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 Deficient Fluid Volume
- Risk for Deficient Fluid Volume
- Capillary permeability with fluid leaks into the interstitial space (third spacing).
- Marked increase in vascular compartment, massive vasodilation.
Possibly evidenced by
- [not applicable].
- Client will maintain adequate circulatory volume as evidenced by vital signs within client’s normal range, palpable peripheral pulses of good quality, and individually appropriate urinary output.
|Measure and record urinary output and specific gravity. Note cumulative intake and output (I&O) imbalances (including insensible losses), and correlate with daily weight. Encourage oral fluids, as indicated.||Decreasing urinary output with a high specific gravity suggests relative hypovolemia associated with vasodilation. Continued positive fluid balanced with corresponding weight gain may indicate third spacing and tissue edema, suggesting a need to alter fluid therapy.|
|Assess for dry mucous membranes, poor skin turgor, and thirst.||Hypovolemia and third spacing of fluid give rise to signs of dehydration.|
|Observe for dependent or peripheral edema in the sacrum, scrotum, back, and legs.||Fluid losses from the vascular compartment into the interstitial space create tissue edema.|
|Monitor blood pressure and heart rate. Measure central venous pressure (CVP) if used.||Reduction in the circulating fluid volume reduces BP and CVP, initiating compensatory mechanism of tachycardia to improve cardiac output and increase systemic blood pressure.|
|Palpate peripheral pulses.||Weak, easily obliterated pulses suggest hypovolemia.|
|Monitor laboratory values:|
||Evaluates changes in hydration/blood viscosity.|
||The BUN/Cr ratio could indicate dehydration or renal dysfunction and failure.|
|Monitor cardiac output, as indicated.||Cardiac output, and other functional parameters such as cardiac index, preload, afterload, contractility, and cardiac work, can be measured noninvasively using thoracic electrical bioimpedance (TEB) technique. Cardiac output determination is useful in determining therapeutic needs and effectiveness.|
|Administer IV fluids, such as isotonic crystalloids (D5W normal saline [NS], lactated ringer’s [LR] and colloids (albumin, fresh frozen plasma), as indicated.||Fluid therapy is most effective early in the course of severe sepsis because as the condition worsens, there is greater dysfunction at the cellular level. Large volumes of fluid may be required to overcome relative hypovolemia or peripheral vasodilation, and replaced losses from increased capillary permeability (e.g., sequestration of fluid in the peritoneal cavity) and increased insensible sources such as fever and diaphoresis.|
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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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- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans