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 Impaired Gas Exchange
- Risk for Impaired Gas Exchange
- Altered oxygen supply–effects of endotoxins on the respiratory center in the medulla (resulting in hyperventilation and respiratory alkalosis); hypoventilation.
- Altered blood flow (changes in vascular resistance), alveolar-capillary membrane changes–increased capillary permeability leading to pulmonary congestion.
- Interference with oxygen delivery and utilization in the tissues (endotoxin-induced damage to the cells and capillaries).
Possibly evidenced by
- [not applicable].
- Client will display ABGs and respiratory rate within the normal range, with breath sounds clear and chest x-ray clear or improving.
- Client will experience no dyspnea or cyanosis.
|Monitor respiratory rate and depth. Note use of accessory muscles or work of breathing.||Rapid, shallow respiration occur because of hypoxemia, stress, and circulating endotoxins. Hypoventilation and dyspnea reflect ineffective compensatory mechanisms and are indications that ventilatory support is needed.|
|Auscultate breath sounds. Note for crackles, stridor, wheezes, and areas of decreased or absent ventilation.||Respiratory distress and the presence of adventitious sounds are indicators of atelectasis, interstitial edema, and pulmonary congestion.|
|Assess for changes in sensorium (confusion, lethargy, personality changes, stupor, delirium, and coma).||Cerebral function is very sensitive to decrease in oxygenation such as hypoxemia, or reduced perfusion.|
|Note for a presence of circumoral cyanosis.||Circumoral cyanosis indicates inadequate central oxygenation and hypoxemia.|
|Note cough and purulent sputum production.||Pneumonia is a common nosocomial infection that occurs by aspiration of oropharyngeal organisms or spread from other sites.|
|Reposition client frequently. Encourage coughing and deep-breathing exercises. Suction, as indicated.||Good pulmonary toilet is important for minimizing ventilation/perfusion imbalance and for mobilizing and facilitating removal of secretions to maximize gas exchange.|
|Maintain client airway. Place client in a position of comfort with the head of bed elevated 30 to 45°.||Elevating the head of bed enhances lung expansion and reduces respiratory effort.|
|Monitor ABGs and pulse oximetry.||Hypoxemia is related to decreased ventilation and pulmonary changes (i.e. atelectasis, interstitial edema and pulmonary shunting) and increased oxygen demands caused by fever or infection. Respiratory acidosis (ph below 7.35 and PaCO2 higher than 40 mm Hg) happens due to hypoventilation and ventilation-perfusion imbalance. As septic condition worsens, metabolic acidosis (ph below 7.35 and HCO3 less than 22-24 mEq/L) develops as a result of build up of lactic acid from anaerobic metabolism.|
|Review serial chest x-rays.||Changes on x-ray reflect progression or resolution of pulmonary complications, such as infiltrates and edema.|
|Administer red blood cells (RBCs), as indicated.||May be required to improve available oxygen to treat sepsis-induced hypoperfusion, or when the hematocrit falls below 30%.|
|Provide supplemental oxygen via appropriate route: nasal cannula, mask, or high-flow rebreathing mask.||Supplemental oxygen is important for correction of hypoxemia with failing respiratory effort or progressing acidosis.|
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Hematologic and Lymphatic Care Plans
Care plans related to the hematologic and lymphatic system:
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- Deep Vein Thrombosis | 5 Care Plans
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- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans