status
- 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 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. Changes in mental status, hypotension, fever, tachycardia, chills, and flushed skin are key sepsis indicators requiring prompt reporting.
2. Monitor WBC count and differential. Leukocytosis (elevated WBC) is common in infection, but sepsis can present with leukocytosis or leukopenia (low WBC). Immature band forms may be elevated even with a normal total WBC count. Differential count can suggest the type of infection (neutrophils: bacterial; lymphocytes: viral; eosinophils: parasitic).
3. Assess risk factors contributing to ineffective protection. Identify factors increasing sepsis risk, such as immunosuppression (cancer, autoimmune diseases, HIV, chemotherapy, immunosuppressants), immobility, malnutrition, and wounds.
Nursing Interventions:
1. Promote rest and sleep. Adequate sleep is crucial for cellular repair and growth hormone release, which supports healing. Sleep disruption impairs these processes.
2. Minimize invasive procedures. Limit catheterizations, injections, and rectal/vaginal procedures to reduce pathogen introduction. Use aseptic techniques for necessary invasive lines.
3. Encourage a high-protein, nutrient-rich diet. Protein supports tissue repair and immune function. Address appetite issues with stimulants or dietitian consultation.
4. Educate patient and family on infection control measures. Emphasize hand hygiene as the simplest way to prevent infection transmission. Instruct on proper handwashing techniques.
Risk for Deficient Fluid Volume related to Sepsis
Septic shock leads to fluid shifts out of the intravascular space, causing hypotension and requiring fluid resuscitation.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related Factors:
- Vasodilation
- Increased membrane permeability
As Evidenced By:
Risk diagnoses do not have “as evidenced by” criteria, as the problem is potential, not actual. Interventions are preventative.
Expected Outcome:
- Patient will maintain adequate circulatory volume, evidenced by stable vital signs and normal urine output.
Nursing Assessments:
1. Monitor for signs of fluid loss. Septic shock causes rapid blood pressure drops due to fluid shifts. Monitor for tachycardia, fever, and dehydration signs (poor skin turgor, dry mucous membranes).
2. Assess intake and output and daily weight. Closely monitor fluid balance.
3. Monitor for edema. Fluid shifting to interstitial spaces causes edema (third spacing). Monitor for edema and weight gain.
4. Review laboratory values. Changes in hemoglobin and hematocrit may indicate fluid volume deficit. Elevated BUN and creatinine suggest kidney dysfunction. High urine specific gravity indicates dehydration and kidney damage.
Nursing Interventions:
1. Administer IV fluids. Crystalloids (normal saline, lactated Ringer’s) are initial resuscitation fluids. Colloids (albumin, fresh frozen plasma) may be needed to maintain intravascular volume due to their larger molecule size.
2. Administer vasopressors. Vasopressors (dopamine, norepinephrine) may be used with fluids or for persistent septic shock to maintain blood pressure.
3. Monitor circulatory function. Assess heart rate, rhythm, MAP, pulse oximetry, urine output, and relevant lab values to evaluate organ perfusion.
Risk for Infection related to Sepsis
Sepsis is itself a systemic infection, highlighting the ongoing risk of further or worsening infection.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Immunosuppression
- Multiple chronic comorbidities
- Compromised skin or tissue integrity
- Malnutrition
- Untreated/worsening infections (UTIs, cellulitis, pneumonia)
As Evidenced By:
Risk diagnoses do not have “as evidenced by” criteria. Interventions are preventative.
Expected Outcomes:
- Patient will remain free of new infections, with vital signs and WBC count within normal limits.
- Patient will show wound healing improvement without infection signs (redness, drainage, odor).
- Patient will identify infection prevention strategies.
Nursing Assessments:
1. Note signs and symptoms of sepsis. Fever, tachycardia, tachypnea, chills, altered mental status are sepsis signs requiring monitoring and intervention.
2. Monitor relevant lab work. Elevated WBC, CRP, and lactate levels suggest infection/sepsis.
3. Obtain specimens for culture. Collect blood, urine, sputum, or wound cultures to identify infection sources.
Nursing Interventions:
1. Administer anti-infectives as prescribed. Prophylactic antibiotics or broad-spectrum antibiotics may be used initially, followed by targeted antibiotics based on culture results.
2. Emphasize hand hygiene. Reinforce handwashing for healthcare providers, patients, and visitors.
3. Discontinue unnecessary invasive lines. Remove IV lines, urinary catheters, and other invasive devices when no longer needed to prevent bloodstream infections.
4. Promote skin integrity. Prevent skin breakdown through regular turning, mobility assistance, skin assessments, and addressing incontinence and nutritional status.
References
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