Sepsis is a systemic response to infection; it may occur after a burn, surgery, or a serious illness and is manifested by two or more clinical symptoms: temperature of more than 38°C or less than 36°C, heart rate of more than 90 beats per minute, respiratory rate of more than 20 breaths per minute, PaCO2 of below 32 mmHg, white blood cell count of more than 12,000 cells/mm3, less than 4,000 cells/mm3 or greater than 10% of bands or immature cells, hyperglycemia, bleeding, and abnormal clotting.
Nursing Care Plans
The nursing care plan for clients with sepsis involves eliminating infection, maintaining adequate tissue perfusion or circulatory volume, preventing complications, and providing information about disease process, prognosis, and treatment needs.
- Risk For Infection
- Risk For Shock
- Risk For Impaired Gas Exchange
- Risk For Deficient Fluid Volume
- Deficient Knowledge
Risk For Infection: At increased risk for being invaded by pathogenic organisms.
- Compromised immune system.
- Failure to recognize or treat infection and/or exercise proper preventive measures.
- Invasive procedures, environmental exposure (nosocomial).
Possibly evidenced by
- [not applicable].
- Client will achieve timely healing; be free of purulent secretions, drainage, or erythema; and be afebrile.
|Assess client for a possible source of infection (e.g., burning urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines).||The most common causes of sepsis are respiratory tract and urinary tract infection, followed by abdominal and soft tissue infections. Other causes of hospital-acquired sepsis are the use of intravascular devices.|
|Teach proper hand washing using antibacterial soap before and after each care activity.||Hand washing and hand hygiene lessen the risk of cross-contamination. Note: Methicillin-resistant Staphylococcus aureus (MRSA) is most commonly transmitted bacteria via direct contact with health care workers who unable to wash hands between client contacts.|
|Maintain sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter.||Medical asepsis inhibits the introduction of bacteria and reduces the risk of nosocomial infection.|
|Investigate reports of pain out of proportion to visible signs.||Pressure-like pain over an area of cellulitis may indicate developing of necrotizing fasciitis due to group A beta-hemolytic streptococci (GABHS), necessitating prompt intervention.|
|Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral nutrition lines. Document signs of local inflammation and infection and changes in character wound drainage, sputum, or urine.||Catheter-related bloodstream infections (CR-BSIs) are increasing where central venous catheters are used in both acute and chronic care settings. Clinical signs, such as local inflammation or phlebitis, may provide a clue to a portal of entry, type of primary infecting organism (s), as well as early identification of secondary infections.|
|Inspect oral cavity for white plaques. Investigate reports of vaginal and perineal itching or burning.||Depression of immune system and use of antibiotics increase the risk of secondary infections, particularly yeast-thrush.|
|Encourage client to cover mouth and nose with a tissue when coughing or sneezing. Place in a private room if indicated. Wear mask when providing direct as appropriate.||Appropriate behaviors, personal protective equipment, and isolation prevent the spread of infection via airborne droplets.|
|Encourage or provide frequent position changes, deep breathing, and coughing exercises.||Good pulmonary toilet may reduce respiratory compromise.|
|Limit use of invasive devices and procedures when possible. Remove lines and devices when infection is present and replace if necessary.||Reduces the number of possible entry sites for opportunistic organisms.|
|Dispose of soiled dressings and other materials in a double bag.||Appropriate disposal of contaminated material reduces contamination and spread of organisms.|
|Wear gloves and gowns when caring for open wounds or anticipating direct contact with secretions or excretions.||Prevents spread of infection and cross contamination.|
|Provide isolation and monitor visitors, as indicated,||Body substance isolation should be used for all infectious clients. Wound and linen isolation and handwashing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions.|
|Note temperature trends and observe for shaking chills and profuse diaphoresis.||Fever [101°F-105°F (38.5°C-40°C)] is the result of endotoxin effect on the hypothalamus and pyrogen-released endorphins. Hypothermia lower than 96°F (36°C) is a grave sign reflecting advancing shock state, decreased tissue perfusion, and failure of the body’s ability to mount a febrile response. Chills often precede temperature spikes in the presence of generalized infection.|
|Monitor for signs of deterioration of condition or failure to improve with therapy.||Deterioration of a clinical condition or failure to improve with therapy may reflect inappropriate or inadequate antibiotic therapy or overgrowth of resistant or opportunistic organisms.|
|Obtain specimens of urine, blood, sputum, wound, and invasive lines or tubes for culture, and sensitivity, as indicated.||Identification of portal of entry and organism causing the septicemia is crucial to effective treatment based on susceptibility to specific medications.|
|Monitor laboratory studies, such as WBC count with neutrophils and band counts||The normal ratio of neutrophils to total WBCs is at least 50%; however, when WBC count is markedly decreased, calculating the absolute neutrophil count is more pertinent to evaluating immune status. Likewise, an initial elevation of band cells reflects the body’s attempt to mount a response to the infection, whereas a decline indicates decompensation.|
|Administer medications, as indicated, for example:|
||Specific antibiotics are determined by culture and sensitivity tests, but therapy is usually initiated before obtaining results, using broad-spectrum antibiotics and/or based on most likely infecting organisms. Antifungal therapy may be considered in a client who has already been treated with antibiotics, who is neutropenic, receiving total parenteral nutrition (TPN), or who has central venous access in place.|
||Administration of recombinant activated protein C inhibits thrombosis and inflammation, promotes fibrinolysis, and may reduce mortality in adult clients with severe sepsis. Drotrecogin alfa (activated) is the first FDA-approved treatment for severe sepsis|
|Assist with or prepare for procedures, such as removal of infected devices, incision and drainage of abscess, or debridement of infected wounds, as indicated.||Removal of infection sources promotes healing.|
|Prepare for hyperbaric therapy, as appropriate.||Exposing wounds to high ambient oxygen tension therapy may be done to fight anaerobic infections.|
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Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans