Nursing Care Plans for Sepsis – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Sepsis plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Blood poisoning is a life-threatening medical condition wherein severe infection circulates within the bloodstream. It is not a medical term, and the condition has nothing to do with poison, “blood poisoning” is used to describe bacteremia, septicemia, or sepsis.

Similar to the out-turns of poisoning, blood infection is a fast killer that can kill in just 12 hours. The condition is unforeseeable and incalculable. The spread of infection is massive and rapid, which can go undiagnosed, misdiagnosed, or show poor prognosis due to its non-specific signs and symptoms. Furthermore, there is a 10% increase in the probability of poor survival for every hour of delayed treatment.   These are why early diagnosis and immediate treatment is crucial in the management of sepsis.

Sepsis is a fatal medical condition requiring immediate clinical management. Mild cases with immediate treatment have a higher recovery rate compared to severe cases that progress to septic shock, which showed a 50% mortality rate. Moreover, statistics revealed an increased incidence rate annually due to the aging population, antibiotic resistance, and weakened immune system secondary to chronic illnesses affecting 1.7 million adults, wherein 270,000 have died (roughly 1 out of 3 patients died in the hospital has sepsis) in the United States of America alone.

Sepsis

As pathogens (germs, bacteria, virus, parasites, or fungi) invade the bloodstream, causing septicemia, the body’s immune system responds overactive to the circulating infection. The overload of invading microorganisms in the bloodstream makes the immune system reacts extremely, releasing chemicals to fight the disease; the reaction will eventually lead to a multi-system inflammatory response called Sepsis. With the presence of infection, endotoxins and exotoxins continuously produce activating inflammatory upsurge resulting in cytokines release into the circulation to restore homeostasis during systemic inflammatory response syndrome.

The prolonged inflammatory response between the infection and chemicals of the immune system, the body’s reaction will get out of balance, and initiating cellular changes—this failure of the mechanism will lead to destructive response losing circulatory integrity. Inflammation may cause small blood clots to form throughout the system, blocking blood and oxygen circulations to vital organs and other body parts, causing tissue death (gangrene). Severe cases of sepsis may progress to septic shock, a medical emergency that can cause complications, including multiple organ systems dysfunction and failure.

Stages of Sepsis

There are three stages of sepsis: sepsis, severe sepsis, and septic shock

1. Sepsis

During the first stage of sepsis, the patient may manifest either hyperthermia (above 38ºC) or hypothermia (below 36ºC), tachycardia (>90 beats per minute heart rate), and tachypnea with hyperventilation (>20 breaths per minute breathing rate) with PaCO2 of <32mm Torr and white blood cell (WBC) of more than 12,000/ul or less than 4,000/ul.

The presence of infections affecting the thermo-regulating centre of the brain may spark a rise in temperature resulting in chills, cold, clammy perspirations, and even febrile convulsion. High readings such as hyperthermia, tachycardia, tachypnea, and leukocytosis are the compensatory mechanism of the body to maintain equilibrium which happens during the early stage of sepsis. As the sepsis progresses to the late stage, the body functioning drops, indicating that the immune system may be weakened and can no longer fight the circulating overloads of infection.

2. Severe sepsis

As the systemic inflammatory response progresses, poor circulation,  hypoperfusion, and hypoxemia will lead to organ dysfunction and failure. Poor oxygenation circulating in the brain due to hypoxemia shows altered mental status such as changes in cognitive ability and decreased level of consciousness. Impaired blood-gas exchange causing lactic acidosis may manifest breathing problems and abnormal heart functions. An increase in serum lactate (lactic acid in the blood) indicates that cells are not using oxygen properly.

The vascular inflammation triggers platelet aggregation, which occurs during thrombotic events resulting in thrombocytopenia or decreased platelet level; this process may lead to thrombus formation or blood clots that eventually impair circulation and block blood vessels. Poor blood circulation causing hypoperfusion in the kidney shows signs of decreased urination and oliguria. The body’s compensatory mechanism engages in faulty energy use as the disease continues, resulting in fatigue and extreme weakness.

