Nursing Diagnosis for Sepsis: A Comprehensive Guide for Nurses

Sepsis is a life-threatening condition that arises when the body’s response to an infection spirals out of control, leading to widespread inflammation and potential organ damage. This systemic infection, often triggered by bacteria, but also viruses, fungi, or parasites, demands immediate and aggressive intervention. If left unchecked, sepsis can rapidly progress to septic shock, a critical stage characterized by organ failure and a significantly increased risk of mortality. For nurses, being able to recognize the subtle early signs of sepsis, understand the underlying pathophysiology, and formulate appropriate nursing diagnoses are paramount to ensuring timely and effective patient care.

This article provides a comprehensive guide to understanding and applying Nursing Diagnosis Sepsis in clinical practice. It will delve into the essential aspects of nursing assessment, crucial interventions, and the development of targeted nursing care plans for patients at risk or experiencing sepsis. Nurses in all specialties, particularly those in critical care, emergency departments, and medical-surgical units, must be adept at identifying sepsis early and initiating prompt, evidence-based care. Infants, older adults over 65, and individuals with compromised immune systems or pre-existing chronic conditions are particularly vulnerable, making vigilant monitoring and proactive nursing care even more critical in these populations.

Sepsis Nursing Assessment: Recognizing the Signs

The cornerstone of effective sepsis management begins with a thorough and timely nursing assessment. This process involves gathering both subjective and objective data to identify patients at risk for or exhibiting signs of sepsis. A comprehensive assessment encompasses a review of the patient’s health history, a detailed physical examination, and the interpretation of relevant diagnostic procedures.

Health History Review

A detailed review of the patient’s health history can reveal critical clues that point towards sepsis or increase their risk. Key areas to explore include:

1. General Sepsis Symptoms: Elicit information about any general symptoms the patient may be experiencing. While non-specific, these symptoms can be early indicators of a developing infection and systemic response:

• Temperature Instability: Note any reports of increased temperature (fever) or, conversely, decreased temperature (hypothermia). Sepsis can manifest with either hyperthermia (>100.4°F or >38°C) or hypothermia (<96.8°F or <36°C).
• Chills: Inquire about the presence of chills, which often accompany fever as the body attempts to raise its core temperature.
• Changes in Mentation: Assess for any alterations in mental status. This can range from subtle confusion or disorientation to lethargy, agitation, or decreased responsiveness. Changes in mentation are a significant indicator of sepsis affecting the central nervous system.
• Rapid Breathing (Tachypnea): Ask about shortness of breath or increased respiratory rate. Tachypnea (>20 breaths per minute) is a common early sign as the body tries to compensate for metabolic acidosis and increased oxygen demand.
• Skin Changes: Note any reported changes in skin color or temperature. Patients may describe flushed skin initially, or cool, clammy skin as sepsis progresses.
• Hypotension: While patients may not report hypotension directly, inquire about dizziness or lightheadedness, which can be associated with low blood pressure.

2. Identifying the Cause of Sepsis: Determine the potential source of infection. Sepsis always arises from an underlying infection. Identifying the likely origin helps guide diagnostic and treatment strategies. Common sources of infection leading to sepsis include:

• Lung Infections (Pneumonia): Inquire about cough, increased sputum production, chest pain, or shortness of breath, which are indicative of pneumonia.
• Kidney, Bladder, and Urinary System Infections (Urinary Tract Infections – UTIs): Ask about urinary frequency, urgency, dysuria (painful urination), flank pain, or changes in urine appearance, suggesting a UTI or pyelonephritis.
• Gastrointestinal System Infections: Explore symptoms such as abdominal pain, diarrhea, vomiting, or signs of peritonitis, which may indicate intra-abdominal infections, such as appendicitis, diverticulitis, or bowel perforation.
• Bloodstream Infections (Bacteremia): Bloodstream infections can arise from various sources or invasive procedures. It’s important to consider this as a potential cause, especially in patients with central lines or recent surgeries.
• Invasive Devices: Note the presence of any invasive devices, such as central venous catheters, peripheral intravenous lines, urinary catheters, endotracheal tubes, or surgical drains. These devices can serve as entry points for pathogens.
• Burns or Wounds: Assess for burns or wounds, as compromised skin integrity increases the risk of infection. Note the characteristics of any wounds, including redness, drainage, pain, and odor.

