Sepsis Nursing Diagnosis Care Plan: A Comprehensive Guide for Nurses

Sepsis is a critical medical emergency that arises when the body’s response to an infection spirals out of control, triggering a widespread inflammation that can lead to systemic infection and an extreme immune response. This life-threatening condition demands immediate recognition and aggressive intervention to avert septic shock, a perilous state that can precipitate organ failure and ultimately, death.

The insidious nature of sepsis lies in its rapid progression and alarmingly high mortality rate if timely diagnosis and robust treatment are not initiated. Vulnerable populations, such as infants and adults over the age of 65, are particularly susceptible, alongside individuals with compromised immune systems or pre-existing chronic illnesses.

In this article, we will delve into a comprehensive Sepsis Nursing Diagnosis Care Plan, providing an in-depth guide for nurses to effectively assess, intervene, and manage patients at risk or affected by sepsis.

Nursing Process for Sepsis Management

While the intensive care unit (ICU) often serves as the primary setting for sepsis treatment, it is imperative that nurses across all units and specialties possess the acumen to recognize and evaluate sepsis indicators. Delays in initiating treatment can have dire, even fatal, consequences. Furthermore, nurses play a crucial role in sepsis prevention through meticulous infection control practices. This includes rigorous hand hygiene, diligent adherence to personal protective equipment (PPE) protocols, proficient wound care techniques, and the consistent application of sterile or aseptic procedures.

Comprehensive Nursing Assessment for Sepsis

The cornerstone of effective nursing care is a thorough nursing assessment. This initial step involves the systematic collection of physical, psychosocial, emotional, and diagnostic data. In the context of sepsis, this assessment is paramount for early identification and intervention. We will now explore the spectrum of subjective and objective data relevant to sepsis assessment.

Review of Health History: Subjective Data Collection

Gathering subjective data through a comprehensive health history is crucial in identifying potential sepsis. This involves carefully noting the patient’s reported symptoms, potential infection sources, and predisposing risk factors.

1. Document General Symptoms: Elicit information about the patient’s overall symptoms, which may include:

• Fluctuations in body temperature: Elevated (hyperthermia) or decreased (hypothermia).
• Chills: Rigors or shaking chills.
• Mental status changes: Confusion, disorientation, lethargy, or agitation.
• Rapid respiration: Shortness of breath or increased breathing rate.
• Skin changes: Flushed, warm, cool, or clammy skin.
• Hypotension: Dizziness or lightheadedness, indicative of low blood pressure.

2. Identify Potential Infection Sources: Investigate possible origins of infection, as sepsis is invariably triggered by an underlying infection. Common sources include infections affecting:

• Lungs (pneumonia): Cough, chest pain, and difficulty breathing.
• Kidneys, bladder, and urinary system: Dysuria, frequency, urgency, flank pain, or changes in urine appearance.
• Gastrointestinal system: Abdominal pain, diarrhea, vomiting.
• Bloodstream infections.
• Invasive devices: Catheters, IV lines, surgical drains.
• Burns or wounds: Breaks in skin integrity that can becomeEntry points for infection.

3. Determine Sepsis Risk Factors: Identify pre-existing conditions and circumstances that elevate the risk of sepsis development:

• Advanced age: Over 65 years old.
• Infancy: Neonates and young infants.
• Immunocompromised state: Weakened immune system due to illness or medications.
• Comorbidities: Presence of chronic conditions such as diabetes or kidney disease.
• Prolonged hospitalizations.
• Indwelling invasive lines: Central venous catheters or urinary catheters.
• Recent prolonged antibiotic therapy (within 90 days): Can lead to antibiotic-resistant infections.
• Use of immunosuppressant medications: Corticosteroids and other drugs that suppress the immune system.

4. Detailed Medical History Review: Explore the patient’s medical history for conditions that predispose them to sepsis:

• Pre-existing, undiagnosed, or untreated infections.
• Conditions causing immune compromise: Cancer, HIV.
• Chronic diseases: COPD, diabetes, heart failure.
• Recent surgical procedures.
• Implanted medical devices: Pacemakers, ports, prosthetic joints.
• History of organ transplant complications.

