The Nurse's Role in Managing Sepsis

This article will define sepsis's etiology, signs and symptoms, diagnostic testing, and treatments. We will also review a case study and nursing care plans appropriate for a septic patient. Students Student Assist Knowledge

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The Nurse's Role in Managing Sepsis

Infections responsible for sepsis can quickly lead to septic shock, causing multi-organ failure and death. According to the World Health Organization, sepsis accounted for nearly 20% of all worldwide deaths in 2017, including 2.9 million children under five.

What Is Sepsis?

Sepsis is a dysfunctional systemic response to an infection. The body's overwhelming physical and biochemical reaction to a microorganism is the hallmark sign of sepsis.

Sepsis exists on a continuum. It begins with initial signs and symptoms and progresses to severe sepsis and septic shock. The patient experiences clinical complications during each stage, resulting in progressive tissue damage, multi-organ failure, and possibly death. Although there are defined stages, progressing from sepsis to life-threatening septic shock can happen within hours to days.

To understand the definition of sepsis, we first need to understand a diagnosis of SIRS (Systemic Inflammatory Response Syndrome). SIRS happens when a patient meets at least two of the following criteria:

  •  Fever greater than 38 C or hypothermia with a temperature less than 36 C
  •  Tachycardia with a heart rate > 90 beats per minute
  •  Tachypnea with a respiratory rate > 20 breaths per minute
  •  Leukocytosis with a WBC > 12,000 /cu mm or leukopenia with WBC < 4,000/cu mm

A patient can meet SIRS criteria without being septic. However, a sepsis diagnosis satisfies SIRS criteria and requires either an infectious source or the suspicion of one.

With severe sepsis, you see profound hypotension indicated by low blood pressure with a systolic BP of less than 90, and organ dysfunction begins because of inadequate tissue perfusion. The body cannot provide enough oxygen to the tissues. Lactic acidosis occurs in this phase when aerobic respiration transitions to anaerobic respiration.

Septic shock occurs when the patient's blood pressure remains low (Systolic BP < 90) despite treatment with fluids and vasoactive medicines. The body does not respond to interventions, making medical management more difficult. Septic shock further subdivides into compensated and uncompensated categories. Once a patient is in uncompensated shock, reversing the damage is challenging and potentially impossible when organ failure occurs.

What Causes Sepsis?

Any bacterial, viral, or fungal infection can cause sepsis. However, the main culprits you will see time and again are gram-negative and gram-positive bacterial infections. Microorganisms frequently isolated in a septic patient include Staphylococcus aureus, Streptococcus pyogenes, Klebsiella, Pseudomonas aeruginosa, and Escherichia coli.

Patients with Infections that begin in the lower respiratory system, such as pneumonia, or the genitourinary system, such as a urinary tract infection, have a higher risk of developing sepsis. While we will discuss high-risk individuals later in this article, it is essential to note that mortality due to sepsis is also increasing in patients with complex comorbidities and those with underlying injuries. 

A patient's age can significantly impact the risk of developing a septic response. For example, Group B streptococcus (GBS) and Escherichia coli (E.coli) are the leading causes of neonatal sepsis. 

Nosocomial infections are hospital-acquired and are on the rise in healthcare institutions. Interventions, including frequent handwashing, diligent use of aseptic and sterile techniques, and the timely removal of unnecessary indwelling catheters like a foley or central line, are conscious measures all healthcare team members can take to reduce a patient's risk for sepsis.

Signs and Symptoms of Sepsis

Although the most critical patients will receive care in the ICU, nurses in all specialties must be able to recognize the signs and symptoms. Signs and symptoms will vary depending on where your patient is on the sepsis spectrum. Remember, some early signs will overlap with the SIRS criteria mentioned earlier in this article.