       3. Septic shock

Septic shocks occur when the body’s systemic functions fail to compensate. Prolonged perfusion abnormalities may result in blood pressure drops, critical oxygen saturation level (SPO2), and a deteriorating level of consciousness (Glasgow Coma Scale), indicating that sepsis progressed to septic shock. This is the state when the body uses energy in a more abnormal way resulting in changes in the circulatory system. Impaired cellular function and altered fluid exchange may cause failure to respond to fluid resuscitation (and eventually leads to fluid shifts such as edema and anasarca. Prolonged altered blood circulation caused by systemic inflammation and thrombotic events worsen the hypoxemic state of the body with the inability to maintain adequate tissue perfusion, and oxygenation can lead to multiple organ system dysfunctions and failure. Unresolved septic shock is most likely to cause death.

Risk Factors for Occurrence of Infections

Prevention is better than cure and a lot way cheaper than the treatment of sepsis. The best method to prevent sepsis is to prevent infections. The following are risk factors responsible for the occurrence of infections, which includes:

1. Unsanitary and unhygienic practices
2. Crowded living conditions
3. Pollution and smoke
4. Poor nutrition
5. Immunosuppression
6. Chronic disease
7. Improper use of antibiotics
8. Improper techniques of wound cleaning

High Risk of Sepsis

No one is exempted from sepsis; anyone can get the illness. However, some people are at high risk of sepsis compares to others. Those high-risk individuals are more susceptible to acquire the disease due to different medical conditions such as:

1. Immunocompromised (i.e. HIV, AIDS, leukemia or receiving chemotherapy)
2. Young children
3. Geriatrics
4. Frequent intravenous medications
5. Poor dental hygiene
6. Long-term indwelling urinary catheter
7. Underwent recent surgery or dental procedures
8. Debilitated with long-term chronic illness
9. People with chronic medical diseases (i.e. diabetes, lung disease, cancer, and kidney
10. disease)
11. Sepsis survivors
12. Prolonged hospital stay / intensive care unit
13. Device related infections (IV cannula, endotracheal tubes, IV access line for dialysis,
14. central line, implants, orthopedic implants/screws/fixators)
15. Neonatal sepsis (related to birth process or after birth, prematurity, low birth weight)

Signs and Symptoms of Sepsis

If a patient exhibits any of the following signs or symptoms, they may be suffering from sepsis. They should immediately seek medical attention to prevent organ damage or death:

1. Fever (if the temperature is over 103˚F)
2. Decreased alertness, lethargy, confusion
3. Difficulty breathing or shortness of breath
4. Laboured breathing
5. Abdominal pain
6. Diarrhea or constipation, nausea, vomiting, [xiv] weakness
7. Decreased urine output – cold and clammy skin; pale and cool to the touch (cyanosis)

In addition to these symptoms, a patient may also experience organ dysfunction as a result of sepsis:

• Decreased blood pressure
• Low heart rate
• Low respiratory rate
• Cold and clammy skin
• Rapid breathing (tachypnea)

Common Infections that Can Cause Sepsis

Sepsis most likely to occur due to current untreated infections, which eventually progresses to septic shock (Cleveland Clinic, 2020; Cirino & Lou, 2018; O’Connell & Sullivan, 2018), which

includes:

1. Abdominal infections (appendicitis, bowel inflammation, peritonitis, gallbladder or liver  infections)
2. Central nervous system infections (brain or spinal cord infections)
3. Pneumonia / Respiratory infections / COVID-19
4. Kidney / Genito-urinary tract infection
5. Injuries / Trauma
6. Fractures / Bone infections
7. Skin infection (condition like cellulitis or inflammation of the skin’s connective tissue)
8. Infected insect bite
9. Device or implants related infections
10. Infected gums or infection post-dental extractions or procedures
11. Infected wound post-surgery
12. Burns
13. Foot gangrene or gangrenous wound (particularly diabetic wounds)
14. Infected bedsores
15. Infected wounds
16. Bloodstream infections
17. Worms / parasitic infestation
18. Drug / antibiotic resistance

Diagnosis of Sepsis

1. Physical examination – to check for vital signs, especially hypotension and fever

2. Blood tests – blood culture from two different sites to check for the presence of infection; full blood count and biochemistry to check for liver and kidney function, electrolyte imbalance, and clotting problems; serum lactate acid levels

3. Urinalysis, wound culture, and sputum- to check for any signs of infection in the urinary system, respiratory system, or in the wound/ burn area.