5. Medication History Analysis: Scrutinize the patient’s medication list, paying particular attention to:

• Corticosteroids and immunosuppressants: Medications that can weaken the immune system.
• Antibiotic use: Assess for patterns of antibiotic use that may contribute to antibiotic resistance, including:
  • Non-adherence to prescribed antibiotic regimens.
  • Inappropriate antibiotic use for viral infections.
  • Frequent or repeated antibiotic courses.
  • Limited access to appropriate medications.
  • Substandard quality medications.
  • Incorrect antibiotic prescribing practices.

Physical Assessment: Objective Data Collection

Objective data is obtained through direct physical examination and observation. In sepsis assessment, vital signs and systemic assessments are crucial for detecting early warning signs and monitoring disease progression.

1. Vital Signs Evaluation: Closely monitor vital signs for early indicators of sepsis:

• Temperature: Hyperthermia (temperature >100.4°F or 38°C) or hypothermia (temperature <96.8°F or 36°C).
• Tachycardia: Elevated heart rate (usually >90 beats per minute).
• Tachypnea: Increased respiratory rate (usually >20 breaths per minute).

2. Systemic Assessment: Conduct a comprehensive system-by-system assessment to identify signs of organ dysfunction, as sepsis can rapidly progress to severe sepsis and septic shock. Pay close attention to:

• Central Nervous System (CNS): Assess for altered mental status, ranging from subtle confusion to coma.
• Respiratory System: Monitor for hypoxia (low oxygen saturation), cough, chest pain, and dyspnea (shortness of breath).
• Cardiovascular System: Evaluate for decreased capillary refill time (a sign of poor peripheral perfusion).
• Gastrointestinal System: Assess for ileus (decreased bowel sounds or absence of bowel movements), signs of perforation (severe abdominal pain, rigidity), abscess formation, and abdominal tenderness.
• Genitourinary System: Monitor urine output for oliguria (decreased urine production) or anuria (absent urine production), both indicators of kidney dysfunction.
• Integumentary System: Observe skin color and temperature for flushing, cyanosis (bluish discoloration), pallor (pale skin), and skin mottling (patchy discoloration).

3. Shock Progression Assessment: Continuously monitor for signs of progression to septic shock, characterized by hypotension and impaired organ perfusion. Key indicators include:

• Peripheral coolness: Cool extremities to the touch.
• Prolonged capillary refill: Delayed capillary refill time (>3 seconds).
• Thready peripheral pulses: Weak and difficult-to-palpate pulses.
• Pallor: Pale skin.
• Diaphoresis: Excessive sweating.
• Confusion: Worsening mental status.
• Decreased level of consciousness: Lethargy, stupor, or coma.

4. Intravenous Line Site Inspection: Carefully examine intravenous (IV) line insertion sites for signs of localized infection or thrombophlebitis (inflammation of a vein related to a blood clot). Look for:

• Swelling.
• Redness (erythema).
• Drainage.
• Pain or tenderness at the site.
  Central venous lines are particularly associated with increased sepsis and bacteremia risk.

5. Wound and Incision Assessment: If wounds or surgical incisions are present, meticulously assess for signs of infection. Note the presence of:

• Abscess formation (localized collection of pus).
• Cellulitis (spreading bacterial infection of the skin and subcutaneous tissue).
• Wound infection: Characterized by pain, purulent (pus-filled) discharge, erythema, swelling, and increased warmth.
  Document all observations and any changes in wound appearance.

Diagnostic Procedures for Sepsis

Diagnostic procedures play a vital role in confirming sepsis diagnosis, identifying the causative pathogen, and assessing the extent of organ dysfunction.

1. Laboratory Studies: Collect samples for the following laboratory tests:

• Complete Blood Count (CBC): May reveal leukocytosis (elevated white blood cell count), leukopenia (decreased white blood cell count), neutropenia (decreased neutrophils), and thrombocytopenia (decreased platelets).
• Kidney Function Tests: Elevated blood urea nitrogen (BUN) and creatinine levels may indicate impaired kidney perfusion and function.
• Blood and Site-Specific Cultures: Obtain cultures from blood, urine, wounds, sputum, or other suspected infection sites to identify the causative pathogen.
• Urinalysis & Culture: Further investigate urinary tract infections as a potential sepsis source.
• Biomarkers: Procalcitonin and presepsin are biomarkers that can aid in early sepsis diagnosis and differentiate sepsis from non-infectious inflammatory conditions.
• Lactate Levels: Elevated lactate levels (>2 mmol/L) correlate with poor tissue perfusion. Levels exceeding 4 mmol/L are strongly indicative of septic shock.
• C-Reactive Protein (CRP): Expected to be elevated as an indicator of inflammation.
• Coagulation Studies (INR and PTT): Elevated INR (International Normalized Ratio) and PTT (Partial Thromboplastin Time) may signal coagulation abnormalities, such as disseminated intravascular coagulation (DIC), a complication of sepsis.

2. Imaging Scans: Prepare the patient for imaging studies as ordered to further investigate the source of infection and assess for organ involvement. These may include:

• Chest X-ray: To evaluate for pneumonia.
• Chest CT Scan: Provides more detailed imaging of the lungs and mediastinum.
• Abdominal Ultrasonography: Useful for visualizing abdominal organs, such as the gallbladder and liver, and detecting abscesses.
• Abdominal CT Scan or MRI: Offers more comprehensive abdominal imaging, particularly for complex infections or suspected intra-abdominal abscesses.
• Site-Specific Soft Tissue Imaging (Ultrasound, CT Scan, or MRI): To evaluate localized infections in soft tissues.
• Contrast-Enhanced CT Scan or MRI of the Brain/Neck: May be indicated in cases of suspected central nervous system infection or neck infections.

3. Invasive Diagnostic Procedures: Anticipate the potential need for invasive procedures when sepsis is suspected, particularly when source control is necessary or samples are needed from normally sterile sites. These procedures may include:

• Thoracentesis: Pleural fluid aspiration for analysis and culture in cases of suspected empyema or complicated parapneumonic effusion.
• Paracentesis: Ascitic fluid aspiration for analysis and culture in cases of suspected spontaneous bacterial peritonitis.
• Fluid Accumulation and Abscess Drainage: Percutaneous or surgical drainage of localized fluid collections or abscesses.
• Bronchoscopy with Lavage, Washing, or Biopsy: To obtain lower respiratory tract samples for culture and analysis in cases of suspected pneumonia or other pulmonary infections.

Nursing Interventions for Sepsis

Prompt and appropriate nursing interventions are paramount to improving patient outcomes in sepsis. These interventions are focused on supporting vital functions, combating infection, and preventing complications.

1. Hospital Admission Preparation: Prepare the patient for immediate admission to the intensive care unit (ICU). Sepsis necessitates continuous monitoring and intensive medical and nursing management.

2. Antibiotic Therapy Initiation: Administer intravenous antibiotic therapy as prescribed without delay. Broad-spectrum antibiotics are typically initiated empirically to cover a wide range of potential pathogens. Once culture and sensitivity results are available, antibiotic therapy may be narrowed to target the specific causative organism.

3. Fluid Volume Resuscitation: Initiate aggressive fluid resuscitation with crystalloid intravenous fluids (e.g., normal saline or lactated Ringer’s solution). The Surviving Sepsis Campaign guidelines recommend administering at least 30 ml/kg of crystalloid fluid within the first three hours of sepsis recognition. The primary goal is to restore and maintain adequate tissue perfusion and hemodynamic stability.

4. Vasopressor Administration: Administer vasopressor medications (e.g., norepinephrine, dopamine) as prescribed if hypotension persists despite adequate fluid resuscitation. Vasopressors work by inducing vasoconstriction, thereby increasing blood pressure and improving organ perfusion.

5. Patient Positioning: Position the patient to optimize respiratory function. Semi-Fowler’s or High-Fowler’s positioning can help improve lung expansion and reduce the risk of aspiration pneumonia. Prone positioning may be considered in patients with sepsis-induced ARDS (acute respiratory distress syndrome) to improve oxygenation.