Signs and symptoms of sepsis include the following:

  •  Increased heart rate, tachycardia
  • Increased respiratory rate, tachypnea
  • Shortness of breath or difficulty breathing, dyspnea  
  • Fever, low temperature and shivering, or feeling very cold
  • Body pain  

It is helpful to consider what happens in the body when sepsis progresses to severe sepsis or septic shock. Remember that hypotension is clinically significant in these stages, and as a result, you will begin to see indicators of poor perfusion and organ damage, such as

  • Weak pulses
  • Cyanosis or mottled skin
  • Cold, clammy skin
  • Altered mental status, including disorientation and confusion
  • Hypoxia 
  • Decreased urine output, oliguria, or anuria

Recognizing these signs and symptoms is critical to improving your patient's risk of morbidity and mortality. Early intervention remains the single most crucial factor for a positive outcome.

Diagnosing Sepsis

There is no one specific test used to diagnose sepsis. Instead, diagnosis depends on your patient's bigger clinical picture by incorporating testing with clinical presentation.

Considering some tests to confirm infection or indicate organ failure is helpful.

  • CBC with differential used to evaluate leukocytosis, leukopenia, bandemia, and  thrombocytopenia
  • Blood, wound, urine, endotracheal, or tracheal cultures
  • C-reactive protein
  • Procalcitonin  
  • Abnormal blood gasses
  • Glucose levels, specifically hyperglycemia
  • Coagulopathy, elevated INR, or PTT
  • Abnormal liver function tests 
  • Urine tests

Imaging tests, including x-rays, ultrasounds, CT scans, and MRIs, are helpful when determining the sight of an infection.

What are the SOFA and qSOFA Scores?

The Sequential Organ Failure Assessment (SOFA) score quantifies a patient's mortality risk when presenting with sepsis. The assessment tool evaluates the degree to which several organ systems are functioning in the body. A higher SOFA score indicates a higher risk of death.

SOFA assigns a score to six categories, assessing respiration status, coagulation, liver laboratory test results, cardiovascular function, central nervous system indicators, and renal performance. 

SOFA is not a perfect predictor and is not without some controversy, but it remains recognized as an easily implemented tool in clinical practice. SOFA scores are valuable in ensuring prompt triage of high-scoring patients and avoiding treatment delays.

Nurses in critical care areas may calculate daily SOFA scores. When nurses plot daily results as a trend, they correlate with the overall prognosis.

The quick SOFA (qSOFA) is a shorter version designed for clinical use outside critical care. This condensed version measures three parameters: altered mental status, respiratory rate, and systolic blood pressure.

Treatment

Treatment consists of a three-step approach involving source control, managing shock, and enhancing the body's response.

Expect doctors to seek the source of the infection, order cultures, and start broad-spectrum IV antibiotics within one hour of diagnosis. For example, if the source is an abscess, anticipate doctors to drain it. If culture results are positive, doctors will change antibiotics to target the specific microorganism. However, not all septic patients will have positive cultures.

Expect fluid resuscitation with IV fluids to maintain volume and perfusion. If the patient further deteriorates hemodynamically, vasopressor support is the next step. IV steroids reduce inflammation and attempt to manage the body's disorganized response.

If organ damage occurs, you can expect these patients to require central lines, arterial lines, ventilator support, renal replacement therapy, transfusions, and other intensive supportive measures.

High-Risk Individuals

Anyone with an injury, underlying condition, or infection has the potential to develop sepsis.

However, certain factors and conditions elevate the risk: 

  • Diabetes
  • Immunocompromised individuals
  • Major surgery
  • Cancer
  • Liver or kidney disease
  • Autoimmune disease
  • Burns
  • Hospitalized patients
  • Neonates 
  • Pregnant or recently pregnant women
  • Older people 

Complications

Recovering from sepsis varies. Full recovery is possible; however, some patients will experience long-term complications, perhaps requiring transfer to lower levels of care like long-term acute care facilities, acute rehab, skilled nursing, or home health services. Possible complications include

  • Insomnia
  • Weakness and fatigue
  • Body pains
  • Confusion 
  • Amputations
  • Organ damage 
  • New baseline requirements for a tracheostomy, g-tube, dialysis, or ostomy 

Nursing Care Plans for Sepsis

Nursing care plans for sepsis involve educating your patient, treating the infection, and maintaining adequate perfusion while preventing complications.