3. Identifying Risk Factors: Determine if the patient has any risk factors that predispose them to sepsis. Recognizing these factors allows for heightened vigilance and proactive prevention strategies:

• Age Over 65: Older adults have age-related declines in immune function, making them more susceptible to infections and sepsis.
• Infancy: Infants, especially newborns, have immature immune systems, increasing their vulnerability to severe infections.
• Compromised Immune System (Immunocompromised): Conditions such as HIV/AIDS, cancer, organ transplantation, autoimmune diseases, and treatments like chemotherapy or immunosuppressants significantly weaken the immune system.
• Comorbidities (Chronic Conditions): Certain chronic illnesses increase sepsis risk. These include:
  • Diabetes Mellitus: Impaired immune function and vascular disease in diabetes increase infection susceptibility.
  • Chronic Kidney Disease: Weakened immune system and fluid imbalances in kidney disease elevate sepsis risk.
  • Chronic Liver Disease (Cirrhosis): Impaired immune function and gut dysbiosis in liver disease increase infection risk.
  • Chronic Obstructive Pulmonary Disease (COPD): Compromised respiratory function and increased susceptibility to respiratory infections in COPD increase sepsis risk.
  • Heart Failure: Reduced cardiac reserve and fluid imbalances in heart failure can exacerbate sepsis severity.
• Longer Hospital Stays: Prolonged hospitalizations increase the risk of healthcare-associated infections, including those caused by drug-resistant organisms.
• Invasive Lines (Central Venous Catheters, Urinary Catheters): These devices breach natural barriers, providing pathways for pathogens to enter the bloodstream.
• Prolonged and Unsupervised Antibiotic Therapy Within the Last 90 Days: Recent antibiotic use can disrupt the normal flora, promote antibiotic resistance, and increase the risk of infections with resistant organisms.
• Use of Corticosteroids and Other Immunosuppressants: These medications suppress the immune system, making individuals more vulnerable to infections and sepsis.

4. Review the Medical History: Delve deeper into the patient’s medical history to identify conditions that may increase sepsis susceptibility or severity:

• Existing Infection: A known infection is the primary trigger for sepsis. Document the type, location, and duration of any current infections.
• Undiagnosed Infection: Consider the possibility of an underlying infection that is not yet diagnosed. Subtle or atypical presentations may delay diagnosis.
• Untreated Infection: Inadequate or delayed treatment of infections can allow them to progress and lead to sepsis.
• Compromised Immune System: Identify conditions that directly impair immune function, such as:
  • Cancer (especially hematologic malignancies): Cancer and cancer treatments weaken the immune system.
  • HIV Infection: HIV directly attacks immune cells, leading to profound immunosuppression.
• Chronic Diseases: Note the presence of chronic conditions that indirectly affect immune function or overall health status, including diabetes and COPD, as mentioned before.
• Recent Surgical Procedures: Surgery disrupts skin integrity and can introduce pathogens. Post-operative infections are a significant cause of sepsis.
• Implanted Devices (Pacemakers, Ports, Prosthetic Joints): Implanted devices can become colonized with bacteria and lead to device-related infections and sepsis.
• Organ Transplant Complications: Transplant recipients require immunosuppression to prevent rejection, which increases their risk of opportunistic infections and sepsis.

5. Review the Patient’s Medication List: Pay close attention to medications that can impact immune function or antibiotic resistance:

• Corticosteroids and Other Immunosuppressants: Document the use of these medications, as they directly suppress the immune response.
• Antibiotic Use History: Assess the patient’s recent and past antibiotic use. Factors that contribute to antibiotic resistance include:
  • Discontinuation of Antibiotics Without Provider Instruction: Incomplete antibiotic courses can lead to the survival and proliferation of resistant bacteria.
  • Unnecessary Antibiotic Use (e.g., for viral infections): Overuse of antibiotics contributes to the selection and spread of resistant strains.
  • Frequent Antibiotic Use: Repeated antibiotic exposure increases the risk of developing resistance.
  • No Access to Medications or Poor Quality Medications: Inadequate treatment due to lack of access or ineffective drugs can promote resistance.
  • Incorrect Drug Prescribing (e.g., wrong dose, duration, or spectrum): Suboptimal antibiotic therapy can fail to eradicate infection and contribute to resistance.

Alt text: A nurse attentively monitors a patient’s vital signs, including blood pressure and heart rate, as part of a sepsis assessment in a hospital setting. The nurse is focused on the monitor, demonstrating the critical role of vital sign monitoring in early sepsis detection.

Physical Examination

A thorough physical examination is crucial to identify objective signs of sepsis and assess the extent of organ involvement.

1. Assess Vital Signs: Vital signs are often the first indicators of physiological changes in sepsis:

• Hyperthermia or Hypothermia: Measure body temperature to detect fever (hyperthermia) or hypothermia.
• Tachycardia: Assess heart rate. Tachycardia (heart rate >100 beats per minute) is a common early sign as the heart tries to compensate for decreased tissue perfusion.
• Tachypnea: Evaluate respiratory rate. Tachypnea (respiratory rate >20 breaths per minute) indicates increased respiratory effort and potential respiratory distress.

2. Perform a Systemic Assessment: Sepsis can progress rapidly to severe sepsis and septic shock, leading to organ dysfunction. A system-by-system assessment is vital to detect early signs of organ compromise:

• Central Nervous System (CNS): Assess neurological status for:
  • Altered Mental Status: Evaluate level of consciousness, orientation, attention span, and cognitive function. Changes may include confusion, disorientation, lethargy, restlessness, anxiety, or coma.
• Respiratory System: Assess respiratory function for:
  • Hypoxia: Monitor oxygen saturation (SpO2) levels. Hypoxia (SpO2 <90% or PaO2 <60 mmHg) indicates inadequate oxygenation.
  • Cough: Note the presence, type, and productivity of cough.
  • Chest Pain: Inquire about chest pain, noting its location, character, and radiation.
  • Dyspnea (Shortness of Breath): Assess for subjective complaints of dyspnea and objective signs of increased work of breathing (e.g., nasal flaring, accessory muscle use, retractions).
• Cardiovascular System: Evaluate cardiovascular status for:
  • Decreased Capillary Refill: Assess capillary refill time by pressing on a nailbed and noting the time it takes for color to return. Delayed capillary refill (>3 seconds) suggests poor peripheral perfusion.
• Gastrointestinal System: Assess the abdomen for:
  • Ileus: Listen for bowel sounds. Absent or hypoactive bowel sounds may indicate ileus (decreased bowel motility).
  • Perforation: Assess for signs of peritonitis, such as rigid abdomen, rebound tenderness, and severe abdominal pain, which may indicate bowel perforation.
  • Abscess: Palpate for abdominal tenderness and masses, which may suggest an abscess.
  • Abdominal Tenderness: Note any areas of tenderness to palpation.
• Genitourinary System: Monitor urine output:
  • Decreased Urine Production (Oliguria): Measure urine output. Oliguria (<0.5 mL/kg/hour) indicates reduced kidney perfusion.
  • Absent Urine Production (Anuria): Anuria (no urine output) is a critical sign of severe renal dysfunction.
• Integumentary System: Observe skin color and temperature:
  • Flushed Skin: Early sepsis may present with flushed, warm skin due to vasodilation.
  • Cyanosis: Bluish discoloration of the skin and mucous membranes indicates hypoxemia.
  • Pallor: Pale skin suggests poor perfusion and vasoconstriction.
  • Skin Mottling: Patchy discoloration of the skin, often with a lace-like pattern, indicates poor peripheral circulation.

3. Assess for Progression to Shock: Closely monitor for signs that sepsis is progressing to septic shock, a life-threatening emergency. Key indicators include:

• Cool Extremities: Palpate extremities for temperature. Cool, clammy extremities indicate peripheral vasoconstriction and poor perfusion.
• Delayed Capillary Refill (>3 Seconds): Capillary refill time remains prolonged in septic shock.
• Thready Pulses: Palpate peripheral pulses (radial, pedal). Thready, weak pulses reflect decreased stroke volume and hypotension.
• Pale Skin: Skin pallor becomes more pronounced in shock.
• Diaphoresis: Excessive sweating (diaphoresis) can occur as the body attempts to regulate temperature and compensate for metabolic stress.
• Confusion: Mental status deteriorates further, with increasing confusion and disorientation.
• Decreased Level of Consciousness: Patients may become increasingly lethargic, stuporous, or comatose.

4. Observe Intravenous Lines: Inspect IV sites for signs of local infection or thrombophlebitis (inflammation of a vein related to a blood clot):

• Swelling: Localized swelling around the IV insertion site.
• Redness (Erythema): Redness extending outward from the insertion site.
• Drainage: Purulent or cloudy drainage from the insertion site.
• Pain: Tenderness or pain at the insertion site.
• Central Venous Lines: Pay particular attention to central lines, as they are a significant risk factor for bloodstream infections and sepsis.

