Sepsis (1) is scary. It can start off showing signs and symptoms of pneumonia, urinary tract infection or the flu. Before you know it, it has already developed into a widespread inflammation and infection, causing organ failure and even death.
As a nurse, it’s your responsibility to ensure that your patients don’t develop infection and sepsis while under your care. And if the patients you are caring for are already diagnosed with it, it’s important that the condition doesn’t worsen and that you’re able to help manage it.
Who’s at risk for sepsis?
Anyone can develop sepsis. However, there are specific groups who are more prone to it.
The list includes:
- People with really weak immune systems
- Young children
- Seniors
- People exposed to invasive devices
- People with chronic illness
What are the symptoms of sepsis?
What makes detection of sepsis tricky is that its symptoms can easily be mistaken for those of other health conditions. As a nurse, you need to be able to recognize its main signs so you can act quickly.
Here’s what you need to watch out for:
- Fever
- Fast heart rate or pulse
- Rapid breathing
- Unusual sweating
Sepsis can quickly turn into severe sepsis. Make it a point to assess your patients for the following signs and symptoms:
- Abrupt changes in mental status
- Difficulty breathing
- Abdominal pain
- Significantly reduced urine output
- A decrease in platelet count
Now, as a way to help you care for your patients, here are a few nursing care plans for sepsis you’ll find handy.
1Hyperthermia
May be related to:
- Elevated metabolic rate
- Inflammatory process
- Dehydration
- Altered temperature regulation
- Effect of circulating endotoxins on the hypothalamus
Possibly evidenced by:
- Flushed skin, warm to touch
- Increased respiratory rate
- Increase in body temperature higher than the normal range
Desired outcome:
- Maintains normal body temperature
| Nursing Interventions | Rationale |
| Monitor the client’s temperature. | Acute infectious disease processes are often suggested by a temperature that’s 102°F and higher. Fever is a common symptom of sepsis (2). |
| Adjust environmental factors as indicated. Remove excess clothing as necessary. | Adjusting room temperature and linens can assist in maintaining a near-normal body temperature. Removing excess cover can expose skin to room air, facilitating in evaporative cooling. |
| Provide tepid sponge baths as necessary. | Tepid sponge baths can help lower fever. Avoid the use of alcohol and ice water as they can elevate temperature and cause skin dehydration. |
| Administer antipyretics as ordered. | Antipyretics acts on the hypothalamus to lower the body’s temperature. |
| Provide a cooling blanket. | Cooling blankets can reduce fever when the temperature is above 104°F. |
2Risk For Deficient Fluid Volume
Risk Factors:
- Increase in vascular compartment, massive vasodilation
- Capillary permeability
Desired outcome:
- Maintains adequate circulatory volume
| Nursing Interventions | Rationale |
| Assess vital signs. | Tachycardia, hypotension, and fever can signal the body’s response to fluid loss. |
| Observe for excessively dry skin and mucous membranes. | This indicates excessive fluid loss as a result of severe dehydration. |
| Monitor for peripheral edema in the legs, back, and scrotum. | Fluid moving from the vascular compartment towards the interstitial space leads to tissue edema. |
| Check peripheral pulses. | Pulses that are weak and easily obliterated indicate hypovolemia. |
| Administer IV fluids as ordered. | Fluid therapy in the early course of sepsis is more effective. It’s a fundamental sepsis therapy (3). |
3Risk for Infection
Risk Factors:
- Invasive procedures
- Increased environmental exposure to pathogens
- Insufficient knowledge regarding avoidance of exposure to pathogens
- Immunosuppression
Desired outcomes:
- Remains free from signs and symptoms of infection
- Maintains white blood cell count and differential within normal limits
- Achieves timely healing
- Absence of drainage, fever, and purulent secretions
| Nursing Interventions | Rationale |
| Monitor vital signs. | Increase in temperature and breathing may indicate developing sepsis. |
| Inspect wound and dressings and note any changes in the characteristics of drainage. | Early detection allows the opportunity for prevention of more serious complications. |
| Maintain aseptic technique in any procedure. | Prevents entry of bacteria and reduces the risk of nosocomial infections. |
| Encourage a balanced diet. | Eating the right foods can boost the immune system. Intake of protein, vitamins A, C, and E, and iron and zinc affects the immune function. |
| Encourage frequent position changes. | Prevents the stasis of body fluids and promotes the functioning of body organs. |
| Promote meticulous perineal care and provide routine catheter care. | Reduces the risk of ascending UTI and prevents bacterial colonization. |
| Use proper handwashing technique and encourage the same in a patient. | Meticulous hand washing (4) decreases the number of pathogens on the skin. |
| Follow transmission-based precautions as indicated. | All infectious patients need to undergo body substance isolation. Patients with diseases that can be transmitted through the air may require droplet and airborne precautions. |
| Administer medications as ordered. | Antibiotic therapy may be directed toward specific organisms while wide-spectrum antibiotics may be used as prophylaxis. |
Nursing Interventions for Sepsis:
4Early Recognition and Assessment:
- Be vigilant for signs and symptoms of sepsis, including fever, increased heart rate, rapid breathing, altered mental status, and signs of infection.
