Risk for sepsis?

VickyRN, MSN, DNP, RN · Oct 1, 2006

Hi guys,
My patient is CCu this week had bacteremia among other things. I was going to use the diagnosis risk for sepsis but I can not seem to find this in any of my books. Did I just come up with this diagnosis in my head or is it actually approved by NANDA? I can't find it on the internet either.Thanks for your help!!! This site is amazing!

Possible NANDA-approved nursing diagnoses for sepsis:

Risk for Infection (Septicemia) - but since the client already had bacteremia, would not be appropriate

Risk for Injury (Hemorrhage/ DIC) r/t possible blood-clotting abnormalities secondary to septicemia

Ineffective Peripheral Tissue Perfusion (cardiopulmonary, renal, cerebral, and peripheral) r/t abnormal distribution of blood flow, metabolic acidosis, or both (in septic shock)

Hope this helps! :) and welcome to allnurses :balloons:

Nursing Student 2005 · Oct 2, 2006

Thank you so much for yur quick response. I don't know why I though that diagnosis was acceptible but the ones you suggested were appropriate and very helpful. Thanks again!!

Daytonite, BSN, RN · Oct 2, 2006

my guess is that you were dreaming (?) :confused:

here are some links where you can get some information about sepsis:

http://www.survivingsepsis.com/index.html - surviving sepsis, a web site for everything you want to know about sepsis, signs and symptoms, common sources of sepsis, septic shock and treatment. links at the left side of the page take you to the various pages of this site. includes links for more information on sepsis, some of which are extensive sites by drug manufactures on the treatment of sepsis.

http://www.ccmtutorials.com/infection/index.htm - critical care medicine tutorial on sepsis (for medicine)

http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/sepsis/sepsis.htm - all about sepsis, also called sirs (systemic inflammatory response syndrome). it's definition, prevalence, pathophysiology, signs and symptoms, diagnosis, treatment and outcome

now, i feel like i have to finish my job here and remind you that any nursing diagnosis has to be based on the symptoms your patient is having--not on his/her medical diagnosis, which is what sepsis is! use the links i've given you to develop a list of what the symptoms for a medical diagnosis of sepsis are. then, compare that list of symptoms to the assessment data you came up with on your ccu patient. did your patient have any of those symptoms? if so, then by all rights you can use those particular symptoms to formulate one or more nursing diagnoses around them. these symptoms, then, will be causing some particular situation, or "related factors" to put it in nanda terminology, that will become the foundation of a nursing diagnosis that you can use in the planning of this patient's care. the nursing interventions you will use are directly aimed at treating the symptoms the patient is exhibiting. this is a very logical process. choosing a nursing diagnosis should not be a hunt, peck, hope i got the right diagnosis thing that should be going on.

do you have a book of care plans or a nursing diagnosis handbook to help you out here? if not, you really need to consider getting one. here are two websites that list the official nanda diagnoses, just a year or two older than the latest complete update published by nanda in 2005. fyi. . .nanda owns the copyright to any listing of the diagnoses, so it is almost impossible to find a free list of them anywhere. most of what is available are older lists. the basic nursing diagnoses that are used in med/surg care plans haven't changed all that much over the years with the exception of the way they are worded.

http://www.nursingstudio.net/2005/03/20/nanda-nursing-diagnoses/ - a complete list of nanda nursing diagnoses organized by gordon's functional patterns

http://www.efn.org/~nurses/ - this is a website maintained by the nursing students at lane community college in eugene, oregon. a list of nanda diagnoses through the 12th conference in 1996 can be found here. this has since been updated by nanda so there have been a few changes. click on "nanda nursing dx" on the left side of this webpage.