When a pathogen invades, the body’s immune response initiates a cascade of events. Mediators are released, amplifying inflammation and coagulation, while simultaneously hindering fibrinolysis and causing endothelial damage. This imbalance results in compromised perfusion and the formation of microthrombi. Furthermore, endothelial damage contributes to capillary leakage and subsequent edema. Systemic hormonal responses to infection exacerbate hemodynamic instability through the release of catecholamines, glucagon, cortisol, and growth hormone. In septic shock, the immune system’s struggle to combat the pathogen can overwhelm the body, leading to organ dysfunction and increased mortality.
The incidence of sepsis is on the rise, making it a leading driver of healthcare costs. Despite this increase, recent studies indicate a decrease in sepsis mortality rates, from 16.5% to 13.8% (Mahapatra & Heffner, 2021). Hospitalizations due to sepsis have exceeded 1,000,000 annually between 2000 and 2008 (Mahapatra & Heffner, 2021). Septic shock remains a primary cause of death among hospitalized patients, emphasizing the critical need for rapid diagnosis and intervention to improve survival rates. Certain factors elevate an individual’s susceptibility to sepsis, including:
- Prolonged hospital stays
- Chronic kidney disease (CKD)
- Major surgical procedures
- Diabetes mellitus
- Invasive lines (e.g., catheters, central venous catheters)
- Burn injuries
- Immunocompromised states
Septic Shock ICD-10 Code: R65.21
- Severe sepsis with septic shock.
Septic Shock Diagnosis: A Nursing Perspective
The diagnosis of septic shock, as defined by the Third International Consensus Definitions for Sepsis and Septic Shock, hinges on meeting two key criteria (Singer et al., 2016):
- The necessity for vasopressor support to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg.
- A serum lactate level exceeding 2 mmol/L (>18 mg/dL), despite adequate fluid resuscitation.
Currently, there is no single definitive biomarker for septic shock diagnosis. The diagnostic process for individuals exhibiting signs and symptoms suggestive of sepsis involves a comprehensive approach guided by the Surviving Sepsis Campaign guidelines. Nurses play a vital role in recognizing these signs and initiating prompt diagnostic measures. Patients may present with a range of abnormal laboratory values, including (Evans et al., 2021):
- Glucose:
- Hyperglycemia (≥ 120 mg/dL)
- Complete Blood Count (CBC):
- Leukocytosis (WBC ≥ 12,000/mm3)
- Leukopenia (WBC ≤ 4000/mm3)
- Thrombocytopenia (Platelets ≤ 100,000/mL)
- Inflammatory Markers:
- Elevated C-reactive protein (CRP) and/or procalcitonin
- Mixed Venous Oxygen Saturation (SvO2):
- Elevated (≥ 70%) – indicating impaired oxygen extraction at the tissue level in early septic shock.
- Arterial Blood Gas (ABG):
- Hypoxemia (Partial pressure of oxygen (PaO2) / Fraction of inspired oxygen (FiO2) ratio ≤ 300 mmHg)
- Lactic acidosis (≥ 2 mmol/L)
- Complete Metabolic Profile (CMP):
- Electrolyte imbalances
- Elevated creatinine (indicating renal dysfunction)
- Hyperbilirubinemia (Bilirubin ≥ 4 mg/dL)
- Elevated liver function tests (LFTs) (indicating hepatic dysfunction)
- Coagulation Studies:
- Prolonged International Normalized Ratio (INR) ≥ 1.5
- Prolonged Partial Thromboplastin Time (PTT) ≥ 60 seconds
- Chest X-ray:
- May be normal or reveal pulmonary infiltrates (suggesting pneumonia or Acute Respiratory Distress Syndrome – ARDS)
- Urinalysis:
- May indicate bacteriuria
- Cultures:
- Blood, wound, sputum, urine, and other relevant sites to identify the source of infection and guide antimicrobial therapy.
- Serum Lactate:
- Elevated – a key indicator of tissue hypoperfusion and anaerobic metabolism.
Alt text: Blood culture bottles are essential for diagnosing septic shock by identifying the infectious organism.