5. Note Any Signs of Infection in Wounds or Incisions: Carefully assess wounds and surgical incisions for signs of infection:

• Abscess: Localized collection of pus within a tissue.
• Cellulitis: Spreading bacterial infection of the skin and subcutaneous tissue, characterized by redness, warmth, tenderness, and swelling.
• Wound Infection: Signs of wound infection include:
  • Pain: Increased pain at the wound site.
  • Purulent Discharge: Thick, cloudy, or foul-smelling drainage from the wound.
  • Erythema: Redness around the wound edges.
  • Swelling: Increased swelling or induration around the wound.
  • Warmth: Increased warmth to touch around the wound.

Alt text: A close-up shot of blood sample vials labeled for laboratory testing, emphasizing the crucial role of diagnostic procedures in identifying sepsis. The vials are arranged on a lab counter, ready for analysis to aid in rapid sepsis diagnosis.

Diagnostic Procedures

Diagnostic procedures play a critical role in confirming sepsis, identifying the causative pathogen, and assessing the severity of organ dysfunction.

1. Collect Samples for Laboratory Studies: Blood and other body fluid samples are essential for laboratory analysis:

• Complete Blood Count (CBC): Evaluates white blood cell (WBC) count, neutrophil count, and platelet count. Sepsis may cause:
  • Leukocytosis: Elevated WBC count (>12,000 cells/µL), indicating infection.
  • Leukopenia: Decreased WBC count (<4,000 cells/µL), which can occur in severe sepsis and indicate bone marrow suppression.
  • Neutropenia: Decreased neutrophil count (<1,500 cells/µL), suggesting impaired immune response.
  • Thrombocytopenia: Decreased platelet count (<150,000/µL), indicating consumptive coagulopathy or bone marrow suppression.
• Kidney Function Tests: Measure blood urea nitrogen (BUN) and creatinine levels to assess kidney function. Elevated levels indicate impaired kidney perfusion and potential acute kidney injury.
• Blood and Site-Specific Cultures: Obtain cultures from blood, urine, sputum, wounds, or other suspected sites of infection before initiating antibiotic therapy. Cultures help identify the causative pathogen and guide antibiotic selection.
• Urinalysis & Culture: If urinary tract infection is suspected, obtain a urinalysis and urine culture to identify urinary pathogens.
• Biomarkers: Measure biomarkers that are elevated in sepsis, aiding in early diagnosis and prognostication:
  • Procalcitonin (PCT): Elevated PCT levels are highly suggestive of bacterial infection and sepsis. PCT is more specific for bacterial infections than other inflammatory markers.
  • Presepsin (sCD14-ST): Presepsin is another biomarker that rises early in sepsis and can help differentiate sepsis from non-infectious inflammation.
• Lactate Levels: Measure serum lactate levels. Elevated lactate levels (>2 mmol/L) indicate anaerobic metabolism due to tissue hypoperfusion. Levels >4 mmol/L are strongly suggestive of septic shock.
• C-Reactive Protein (CRP): CRP is an acute-phase reactant that is elevated in inflammation and infection, including sepsis. While not specific for sepsis, elevated CRP supports the diagnosis.
• Coagulation Studies (INR and PTT): Measure International Normalized Ratio (INR) and Partial Thromboplastin Time (PTT) to assess coagulation status. Elevated INR and PTT indicate coagulopathy, a common complication of sepsis, such as disseminated intravascular coagulation (DIC).

2. Prepare the Patient for Imaging Scans: Imaging studies help identify the source of infection and assess for complications:

• Chest X-ray: Used to diagnose pneumonia and other lung infections.
• Chest CT Scan: Provides more detailed images of the lungs and mediastinum, useful for detecting complex pneumonia, lung abscesses, or empyema.
• Abdominal Ultrasonography: Useful for evaluating the gallbladder, liver, kidneys, and detecting abdominal abscesses or fluid collections.
• Abdominal CT Scan or MRI: Provides detailed images of abdominal organs and retroperitoneum, helpful for diagnosing intra-abdominal infections, such as appendicitis, diverticulitis, pancreatitis, or abscesses.
• Site-Specific Soft Tissue Imaging (Ultrasound, CT Scan, MRI): Used to evaluate localized infections, such as cellulitis, abscesses, or osteomyelitis.
• Contrast-Enhanced CT Scan or MRI of the Brain/Neck: Considered if central nervous system infection (meningitis, encephalitis) or neck infection (deep neck space infection) is suspected.

