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.
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.
Here are six (6) nursing care plans (NCP) and nursing diagnosis for patients with sepsis and septicemia:
- Risk For Infection
- Risk For Shock
- Risk For Impaired Gas Exchange
- Risk For Deficient Fluid Volume
- Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to a specific topic.
May be related to
- Cognitive limitation.
- Lack of exposure or recall information misinterpretation.
Possibly evidenced by
- Inaccurate follow-through of instructions, development of preventable complications.
- Questions, request for information, statement of misconception.
- Client will verbalize understanding of disease process, prognosis, and potential complications.
- Client will verbalize understanding of therapeutic needs.
- Client will participate in the treatment regimen.
- Client will initiate necessary lifestyle changes.
- Client will correctly perform necessary procedures and explain the rationale for the actions.
|Review disease process and future expectations.||Discussing the disease and clinical expectations provides a knowledge base from which client can make informed choices.|
|Review individual risk factors, mode of transmission, and portal of entry of infections.||Awareness of means of infection transmission provides an opportunity to plan for and institute preventive measures.|
|Review necessity of personal hygiene and environmental cleanliness, proper cooking techniques, and food storage.||Personal hygiene and environmental cleanliness lessen the exposure to pathogens.|
|Discuss need for a good nutritional intake or balanced diet.||Good nutrition is necessary for optimal healing, immune system enhancement, and general well-being.|
|Discuss proper use of avoidance of tampons with menstruating women, as indicated.||Superabsorbent tampons or infrequent tampon changing increases the risk of Staphylococcus aureus infection.|
|Provide information about drug therapy, interactions, side effects, and the importance of compliance with the treatment regimen.||Sufficient and appropriate information promotes understanding and enhances compliance with treatment or prophylaxis, and reduces the risk of recurrence and complications.|
|Identify signs and symptoms requiring medical evaluation: persistent high fever, increased heart rate, syncope, rashes of unknown origin, unexplained fatigue, anorexia, increased thirst, and changes in bladder function.||Early recognition of developing infection will allow a timely intervention and reduces the risk of life-threatening complications.|
|Stress the importance of prophylactic immunizations and antibiotic therapy, as needed.||Prophylactic vaccines and antibiotics prevent the occurrence of infection, especially in high-risk groups such as those of extreme ages or with chronic illness and a history of infective heart disease and immunosuppression.|
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Hematologic and Lymphatic Care Plans
Care plans related to the hematologic and lymphatic system:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 4 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- 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