6. Invasive Hemodynamic Monitoring: Prepare for and assist with the insertion of invasive arterial and central venous catheters for continuous hemodynamic monitoring. Invasive arterial monitoring provides real-time blood pressure measurements, while central venous catheters allow for central venous pressure (CVP) monitoring and central venous access.

7. Oxygen Therapy and Mechanical Ventilation: Administer supplemental oxygen to patients experiencing hypoxia. For patients with respiratory failure or severe hypoxemia, prepare for and assist with endotracheal intubation and mechanical ventilation.

8. Insulin Administration for Hyperglycemia: Monitor blood glucose levels closely. Sepsis often induces stress hyperglycemia, even in patients without pre-existing diabetes. Administer intravenous insulin as prescribed to maintain blood glucose levels within the target range (typically <180 mg/dL).

9. Surgical Intervention Preparation: Prepare the patient for potential surgical intervention if source control is needed. Surgical removal of infected or necrotic tissue may be necessary to eliminate the source of sepsis, such as in cases of abscesses, necrotizing fasciitis, or perforated organs.

10. Intravascular Device Removal: Promptly remove any intravascular access devices (e.g., central lines, peripheral IV catheters) that are suspected to be the source of sepsis.

11. Strict Hygiene Practices: Implement meticulous hygiene measures to prevent healthcare-associated infections and reduce bacterial burden. This includes:

• Frequent hand hygiene for all healthcare providers, patients, and visitors.
• Daily bathing or showering for patients, with particular attention to skin folds and perineal area.
• Aseptic technique for all invasive procedures, such as catheter insertion and dressing changes.
• Regular disinfection of patient care equipment and the patient environment.

12. Transmission-Based Precautions: Implement appropriate infection control precautions to prevent cross-transmission of pathogens. This may include contact precautions, droplet precautions, or airborne precautions, depending on the suspected or confirmed pathogen. In some cases, protective isolation may be necessary for severely immunocompromised patients to minimize their exposure to potential pathogens.

13. Personal Protective Equipment (PPE) Utilization: Ensure consistent and correct use of PPE by all healthcare personnel. This includes:

• Gowns and gloves upon entry into the patient’s room.
• Face masks (surgical masks or N95 respirators, depending on the situation) and eye protection (goggles or face shields) to protect against respiratory droplets and airborne microorganisms.

14. Nutritional Support: Initiate early enteral (tube feeding) or parenteral (intravenous nutrition) nutrition support. Nutritional support is crucial to address micronutrient deficiencies, provide adequate protein intake, and meet the increased metabolic demands associated with sepsis. Enteral nutrition is preferred when feasible to maintain gut function and reduce the risk of infectious complications.

Sepsis Nursing Care Plans: Addressing Specific Needs

Once nursing diagnoses are identified based on the comprehensive assessment, nursing care plans are developed to prioritize nursing interventions and establish both short-term and long-term goals for patient care. The following sections outline examples of nursing care plans for common nursing diagnoses associated with sepsis.

Nursing Care Plan for Decreased Cardiac Output

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

Nursing Diagnosis: Decreased Cardiac Output related to altered hemodynamic parameters, impaired cardiac contractility, impaired myocardial circulation, loss of vascular tone, and hypovolemia.

As evidenced by: Tachycardia, abnormal central venous pressure, abnormal mean arterial pressure, cyanosis, pallor, prolonged capillary refill time, hypotension, oliguria, altered level of consciousness, cold and clammy skin, decreased peripheral pulses, cardiac dysrhythmias, and presence of murmurs.

Expected Outcomes:

• Patient will demonstrate adequate cardiac output as evidenced by:
  • Vital signs within normal limits:
    • Blood pressure: Systolic 90-120 mmHg, Diastolic 60-80 mmHg
    • Pulse rate: 60-100 beats per minute, regular rhythm
    • Central venous pressure (CVP): 8-12 mmHg
    • Mean arterial pressure (MAP): 65-90 mmHg
  • Urine output: 0.5-1.5 mL/kg/hour
  • Absence of overt cardiac compromise:
    • Normal precordial activity
    • Absence of cardiac dysrhythmias on ECG
    • Absence of new murmurs

Assessments:

1. Monitor for signs and symptoms of cardiac and circulatory compromise. Hypotension, tachycardia, tachypnea, and weak peripheral pulses are indicative of severe sepsis and reduced cardiac output.