3. Anticipate the Possibility of Invasive Diagnostic Procedures: Invasive procedures may be necessary to obtain samples for diagnosis or to drain fluid collections:

• Thoracentesis: Pleural fluid aspiration for analysis and culture in cases of suspected empyema or pleural effusion.
• Paracentesis: Ascitic fluid aspiration for analysis and culture in cases of suspected spontaneous bacterial peritonitis.
• Fluid Accumulations and Abscess Drainage: Percutaneous or surgical drainage of abscesses or other fluid collections to obtain samples for culture and to remove the source of infection.
• Bronchoscopy with Lavage, Washing, or Other Invasive Samples: Bronchoscopy with bronchoalveolar lavage (BAL) or bronchial washings may be performed to obtain lower respiratory tract samples for culture and cytology in cases of pneumonia, especially in immunocompromised patients.

Nursing Interventions for Sepsis: Immediate and Ongoing Care

Prompt and aggressive nursing interventions are critical to improving patient outcomes in sepsis. These interventions are multifaceted and aim to address the underlying infection, support organ function, and prevent complications.

1. Prepare the Patient for Hospital Admission and ICU Transfer: Sepsis requires intensive monitoring and treatment in a hospital setting, often in the intensive care unit (ICU). Rapid transfer to an ICU is essential for patients with severe sepsis or septic shock.

2. Initiate Antibiotic Therapy as Ordered: Administer antibiotics intravenously as soon as possible after obtaining cultures. Timely antibiotic administration is a cornerstone of sepsis treatment.

• Broad-Spectrum Antibiotics: Initially, broad-spectrum antibiotics are used to cover a wide range of potential pathogens, as the causative organism is often unknown at first.
• Narrow-Spectrum Antibiotics: Once culture results identify the specific pathogen, antibiotic therapy may be narrowed to a more targeted, narrow-spectrum antibiotic to minimize antibiotic resistance and side effects.

3. Start Fluid Volume Resuscitation: Aggressive fluid resuscitation is crucial to address hypovolemia and improve tissue perfusion in sepsis.

• Crystalloid Fluids: Administer crystalloid fluids (e.g., normal saline, lactated Ringer’s) intravenously. The Surviving Sepsis Campaign recommends an initial bolus of at least 30 mL/kg of crystalloid fluid within the first three hours of sepsis recognition.
• Perfusion Pressure Goal: Fluid resuscitation is guided by hemodynamic monitoring and aimed at achieving adequate perfusion pressure, typically assessed by mean arterial pressure (MAP).

4. Administer Vasopressors as Prescribed: Vasopressors may be necessary if hypotension persists despite adequate fluid resuscitation.

• Vasopressor Medications: Vasopressors (e.g., norepinephrine, dopamine) are medications that constrict blood vessels, raising blood pressure and improving organ perfusion. Vasopressors are typically initiated when MAP remains <65 mmHg despite fluid resuscitation.

5. Position as Advised: Patient positioning can optimize respiratory function and prevent complications.

• Semi-Fowler’s or High-Fowler’s Position: Elevating the head of the bed to semi-Fowler’s (30-45 degrees) or high-Fowler’s (60-90 degrees) position can improve lung expansion and reduce the risk of aspiration pneumonia.
• Prone Positioning: In patients with sepsis-induced Acute Respiratory Distress Syndrome (ARDS), prone positioning (placing the patient on their stomach) can improve oxygenation and reduce mortality.

6. Begin Invasive Monitoring: Invasive hemodynamic monitoring provides continuous and accurate assessment of cardiovascular function in critically ill sepsis patients.

• Arterial Line Insertion: Insertion of an arterial line allows for continuous blood pressure monitoring and frequent arterial blood gas sampling.
• Central Venous Catheter (CVC) Insertion: CVC insertion allows for central venous pressure (CVP) monitoring, administration of vasoactive medications, and central venous oxygen saturation (ScvO2) monitoring.

7. Apply Oxygen or Prepare for Mechanical Ventilation: Respiratory support is often needed to address hypoxemia and respiratory failure in sepsis.