4. Imaging – chest X-ray for a suspected lung infection; CT scan or MRI to view the body’s internal structures; ultrasound to visualize any infection in the body, especially in the ovaries or gallbladder.

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Treatment for Sepsis

1. Antibiotics. IV broad-spectrum antibiotics are the initial treatment of choice for sepsis because they kill a wide range of bacteria. Once the causative agent has been identified, then the physician may shift to the right type of antibiotics to treat the underlying infection.

2. Intravenous fluids and vasopressors. Low blood pressure levels may require a bolus intravenous fluids and vasopressor to increase them and help stabilize blood circulation.

3. Oxygen therapy. Patients with sepsis may develop low oxygen saturation levels, requiring oxygen therapy.

Nursing Care Plans for Sepsis Based on Diagnosis

Nursing Care Plan 1: Hyperthermia.

It is related to sepsis secondary to severe pneumonia as evidenced by a temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and a weak pulse.

Desired Outcome

Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Interventions	Rationale
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.	To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol)  administered.
Remove excessive clothing, blankets and environment and make it more Comfortable for the patient.	To regulate the temperature of the linens. Adjust the room temperature.
Administer the prescribed antibiotic and anti-pyretic medications	Use the antibiotic to treat a bacterial infection, which is the underlying cause of the patient’s hyperthermia secondary to sepsis. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.	To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.	Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 2: Risk for Septic Shock

Desired Outcome:

The patient establishes normal vital signs, balanced input and output, and usual mentation.

Interventions	Rationale
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.	To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol)  administered.
Start strict input and output monitoring. Measure the urine output hourly.	Decreased urinary output is a sign of diminished renal perfusion, indicating damage to the kidneys due to sepsis.
Assess for changes in the level of consciousness/ mentation.	Decreasing levels of consciousness indicate diminished cerebral perfusion and hypoxemia.
Administer intravenous fluid therapy. Administer vasopressors and inotropic agents as prescribed.	To facilitate effective tissue perfusion and maintain circulatory blood volume. To maintain blood pressure levels and help improve organ perfusion.
Place the patient on bed rest. Assist them with important activities of daily living or ADLs.	To decrease myocardial workload and oxygen consumption.

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Nursing Care Plan 3: Deficient Knowledge

It is related to diagnosis and needs for emergency treatment as evidenced by the patient’s verbalization of “I do not know what’s happening?

Desired Outcome

The patient will be able to have sufficient knowledge of sepsis and its management.

Interventions	Rationale
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits).	To address the patient’s cognition and mental status towards sepsis and to help the patient overcome blocks to learning.
Explain what sepsis is and how it affects the vital organs such as the kidneys, brain, and lungs. Avoid using medical jargon and explain in layman’s terms.	To provide information on SIADH and its pathophysiology in the simplest way possible.
Educate the patient about proper nutritional intake and its role in combatting sepsis as well as the underlying infection that has caused it.	To give the patient enough information on how good nutrition can help boost the immune system fight the infection and help them have optimal healing.
Review proper hand hygiene, overall personal hygiene, and environmental cleanliness.	To lessen the patient’s exposure to pathogens.
Inform the patient of the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) that are being given to treat sepsis.	To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, and any possible adverse events.

Related FAQs

1. What is the nursing priority for sepsis?

Recommendation: In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly. Tip: Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.

2. What is a nursing diagnosis for infection?

Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the body’s inflammatory response, which allows microorganisms to invade the body and cause infection. It is a common problem in people with low immune system.

3. What are nursing considerations?

With medication administration, a nursing consideration would include the following: Are there any reasons why this patient shouldn’t have this medication? What will the effect of this medicine be on this patient? Is there anything I need to ask or teach this patient before or after the administration?

4. What is a sepsis protocol?

What are Sepsis Protocols? A protocol in a medical context refers to a set of rules or a specific plan that doctors and nurses must follow during treatment. Sepsis protocols describe the treatment guidelines that clinicians must follow when assessing and treating patients with sepsis. Sepsis Protocols Save Lives.

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