Nursing Care Plan for Sepsis

Hospital Ward: Professional Black Head Nurse Wearing Face Mask Does Checkup of Patient's Vitals, Checking Heart Rate Computer, Intravenous or Iv Fluids Drip Bag. Caring Nurse Monitors Person Recovery

Sepsis Pathophysiology

Sepsis is the body’s response to infection, and occurs when an infectious agent such as a virus or bacteria spreads throughout the body. The term “sepsis” is often used interchangeably with “septicemia,” which refers to blood poisoning.

Sepsis is also considered a systemic inflammatory response syndrome that results from an infection. 

Sepsis can trigger a “cytokine storm” – cytokines are chemical messengers that help regulate the immune system’s response to infection. When cytokines get out of control, they cause the body’s immune system to attack itself, making it difficult for a client’s organs to function normally.

Sepsis is a serious condition that can lead to organ failure and death if not treated quickly. If these symptoms persist for more than six hours without improvement, or if they worsen after seventy-two hours, it is likely that the client is becoming septic and requires emergency treatment.

Remember: Sepsis is life-threatening.

Risk Factors

  • Pneumonia
  • Being an infant or elderly
  • Pregnancy
  • Chronic illness or immuno-compromised clients 
  • Catheter or tracheostomy insertion

Rationale:

Premature infants are extremely susceptible to sepsis, due to an underdeveloped immune system. Children also can become septic because manifestations (signs and symptoms) look different in children vs. adults. Children have less cardiac reserve than adults and may present differently.

Older adult clients are more susceptible to contracting infectious pathogens due to their declining immune system. In addition, other age-related changes and co-morbidities (chronic health problems, e.g., diabetes, cardiovascular disease, etc)  impact the resistance to pathogens. 

The elderly often present with different manifestations (signs and symptoms) than other populations which makes it more difficult to diagnose sepsis.

Clients who are immunocompromised or have comorbidities (chronic illness) do not have the ability to fight infection as do healthy individuals. 

Women in the third trimester of pregnancy tend to have a decreased immune system, thus increasing the risk for infection and sepsis.

Fluid replacement therapy directly affects sepsis factors (adequate urine output, changes in mental state, and stability of vital signs).

Causes

  • Infection
  • Foreign material in the body
  • Bacterial overgrowth in the small intestine
  • Fungal infections
  • Prolonged IV or Foley Catheter use

Subjective (Client May Report)

  • Pain
  • Difficulty breathing
  • Burning with urination
  • Frequent cough
  • Green mucus

Objective

  • Increased or decreased temperature > than 100.4℉ (38 ℃)  or < 96.8 ℉ (36 ℃)
  • Respiratory distress (rate over 20 bpm)
  • Decreased urinary output
  • Hypotension
  • Increased or decreased  white blood cell count (WBC) > 12,000 cells/mm3 or < 4,000 cells/mm3 
  • Decreased platelet count
  • Edema
  • Hyperglycemia
  • Increased lactic acid or creatinine

Symptoms & Signs of Sepsis

  • Fever
  • Disorientation
  • Shortness of breath
  • Low blood pressure 
  • Fatigue
  • Chills
  • Low urine output 
  • Chest pain
  • Confusion
  • Low blood oxygen levels 

Nursing Diagnosis for Sepsis

When diagnosing a client with (possible) sepsis, look for signs of infection (e.g., fever, chills) AND either evidence of systemic inflammation or hypoperfusion.

Assessment 

The client has three or more of the following clinical criteria: 

  1. Temperature over 100.4F or below 96.8F 
  2. Heart rate over 90 beats per minute
  3. Respiratory rate over 20 breaths per minute 
  4. White blood cell count over 12,000 cells/mm3 
  5. Platelet count less 100 000 cells/mm3 
  6. Creatinine increase over 0.3 mg/dL in first 24 hours after presentation
  7. Hypotension (systolic blood pressure less than 90 mm Hg)

Nursing Interventions for Sepsis

Sepsis is a complex condition involving inflammation and dysfunction of the immune system. Nursing interventions for sepsis are focused on monitoring and managing the client’s response to infection. 

However, it’s important to recognize that sepsis can result in morbidity and mortality in clients even if they receive appropriate treatment. Early detection and treatment of sepsis is key.

When blood is infected with bacteria, the body recruits white blood cells to fight them off. However, this process can be prolonged or excessive, which leads to an inflammatory response that can damage tissues and organs throughout the body.

Assessment

For signs and symptoms of sepsis, monitor the client for changes in condition (after assessment).

Cardiac Function

  • Decreased cardiac output

Respiratory function

  • Decreased delivery and use of oxygen 
  • Fatigued respiratory muscles 

Neurologic and Sensory Functions

  • Confusion
  • Lack of energy
  • Changes in personality
  • Delirium
  • Seizures

Visual Appearance & Labs

  • WBC count (CBC)
  • O2 to tissues lowered by lactate
    • This could result in: pale blue skin, lips, tongue or nail beds of the fingers
  • Kidney performance (BMP)
  • Change in level of consciousness (LOC)
  • Positive blood cultures
  • Acidosis detected by ABG

Nursing Actions & Care Note for Sepsis

Nurses are the first point of contact for clients with sepsis, and their actions can greatly impact a client’s recovery.

The initial treatment for sepsis is the same for all clients, regardless of age or medical history. This includes taking a detailed history and performing a physical exam to evaluate the client’s overall health and determine if they are at risk for developing sepsis.

Perform

  • A thorough assessment of the client’s airway, breathing, and circulation.

Provide

  • IV fluids as prescribed to support sufficient urine output
  • Oxygen to support 02 saturation of 93% or greater
  • Medications as prescribed

Avoid

  • Invasive procedures or blood draws

Administer

  • Antibiotics as prescribed

Monitor

  • Vital signs including: 
    • Heart rate
    • Respiratory rate
    • Temperature
    • Blood pressure
    • Pulse oximetry
    • Urine output

Encourage

Nurses should encourage clients upon discharge or for home care to eat a healthy diet and maintain their normal fluid intake. They should be encouraged to take their temperature daily as well as keep track of how much water they consume each day.

Clients should also stay hydrated, avoid becoming overly fatigued and stressed, and try to get rest. Nurses need to encourage clients to follow their prescribed treatment plan and avoid any over-the-counter medications or remedies that may interfere with their treatment.

Goals and Outcomes

  • Clear airway
  • Reduced infection
  • Reduced pain and discomfort

Sepsis NCLEX Question

An older adult client diagnosed with sepsis becomes angry at the unlicensed assistive personnel (UAP) and refuses oral care. The UAP reports this incident to the registered nurse (RN). 

Which response by the RN is appropriate?

Answer: “We will talk to the client about the issue together.”

Rationale: The angry client must be allowed to express concerns openly. It’s appropriate to approach the situation with an unbiased attitude of acceptance and openness.

Find our other Nursing Care Plans here

Sources

https://alraziuni.edu.ye/uploads/pdf/Nursing-Care-Plans-Edition-9-Murr-Alice-Doenges-Marilynn-Moorehouse-Mary.pdf