• Supplemental Oxygen: Administer supplemental oxygen via nasal cannula, face mask, or non-rebreather mask to maintain adequate oxygen saturation.
• Mechanical Ventilation: Prepare for intubation and mechanical ventilation if patients develop respiratory failure, as evidenced by persistent hypoxemia, hypercapnia (elevated carbon dioxide levels), or increased work of breathing.

8. Administer Insulin: Hyperglycemia (high blood glucose levels) is common in sepsis, even in patients without pre-existing diabetes.

• Insulin Therapy: Administer intravenous insulin to maintain blood glucose levels within a target range, typically 140-180 mg/dL. Strict glucose control may improve outcomes in sepsis.

9. Prepare the Patient for Possible Surgery: Surgical intervention may be necessary to remove the source of infection in certain cases.

• Source Control Surgery: Surgery may be required to drain abscesses, debride necrotic tissue, remove infected devices, or repair bowel perforations, depending on the source of sepsis.

10. Remove Intravascular Devices: Promptly remove intravascular access devices (IV lines, catheters) if they are suspected to be the source of infection.

11. Implement Hygiene Practices: Strict hygiene practices are essential to prevent healthcare-associated infections and cross-transmission of pathogens.

• Hand Hygiene: Perform meticulous hand hygiene with soap and water or alcohol-based hand sanitizer before and after patient contact and procedures.
• Patient Hygiene: Provide regular bed baths and assist with hygiene needs.
• Aseptic Cleaning of Catheters and IV Hubs: Clean catheter insertion sites and IV hubs using aseptic technique according to facility guidelines.
• Equipment Disinfection: Regularly disinfect patient care equipment, such as blood pressure cuffs, stethoscopes, and ventilators.

12. Implement the Appropriate Precautions: Implement transmission-based precautions to prevent the spread of infection.

• Standard Precautions: Apply standard precautions for all patients, including hand hygiene and use of personal protective equipment (PPE) as needed.
• Transmission-Based Precautions: Implement contact precautions, droplet precautions, or airborne precautions based on the suspected or confirmed pathogen and mode of transmission.
• Protective Isolation: Consider protective isolation for severely immunocompromised patients to minimize exposure to potential pathogens.

13. Use Appropriate PPE: Consistent and correct use of PPE protects healthcare workers and patients from infection transmission.

• Gowns and Gloves: Don gowns and gloves before entering the patient’s room, especially when contact with body fluids is anticipated.
• Face Masks and Eye Protection: Use face masks and eye protection (goggles or face shields) to protect against respiratory droplets and splashes of body fluids.

14. Initiate Enteral Feedings: Early nutritional support is important to meet metabolic demands and support immune function in sepsis.

• Enteral Nutrition: Initiate enteral nutrition (feeding through a tube into the stomach or small intestine) as soon as feasible, ideally within 24-48 hours of sepsis diagnosis, if the patient can tolerate it.
• Parenteral Nutrition: Consider parenteral nutrition (intravenous feeding) if enteral nutrition is contraindicated or not tolerated.

Nursing Care Plans for Sepsis: Addressing Key Nursing Diagnoses

Nursing care plans provide a structured framework for organizing and delivering individualized patient care based on identified nursing diagnoses. For sepsis, several key nursing diagnoses are commonly relevant, guiding assessment priorities and nursing interventions.

Decreased Cardiac Output

Severe sepsis and septic shock often lead to decreased cardiac output due to factors such as hypovolemia, vasodilation, and myocardial dysfunction (septic cardiomyopathy).

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Altered hemodynamic parameters (hypovolemia, vasodilation)
• Impaired cardiac contractility (septic cardiomyopathy)
• Impaired myocardial circulation
• Loss of vascular tone
• Hypovolemia

As evidenced by:

• Tachycardia
• Hypotension
• Elevated or decreased Central Venous Pressure (CVP)
• Decreased Mean Arterial Pressure (MAP)
• Cyanosis
• Pallor
• Prolonged capillary refill time
• Oliguria
• Alteration in the level of consciousness
• Cold, clammy skin
• Decreased peripheral pulses
• Cardiac dysrhythmias
• Presence of murmurs

Expected outcomes:

• Patient will manifest adequate cardiac output as evidenced by:
  • Vital signs within normal limits:
    • Blood pressure: Systolic 90-120 mmHg, Diastolic 60-80 mmHg
    • Pulse rate: 60-100 beats per minute
    • Central venous pressure 8-12 mmHg
    • Mean arterial pressure 65-90 mmHg
  • Urine output: 0.5-1.5 cc/kg/hour
  • Unremarkable cardiac findings:
    • Adynamic precordium
    • Absence of cardiac dysrhythmias
    • Absence of murmurs

