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
May be related to
- Direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation.
- Increased metabolic rate, illness.
Possibly evidenced by
- Flushed skin, warm to touch.
- Increased in body temperature higher than the normal range.
- Increased respiratory rate, tachycardia.
- Client will experience no associated complications.
- Client will demonstrate temperature within normal range and be free of chills.
|Monitor client temperature–degree and pattern. Note shaking chills or profuse diaphoresis.||Temperature of 102°F to 106°F (38.9°C- 41.1°C) suggest acute infectious disease process. Fever pattern may help in the diagnosis. Sustained or continuous fever curves lasting more than 24 hours indicates pneumococcal pneumonia, scarlet, or typhoid fever; remittent fever varying only a few degrees in either direction reflects pulmonary infections; and intermittent curves or fever that returns to normal once in 24-hour period suggest septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes.|
|Monitor environmental temperature. Limit or add bed linens, as indicated.||Room temperature and linens should be altered to maintain near-normal body temperature.|
|Provide tepid sponge baths. Avoid use of alcohol.||Tepid sponge baths may help reduce fever. The use of alcohol may cause chills, elevating temperature, and skin dehydration.|
|Provide cooling blanket, or hypothermia therapy as indicated.||Used to reduce fever, especially when higher than 104°F to 105°F (39.9°C–40°C), and when seizures or brain damage are likely to occur.|
|Administer antipyretics, such as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol).||Antipyretics reduce fever by its central action on the hypothalamus; fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial in limiting the growth of organisms and enhancing autodestruction of infected cells.|
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Hematologic and Lymphatic Care Plans
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