Septic Shock Treatment and Management: An Interdisciplinary Approach
Effective septic shock treatment necessitates a rapid and multifaceted approach. While clinical guidelines provide a framework for care, individualized provider judgment remains paramount (Evans et al., 2021). The Surviving Sepsis Campaign guidelines (2021) advocate for immediate initiation of the following interventions:
- Antimicrobial Therapy:
- Initiate empirical broad-spectrum antibiotics and/or antifungals within one hour of sepsis recognition. Tailor therapy to specific pathogens once identified.
- Consider empiric antifungal therapy if fungal infection is strongly suspected.
- Antiviral therapy is not routinely recommended unless specific viral pathogens are identified.
- Resuscitation:
- Administer intravenous (IV) crystalloid fluid bolus of 30 mL/kg within the first three hours of symptom onset. Adjust subsequent fluid administration based on individual volume status.
- Utilize dynamic assessments of fluid responsiveness (e.g., stroke volume [SV], stroke volume variation [SVV], pulse pressure variation [PPV], echocardiography) in preference to static measures like physical examination.
- In patients requiring large crystalloid volumes, consider incorporating albumin IV.
- Hemodynamic Support:
- Maintain a MAP ≥ 65 mmHg.
- Initiate vasopressors, typically norepinephrine (Levophed®), if fluid resuscitation fails to achieve adequate blood pressure.
- If norepinephrine monotherapy is insufficient (MAP < 65 mmHg), adding vasopressin (Vasostrict®) is recommended over escalating norepinephrine dosage.
- For patients with pre-existing cardiac dysfunction unresponsive to fluid resuscitation, start norepinephrine in combination with an inotrope instead of vasopressin.
- Glycemic Control:
- Manage glucose levels with insulin to maintain a target range of ≤ 180 mg/dL and > 90 mg/dL.
- Vascular Access:
- Central venous access may be required if peripheral IV access is problematic. Peripheral vasopressor administration is acceptable until central access is established.
- Arterial line insertion may be indicated for continuous MAP monitoring.
Alt text: Intravenous fluid administration is a cornerstone of septic shock resuscitation to improve hemodynamic stability.
Septic Shock Nursing Care Plan: A Detailed Guide
The septic shock nursing care plan is integral to patient survival and recovery. It focuses on early detection, prompt intervention, and continuous monitoring.
Nursing Assessment
Nurses are at the forefront of early sepsis recognition. Vigilant and routine assessment of at-risk individuals is paramount. Early detection and immediate provider notification are critical for timely treatment initiation. Patients with septic shock exhibit symptoms across multiple organ systems. Common clinical manifestations include (Mahapatra & Heffner, 2021):
- Cardiovascular:
- Hypotension (systolic BP < 90 mmHg or MAP < 65 mmHg)
- Tachycardia (heart rate > 90 bpm)
- Cardiac dysrhythmias
- Fever or hypothermia
- Respiratory:
- Tachypnea (respiratory rate > 20 breaths/min)
- Hypoxemia (SpO2 < 90% or PaO2/FiO2 ratio < 300)
- Increased work of breathing, use of accessory muscles
- Renal:
- Oliguria (urine output < 0.5 mL/kg/hour)
- Elevated creatinine and blood urea nitrogen (BUN)
- Gastrointestinal:
- Decreased or absent bowel sounds
- Abdominal distention
- Nausea and vomiting
- Ileus
- Neurological:
- Altered mental status: confusion, lethargy, agitation, decreased Glasgow Coma Scale (GCS) score
Nursing Diagnosis/Risk For
Based on the assessment findings, relevant nursing diagnoses for septic shock may include:
- Hemodynamic Instability related to systemic vasodilation and fluid shifts.
- Deficient Fluid Volume related to capillary leak and inadequate fluid resuscitation.
- Impaired Gas Exchange related to ventilation-perfusion mismatch and pulmonary edema.
- Hyperthermia related to infectious process and inflammatory response.
- Risk for Infection (if the primary source of infection is not yet controlled or if secondary infections are a concern).
- Decreased Cardiac Output related to myocardial depression and reduced preload.
- Impaired Tissue Perfusion related to hypotension, microthrombi, and reduced oxygen delivery.
- Anxiety related to critical illness and uncertain prognosis.
- Risk for Skin Breakdown related to immobility, edema, and poor perfusion.
Nursing Interventions
Nursing interventions are aimed at stabilizing the patient, supporting organ function, and preventing complications.
Hemodynamic Stability:
- Continuous Vital Sign Monitoring:
- Closely monitor blood pressure (invasive arterial blood pressure monitoring is often necessary), heart rate, respiratory rate, temperature, and oxygen saturation. Document trends and report significant changes promptly.
- Temperature Management:
- Manage hyperthermia with cooling measures such as cooling blankets, ice packs to groin, axillae, and neck, and antipyretic medications as ordered. Monitor for hypothermia as a sign of worsening sepsis.
- Airway and Oxygenation Optimization:
- Ensure a patent airway. Position the patient to optimize ventilation.
- Administer supplemental oxygen as ordered, titrating to maintain SpO2 as per physician orders (typically > 92-95%). High flow nasal cannula or mechanical ventilation may be required.
- If intubated, provide meticulous oral care, suctioning, and manage the mechanical ventilator according to hospital protocols and physician orders.
- Fluid Management:
- Strict Intake and Output Monitoring: Accurately measure and record all fluid intake and output.
- Maintain urine output ≥ 0.5 mL/kg/hour as an indicator of adequate renal perfusion.
- Insert an indwelling urinary catheter if indicated to facilitate accurate urine output monitoring.
- Administer IV fluid resuscitation as prescribed, monitoring for signs of fluid overload (e.g., pulmonary edema, jugular venous distention).
- Medication Administration:
- Antibiotics/Antifungals/Antivirals: Administer prescribed antimicrobials promptly, ensuring correct dosage, route, and timing. Monitor for therapeutic effects and adverse reactions.
- Vasopressors and Inotropes: Administer and titrate vasopressors (e.g., norepinephrine, vasopressin) and inotropes (e.g., dobutamine) as ordered to maintain MAP ≥ 65 mmHg and optimize cardiac output. Closely monitor hemodynamic response and adjust infusions as needed.
- Antipyretics and Analgesics: Administer antipyretics (e.g., acetaminophen) for fever and analgesics (e.g., fentanyl, morphine) for pain management as ordered and PRN.
Alt text: Continuous vital sign monitoring is crucial in septic shock nursing care to detect subtle changes in patient status.
Expected Outcomes
Septic shock remains a critical illness with a high mortality rate, potentially exceeding 40% despite advancements in treatment (Mahapatra & Heffner, 2021). Prognosis is influenced by factors such as the type of infection, antibiotic effectiveness, and the extent of organ dysfunction. Patients requiring inotropic and vasopressor support and experiencing respiratory compromise have a poorer prognosis. Positive expected outcomes for septic shock management include:
- Maintenance of adequate tissue perfusion, evidenced by stable vital signs (MAP ≥ 65 mmHg, adequate urine output, improving lactate levels).
- Thermoregulation within normal limits.
- Identification and eradication of the causative organism through appropriate antimicrobial therapy.
- Improved oxygenation and ventilation, with resolution of hypoxemia and respiratory distress.
- Restoration of hemodynamic stability and organ function.
- Prevention of secondary infections and complications.
- Patient survival and recovery to pre-septic state of health or best possible functional level.
Patient/Caregiver Education
- Infection Prevention Strategies: Educate patients and caregivers on crucial infection prevention measures, including meticulous hand hygiene and adherence to recommended vaccination schedules.
- Antimicrobial Regimen Adherence: Emphasize the importance of completing the prescribed antibiotic and/or antifungal regimen as directed, even after symptom improvement.
- Sepsis Recognition: Educate patients and caregivers on the signs and symptoms of sepsis to facilitate early recognition and prompt medical attention in the future. Provide specific, actionable information about when to seek immediate medical help.
- Home Health and Rehabilitation: If appropriate, discuss home health options and rehabilitation services to support recovery and functional restoration post-hospitalization.
This comprehensive septic shock nursing care plan diagnosis and management guide provides a framework for nurses to deliver evidence-based care, improving patient outcomes in this life-threatening condition.
References
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., … & Levy, M. M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181-1247.
Mahapatra, S., & Heffner, A. C. (2021). Septic shock. StatPearls [Internet].