Assessment:

1. Assess for signs and symptoms of cardiac and circulatory compromise: Hypotension, tachycardia, tachypnea, and thready peripheral pulses are key indicators of decreased cardiac output in sepsis.
2. Monitor hemodynamic parameters (CVP, Pulmonary Artery Diastolic Pressure (PADP), Pulmonary Capillary Wedge Pressure (PCWP)):
   • CVP reflects right ventricular preload (volume status).
   • PADP and PCWP provide information about left ventricular preload and pulmonary artery pressure.
3. Monitor laboratory data: Assess for biomarkers of septic cardiomyopathy:
   • Elevated cardiac markers:
     • Troponins (I or T): Elevated troponins may indicate myocardial injury and left ventricular systolic dysfunction.
     • BNP and NT-proBNP: Elevated B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) may correlate with disease severity and cardiac dysfunction.
   • Decreased ejection fraction (Ejection Fraction): Echocardiography may reveal reduced left ventricular ejection fraction, indicating septic cardiomyopathy.

Interventions:

1. Administer fluid resuscitation as prescribed: Adequate fluid volume is crucial to improve preload and stroke volume. However, cautious fluid management is needed in septic cardiomyopathy to avoid fluid overload.
2. Administer medications as prescribed:
   • Antibiotics: Administer broad-spectrum antibiotics promptly.
   • Vasopressors: Administer vasopressors to increase blood pressure and improve perfusion if hypotension persists despite fluid resuscitation.
3. Anticipate the need for adjunctive therapies as indicated: Mechanical circulatory support may be required in severe septic cardiomyopathy.
   • Intra-aortic balloon pump (IABP): IABP can augment diastolic blood pressure and improve coronary perfusion.
   • Percutaneous ventricular assist devices (VADs): VADs can provide temporary mechanical circulatory support.
   • Extracorporeal membrane oxygenation (ECMO): ECMO may be considered in refractory septic shock with severe cardiac and respiratory failure.
4. Meet oxygen demands: Ensure adequate oxygenation to support cardiac function and tissue perfusion. Provide supplemental oxygen or mechanical ventilation as needed.

Hyperthermia

Hyperthermia (fever) is a common physiological response to infection and inflammation in sepsis, but excessively high or prolonged fever can be detrimental.

Nursing Diagnosis: Hyperthermia

Related to:

• Dehydration
• Increased metabolic rate
• Inflammatory process

As evidenced by:

• Increased body temperature higher than normal range (>100.4°F or >38°C)
• Flushed skin, warm to touch
• Tachypnea
• Tachycardia
• Confusion
• Seizures

Expected outcomes:

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

Assessment:

1. Assess temperature rectally: Rectal temperature measurement is considered the most accurate for core body temperature.
2. Assess neurological status: Uncontrolled hyperthermia can lead to neurological damage. Monitor for altered level of consciousness, confusion, and seizures.

Interventions:

1. Provide a cool environment: Adjust room temperature, remove excess blankets and clothing to promote heat dissipation.
2. Apply a cooling blanket: Use a cooling blanket to reduce surface temperature. Monitor for shivering, which can paradoxically increase body temperature.
3. Administer antipyretics: Administer acetaminophen or other antipyretics as prescribed to reduce fever.
4. Provide cool rags or a tepid bath: Apply cool, damp cloths to areas with high blood flow, such as the groin and axillae. Provide tepid sponge baths to promote evaporative cooling.

Ineffective Protection

Patients with sepsis have a compromised ability to protect themselves from infection and its consequences due to the systemic inflammatory response and potential immunosuppression.

Nursing Diagnosis: Ineffective Protection

Related to:

• Infectious process (sepsis)
• Immunosuppression
• Abnormal blood profiles (leukopenia, thrombocytopenia)
• Poor nutrition
• Medication regimen (immunosuppressants)
• 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 secondary infection.
• Patient will verbalize understanding of measures to enhance immune system protection.
• Patient will demonstrate measures to protect or increase immune system protection.