- Perform a thorough assessment of the patient, including vital signs, oxygen saturation, mental status, and skin appearance.
- Obtain cultures (blood, urine, wound, respiratory secretions) as ordered to identify the source of infection.
- Assess for any potential sites of infection or sources of sepsis, such as surgical wounds, catheter sites, or respiratory infections.
5Immediate Actions:
- Initiate appropriate infection control measures, including proper hand hygiene, isolation precautions if necessary, and use of personal protective equipment.
- Administer supplemental oxygen to maintain oxygen saturation above 92%.
- Establish vascular access for fluid resuscitation and administration of medications.
- Administer broad-spectrum antibiotics as ordered within the recommended time frame.
6Fluid Resuscitation:
- Administer intravenous fluids promptly to restore intravascular volume and improve tissue perfusion.
- Use crystalloid solutions, such as normal saline or lactated Ringer’s, as the initial fluid of choice.
- Monitor the patient’s fluid status closely, assessing for signs of fluid overload or inadequate response to fluid resuscitation.
- Collaborate with the healthcare team to adjust fluid administration based on the patient’s response and hemodynamic parameters.
7Hemodynamic Support:
- Monitor the patient’s hemodynamic parameters, including blood pressure, central venous pressure, and urine output.
- Administer vasopressor medications, such as norepinephrine or dopamine, to maintain adequate mean arterial pressure and tissue perfusion.
- Titrate vasopressors according to the patient’s response and hemodynamic targets.
8Continuous Monitoring and Assessment:
- Continuously monitor vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
- Monitor oxygenation status using pulse oximetry and arterial blood gas analysis as needed.
- Assess urine output and renal function to evaluate organ perfusion.
- Monitor laboratory values, including complete blood count, coagulation profile, liver and renal function tests, and lactate levels.
9Supportive Care:
- Administer antipyretics to control fever, if ordered.
- Provide pain management to ensure patient comfort.
- Maintain strict infection control practices, including proper wound care and catheter care.
- Position the patient to optimize respiratory function and prevent complications, such as aspiration or pressure ulcers.
- Administer appropriate nutritional support to meet the patient’s metabolic needs.
10Psychosocial Support and Education:
- Offer emotional support to the patient and their family, addressing their fears, concerns, and questions.
- Provide clear and concise explanations about the patient’s condition, treatment plan, and potential complications.
- Educate the patient and their family about sepsis, its causes, signs, and symptoms, as well as the importance of early recognition and seeking prompt medical attention.
11Collaborative Care and Communication:
- Collaborate closely with the healthcare team, including physicians, pharmacists, and other healthcare professionals, to ensure timely and coordinated care.
- Communicate changes in the patient’s condition promptly and report any concerns or adverse reactions to interventions.
- Participate in interdisciplinary rounds and team meetings to discuss the patient’s progress, goals, and treatment plan adjustments.
12Continuity of Care and Discharge Planning:
- Coordinate with the healthcare team to plan for the patient’s ongoing care, including appropriate antibiotic therapy, follow-up appointments, and referrals for further evaluation or rehabilitation.
- Educate the patient and their family about signs of infection and sepsis recurrence and the importance of adhering to prescribed medications and follow-up care.
- Provide appropriate discharge instructions and resources for the patient and their family to ensure a safe transition to home care.
References:
1. Lever, A., & Mackenzie, I. (2007). Sepsis: definition, epidemiology, and diagnosis. Bmj, 335(7625), 879-883.
2. Schortgen, F. (2012). Fever in sepsis. Minerva anestesiologica, 78(11), 1254-1264.
3. Brown, R. M., & Semler, M. W. (2019). Fluid management in sepsis. Journal of intensive care medicine, 34(5), 364-373.
4. Toney-Butler, T. J., & Carver, N. (2018). Hand, Washing (Hand Hygiene).
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