2. Continuously monitor hemodynamic parameters. Central Venous Pressure (CVP), Pulmonary Artery Diastolic Pressure (PADP), and Pulmonary Capillary Wedge Pressure (PCWP) provide valuable data on fluid volume status and cardiac function.

• CVP reflects right atrial pressure and right ventricular preload.
• PADP and PCWP estimate left atrial pressure and left ventricular preload.

3. Evaluate relevant laboratory data. Sepsis-induced cardiomyopathy can manifest in specific laboratory abnormalities:

• Elevated cardiac biomarkers:
  • Elevated plasma troponins I or T may signify myocardial injury and left ventricular systolic dysfunction in sepsis.
  • Elevated BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro-B-type natriuretic peptide) in sepsis patients can correlate with disease severity.
• Decreased ejection fraction:
  • Left ventricular ejection fraction is a key indicator of septic cardiomyopathy and systolic function.

Interventions:

1. Administer intravenous fluid resuscitation as prescribed. Aggressive volume resuscitation is essential to address sepsis-induced tissue hypoperfusion and counteract hypovolemia caused by vasodilation, fluid losses, and capillary leak. Fluid administration increases preload, which, according to the Frank-Starling mechanism, can improve stroke volume and cardiac output. However, caution is necessary, as sepsis-induced cardiomyopathy can alter the Frank-Starling curve, and excessive fluid administration can lead to fluid overload complications.

2. Administer medications as ordered.

• Antibiotics: Initiate broad-spectrum antibiotics promptly, ideally after obtaining blood cultures.
• Vasopressors: Administer vasopressors to induce vasoconstriction, counteract systemic vasodilation, increase blood pressure, and improve tissue perfusion.

3. Anticipate and prepare for adjunctive therapies. Mechanical circulatory support may be necessary in severe septic cardiomyopathy. Intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), or extracorporeal membrane oxygenation (ECMO) may be considered to augment cardiac output when conventional therapies are insufficient.

4. Optimize oxygen delivery. Ensure adequate oxygenation to support myocardial function and tissue perfusion. Administer supplemental oxygen via high-flow nasal cannula or non-rebreather mask, or prepare for mechanical ventilation as needed to maintain adequate oxygen saturation.

Nursing Care Plan for Hyperthermia

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

Nursing Diagnosis: Hyperthermia related to dehydration, increased metabolic rate, and the inflammatory process.

As evidenced by: Elevated body temperature above the normal range, flushed and warm skin, tachypnea, tachycardia, confusion, and potential seizures.

Expected Outcomes:

• Patient will achieve and maintain a body temperature within the normal range (97.6°F-100.4°F or 36.4°C-38°C).
• The underlying cause of hyperthermia (infection) will be effectively treated to prevent persistent or worsening fever.

Assessments:

1. Accurately measure body temperature, preferably rectally. Rectal temperature measurement is generally considered the most accurate method for assessing core body temperature.

2. Continuously monitor neurological status. Uncontrolled hyperthermia can lead to neurological damage. Assess for changes in level of consciousness (LOC), confusion, and seizures, which may indicate neurological deterioration.

Interventions:

1. Create a cool environment. Adjust the room temperature to a cooler setting, remove excessive blankets or linens, and ensure the patient is wearing lightweight, non-restrictive clothing.

2. Apply a cooling blanket if indicated. A cooling blanket can effectively lower surface body temperature. Closely monitor the patient during cooling blanket use to prevent shivering, which can paradoxically increase body temperature due to increased metabolic activity.

3. Administer antipyretic medications as prescribed. Administer acetaminophen or other prescribed antipyretics to reduce fever. Follow prescribed dosage and frequency.