Knowledge Deficit Care Plan

Knowledge deficit occurs if your patient has a cognitive impairment or does not understand a specific topic.

Nursing Diagnosis  

  • Knowledge deficit related to unexpected hospital admission as evidenced by seeking additional information on sepsis diagnosis and treatment

Care Plan Goals and Expected Outcomes

  • The patient will explain sepsis, recognize the need for medications, and understand treatments

Nursing Assessment and Rationale

  • Assess your patient's ability to learn and retain information

    • Rationale: Cognitive impairments, unexpected hospitalization, and complications such as confusion can affect the individual's ability to learn and understand information

  • Assess your patient's cultural background
    • Rationale: Cultural differences can affect whom a patient is comfortable talking with about private health information

Nursing Interventions and Rationale

  • Consider the content and timing of the information

    • Rationale: Providing the patient with explanations while completing interventions provides an opportunity to teach. Explaining an IV medication before administration informs and empowers the patient and offers time for questions

  • Consider your patient's language and cultural needs. Utilize interpreter services as needed and available

    • Rationale: People are often more comfortable communicating in their preferred language when discussing serious topics

Deficient Fluid Volume Care Plan 

Deficient fluid volume occurs when fluid and electrolyte output surpasses the body's intake and results in decreases or shifts in intravascular, intracellular, or interstitial fluid.

Nursing Diagnosis

  • Deficient fluid volume related to insufficient fluid intake as evidenced by BP 88/58, and elevated body temperature of 38.7 C 

Care Plan Goals and Expected Outcomes

  • Within one hour of nursing interventions, the patient will maintain normal blood pressure, heart rate, and temperature

Nursing Assessment and Rationale

  • Frequently assess vital signs, heart rate, respiratory rate, blood pressure, temperature, and oxygen saturation

    • Rationale: Decreased fluid volume causes vital sign changes, including tachycardia, tachypnea, hypotension, and temperature extremes

  • Assess intake and output frequently every four hours or more often for an unstable patient

    • Rationale: Decreased urine output of less than 0.5 mls/kg/hr places your patient at higher risk of acute kidney injury

Nursing Interventions and Rationale

  • Administer IV fluids as ordered
    • Rationale: Fluid resuscitation supports perfusion and oxygenation
  • Administer IV antiemetics if ordered
    • Rationale: Vomiting furthers fluid losses

Impaired Gas Exchange Care Plan

An excess or deficit in oxygen or carbon dioxide at the alveolar-capillary level of the lungs causes impaired gas exchange.

Nursing Diagnosis

  • Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by a respiratory rate of 24/min and hypoxemia with an oxygen saturation of 86%

Care plans Goals and Expected Outcomes

  • Within one hour of nursing interventions, the patient will demonstrate improved ventilation and adequate oxygenation, as evidenced by blood gas levels within the normal range

Nursing Assessment and Rationale

  • Use pulse oximetry to monitor oxygen saturation
    • Rationale: Normal oxygen saturations are at 90% or greater. Oxygen saturations help guide changes in supplemental respiratory therapy
  • Assess the quality of respirations, including rate, depth, effort, and any use of accessory muscles
    • Rationale: Hypo and hyperventilation affect gas exchange. Shallow and rapid breathing impair gas exchange. The use of accessory muscles indicates increased work of breathing
  • Assess lung fields for diminished breath sounds, decreased ventilation, and adventitious lung sounds
    • Rationale: Wheezes, crackles, or poor ventilation may identify worsening symptoms

Nursing Interventions and Rationale

  • Maintain supplemental oxygen delivery devices as ordered to keep oxygen saturation at 90% or higher
    • Rationale: Supplemental O2 via nasal cannula, mask, BiPap, or ventilator may be needed to maintain PaO2 levels
  • Provide education and reassurance to decrease anxiety
    • Rationale: An anxious patient may exhibit an increased work of breathing

Next Gen NCLEX Review Questions with Rationales

Review the following case study using the information provided in this article to identify what factors, if any, would indicate sepsis. 