Assessment:

1. Monitor for signs of sepsis: Continuously assess for changes in mental status, vital signs (hypotension, fever, tachycardia), chills, and skin changes, which may indicate worsening sepsis or secondary infection.
2. Monitor WBC and differential count: Assess WBC count and differential. Leukocytosis or leukopenia, as well as changes in neutrophil counts, can indicate infection or the body’s response to sepsis.
3. Monitor risk factors against protection: Regularly reassess the patient’s risk factors for ineffective protection, such as immunosuppression, immobility, malnutrition, and presence of wounds.

Interventions:

1. Encourage rest: Promote adequate rest and sleep to support immune function and cellular repair.
2. Avoid invasive procedures as much as possible: Minimize invasive procedures (catheterizations, injections) to reduce the risk of introducing pathogens. Use aseptic technique for any necessary invasive procedures.
3. Encourage high protein, nutrient-rich diets: Ensure adequate nutritional support, including high protein intake, to support tissue repair and immune function. Consult with a dietitian as needed.
4. Educate the patient and family about infection control measures: Educate the patient and family about hand hygiene, cough etiquette, and other infection control measures to prevent secondary infections and transmission.

Risk for Deficient Fluid Volume

Sepsis-induced vasodilation and increased capillary permeability lead to fluid shifts out of the intravascular space, increasing the risk for deficient fluid volume and hypotension.

Nursing Diagnosis: Risk for Deficient Fluid Volume

Related to:

• Vasodilation
• Increased membrane permeability
• Fluid shifts (third spacing)

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 vital signs and urinary output within normal limits.

Assessment:

1. Monitor for signs of fluid loss: Closely observe for signs of hypovolemia, such as hypotension, tachycardia, decreased skin turgor, and dry mucous membranes.
2. Assess intake and output and weight: Accurately monitor fluid intake (oral and intravenous) and urine output. Daily weights can help assess fluid balance changes.
3. Monitor for edema: Assess for peripheral edema, which may indicate fluid shifting into the interstitial space (third spacing) despite intravascular volume depletion.
4. Review lab values: Monitor hemoglobin, hematocrit, BUN, creatinine, and urine specific gravity. Changes may reflect fluid volume status and kidney function.

Interventions:

1. Administer IV fluids: Administer crystalloid fluids (normal saline, lactated Ringer’s) as prescribed for fluid resuscitation. Colloids (albumin) may be considered in certain situations.
2. Administer vasopressors: Administer vasopressors as prescribed to maintain blood pressure if hypotension persists despite fluid resuscitation.
3. Monitor circulatory function: Continuously monitor heart rate, blood pressure, MAP, CVP, urine output, and oxygen saturation to assess circulatory function and response to fluid resuscitation.

Risk for Infection

While sepsis itself is an infection, patients remain at risk for developing secondary infections due to immunosuppression, invasive devices, and prolonged hospitalization.

Nursing Diagnosis: Risk for Infection

Related to:

• Immunosuppression
• Multiple chronic comorbidities
• Compromised skin or tissue integrity
• Malnutrition
• Untreated/worsening infections (UTIs, cellulitis, pneumonia)
• Invasive devices (catheters, lines)

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 of secondary infection as evidenced by normal vital signs and WBC count.
• Patient will demonstrate improvement in wound healing without signs of infection.
• Patient will identify interventions to prevent or reduce risk of infection.

Assessment:

1. Note signs and symptoms of sepsis: Continuously monitor for signs and symptoms of sepsis, including fever, tachycardia, tachypnea, altered mental status, and chills, which may indicate worsening sepsis or secondary infection.
2. Monitor lab work: Monitor WBC count, CRP, and lactate levels. Elevated levels may suggest infection.
3. Obtain specimens for culture: Obtain cultures (blood, urine, sputum, wound) as needed to identify potential secondary infections.

Interventions:

1. Administer antiinfectives: Administer prophylactic antibiotics or continue therapeutic antibiotics as prescribed to prevent or treat infections.
2. Hand hygiene: Maintain meticulous hand hygiene practices and ensure patient and family adherence to hand hygiene.
3. Discontinue unnecessary invasive lines: Assess the necessity of invasive lines (IV catheters, urinary catheters) daily and discontinue them as soon as they are no longer needed to reduce infection risk.
4. Promote skin integrity: Implement measures to maintain skin integrity and prevent pressure ulcers, such as frequent turning, pressure redistribution devices, and skin assessments.

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, C. E., & Flood, R. G. (2022). Sepsis. In StatPearls [Internet]. StatPearls Publishing.