4. Implement cooling measures such as cool compresses and tepid baths. Apply cool, damp cloths to areas with high blood flow, such as the groin and axillae, to promote heat dissipation. Tepid sponge baths can also enhance heat loss through evaporation. Avoid using cold water or ice baths, as these can induce shivering.

Nursing Care Plan for Ineffective Protection

Patients with sepsis are at high risk for ineffective protection due to the systemic inflammatory response and potential immune compromise.

Nursing Diagnosis: Ineffective Protection related to infectious process, immunosuppression, abnormal blood profiles, poor nutritional status, medication regimen, and advanced age.

As evidenced by: Changes in level of consciousness, insomnia, immobility, impaired stress management, open wounds, and pressure ulcers.

Expected Outcomes:

• Patient will remain free from new infections throughout hospitalization.
• Patient will verbalize understanding of nutritional needs and make appropriate food choices to support immune function.
• Patient will demonstrate measures to enhance and protect their immune system.

Assessments:

1. Vigilantly monitor for signs and symptoms of sepsis. Early recognition of sepsis is crucial. Be alert for changes in mental status, hypotension, fever, tachycardia, chills, and flushed skin, and report any concerning findings promptly.

2. Monitor white blood cell (WBC) count and differential. Leukocytosis (elevated WBC count) is often seen in infection, but in sepsis, both leukocytosis and leukopenia (decreased WBC count) can occur, depending on the stage and severity. In some cases, the total WBC count may be within the normal range, but an elevated number of immature neutrophils (bands) may be present, indicating infection. Differential WBC counts can provide clues to the type of infection (e.g., neutrophils – bacterial; lymphocytes – viral; eosinophils – parasitic).

3. Identify and monitor risk factors for ineffective protection. Assess for factors that compromise the patient’s protective mechanisms and increase sepsis risk, such as immunosuppression (due to conditions like cancer, autoimmune diseases, HIV, or treatments like chemotherapy or immunosuppressant medications), immobility, malnutrition, and presence of wounds.

Interventions:

1. Promote rest and sleep. Adequate sleep is essential for cellular repair, immune function, and the release of growth hormone, which is vital for healing. Sleep disruption or deprivation can suppress growth hormone release and impair immune responses.

2. Minimize invasive procedures whenever possible. Avoid or limit invasive procedures like catheterizations, injections, and rectal or vaginal procedures, as these can create entry points for pathogens. When invasive lines are necessary, strictly adhere to aseptic techniques during insertion and maintenance.

3. Encourage a high-protein, nutrient-rich diet. Protein is crucial for tissue repair and immune function. Ensure adequate protein intake to support the body’s defense mechanisms. If the patient has poor appetite, consider appetite stimulants or dietary consultation to optimize nutritional intake.

4. Educate the patient and family about infection control measures. Hand hygiene is the most effective and simple way to prevent infection transmission. Instruct the patient and family/caregivers on proper handwashing techniques and the importance of hand hygiene.

Nursing Care Plan for Risk for Deficient Fluid Volume

Sepsis progression to septic shock is characterized by fluid shifts out of the intravascular space, leading to hypovolemia and hypotension.

Nursing Diagnosis: Risk for Deficient Fluid Volume related to vasodilation and increased membrane permeability.

As evidenced by: (A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention).

Expected Outcome:

• Patient will maintain adequate circulatory volume as evidenced by stable vital signs and urine output within the normal range for their age and condition.

Assessments:

1. Monitor for early signs of fluid volume loss. Septic shock can cause a rapid and significant drop in blood pressure as fluid shifts out of the intravascular space. Monitor for tachycardia, fever, and signs of dehydration, such as poor skin turgor and dry mucous membranes.

2. Accurately monitor intake and output (I&O) and daily weight. Closely track fluid intake (oral, intravenous) and urine output to identify fluid imbalances. Daily weight monitoring can also provide insights into fluid status changes.

3. Assess for edema formation. Fluid shifting into the interstitial space can lead to peripheral edema (swelling). Monitor for edema in dependent areas (e.g., ankles, feet, sacrum) and generalized edema. Weight gain may also indicate fluid retention and third spacing.

4. Review relevant laboratory values. Changes in hemoglobin and hematocrit levels can suggest hemoconcentration due to fluid volume deficit. Elevated BUN and creatinine levels may indicate kidney dysfunction and dehydration. Urine specific gravity can be elevated in dehydration and kidney injury.

Interventions:

1. Administer intravenous fluids as prescribed. Crystalloid solutions (e.g., normal saline, lactated Ringer’s) are typically the initial fluids of choice for volume resuscitation in sepsis due to their availability and cost-effectiveness. Colloid solutions (e.g., albumin, fresh frozen plasma) may be used adjunctively in some situations, as they tend to remain in the intravascular space for longer due to their larger molecular size.

2. Administer vasopressors as prescribed. Vasopressors (e.g., dopamine, norepinephrine) are often used in conjunction with intravenous fluids or when septic shock persists despite fluid resuscitation. Vasopressors help to restore and maintain blood pressure by inducing vasoconstriction.

3. Continuously monitor circulatory function. Closely monitor heart rate, cardiac rhythm (via ECG monitoring), blood pressure (invasively if indicated), and pulse oximetry to assess overall circulatory function and tissue perfusion. Mean arterial pressure (MAP) is a critical indicator of organ perfusion. Monitor urine output and relevant laboratory values (e.g., lactate, renal function tests) to assess kidney function and perfusion.

Nursing Care Plan for Risk for Infection

Patients with sepsis are already experiencing a systemic infection, but they remain at risk for secondary infections and complications.

Nursing Diagnosis: Risk for Infection related to immunosuppression, multiple chronic comorbidities, compromised skin or tissue integrity, malnutrition, and untreated or worsening infections (UTIs, cellulitis, pneumonia).

As evidenced by: (A risk diagnosis is not evidenced by actual signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention).

Expected Outcomes:

• Patient will remain free of new infections during hospitalization, with vital signs and white blood cell count within normal limits.
• Patient will demonstrate improvement in wound healing (if applicable) without signs of infection (redness, drainage, odor).
• Patient will identify and implement interventions to prevent or reduce their risk of infection.

Assessments:

1. Continuously monitor for signs and symptoms of sepsis. Be vigilant for recurring or worsening signs of sepsis, including fever, tachycardia, tachypnea, chills, and altered mental status. Promptly report any abnormal vital signs or concerning changes.

2. Monitor relevant laboratory values. Monitor serial WBC counts, CRP, and lactate levels, as trends in these values can indicate worsening infection or response to treatment.

3. Obtain specimens for culture as indicated. Obtain blood cultures, urine cultures, sputum cultures, wound cultures, or other specimens as needed to identify potential new sources of infection or to monitor the causative organism’s response to antibiotics.

Interventions:

1. Administer anti-infective medications as prescribed. Prophylactic intravenous antibiotics may be administered in specific situations to prevent secondary infections. Broad-spectrum antibiotics are used to treat the primary sepsis, and antibiotic therapy may be adjusted based on culture and sensitivity results.

2. Emphasize and practice meticulous hand hygiene. Reinforce the importance of hand hygiene for all healthcare providers, patients, and visitors. Ensure that nurses are consistently performing proper handwashing techniques and educate patients and families on hand hygiene practices.

3. Discontinue unnecessary invasive lines and devices. Routinely assess the necessity of indwelling IV lines, urinary catheters, vascular access devices, NG tubes, PEG tubes, drains, and mechanical ventilation. Remove these devices as soon as they are no longer clinically indicated, as they are potential sources of bloodstream infections.

4. Promote skin integrity. *Patients with sepsis are often immobile, increasing their risk of pressure ulcers and skin breakdown. Incontinence, poor nutrition, and dehydration further compromise skin integrity. Implement measures to promote skin integrity, such as:

• Turning and repositioning the patient at least every 2 hours.
• Assisting with ambulation as tolerated.
• Regularly inspecting the skin, particularly pressure points, for signs of breakdown.
• Implementing pressure-relieving measures (e.g., specialty mattresses, cushions).
• Providing meticulous perineal care and managing incontinence promptly.*

References

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