A 79-year-old female presents to the emergency room complaining of abdominal pain in the right upper quadrant radiating to the back and left ear. She has recently been to urgent care and diagnosed with bilateral tympanic membrane ruptures but has not yet filled the prescribed antibiotic. A chest CT revealed ground glass opacities and concern for either fluid overload or atypical pneumonia. The patient was diagnosed with a respiratory tract infection with leukopenia (WBC  2.7 x 109/L) and a urinary tract infection.

Past history: Hashimoto's thyroiditis, Addison's disease, breast cancer, and chronic fatigue syndrome. She is on chronic steroids.

On assessment:

  • She has an unsteady gait requiring assistance to transfer from chair to bed
  • She reports feeling weak and tired
  • She rates her back pain score a 7 out of 10, and her skin is warm to the touch
  • Per auscultation, she has diminished breath sounds bilaterally

Vital signs on admission: Temperature 39.0 C, Heart rate 113, Respirations 24,  Blood pressure 113/76, O2 Sat 89% 

Answer

  • Age 78 years old
  • Known infection, antibiotics were prescribed but failed to start
  • Chest CT suspicious of pneumonia
  • A new urinary tract infection
  • Leukopenia (WBC  2.7 x 109/L)
  • Immunosuppressed 
  • Reports significant pain and weakness
  • Impaired gas exchange, hypoxemia, and tachypnea
  • Fever and tachycardia

Anecdotal

The case study above represents an actual patient who experienced additional diagnoses not included here. But her course represents the timeline from initial infection to life-threatening septic shock.

She arrived ambulatory via the emergency department and began interventions for sepsis immediately. Despite best efforts, she quickly deteriorated within 24-48 hours of arrival. During her prolonged ICU admission, she required intubation, mechanical ventilation, multiple lines and drips, pressors, sedatives, steroids, antibiotics, and transfusions. 

When she finally began to improve, she did not tolerate extubation or attempts to wean the ventilator. She had a tracheostomy placed and remained ventilator dependent. For nutrition, she required a surgically placed gastrostomy tube.

She was now stable enough to transfer to a long-term acute care facility (LTAC) where ventilator weaning could continue. A leaking G-tube complicated her progress and put her at further risk for skin breakdown. Four weeks later, she went home without a tracheostomy or gastronomy tube.

This lady presented with an infection to the emergency room and left eight weeks later. Therapy and further follow-up are needed to help her recover completely. But this illustrates the speed at which life can change because of an infection.

Conclusion

From community nurses to those working in critical care units, you may be the first to suspect sepsis in your patient. With a complete understanding of sepsis, nurses can positively impact patient outcomes for this worldwide condition.

STAFF NOTE: Original Community Post

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:

Quote

I have my first Care Plan due and my patients diagnosis was sepsis.

The books I have have little to no information on sepsis. I could use help with nursing interventions for the nursing diagnosis of social interaction impaired and impaired comfort! My pt was 89 yrs old had hx of kidney disease, chronic dementia, diabetes and was nonverbal and during my whole shift.

Thank you!

References

  1. World Health Organization. (2020, August 26). Sepsis. World Health Organization. Retrieved February 21, 2023, from https://www.who.int/news-room/fact-sheets/detail/sepsis
  2. Jarczak, D., Kluge, S., & Nierhaus, A. (2021). Sepsis-pathophysiology and therapeutic concepts. Frontiers in Medicine, 14(8), 628302. doi: 10.3389/fmed.2021.628302. Retrieved February 21, 2023, from https://pubmed.ncbi.nlm.nih.gov/34055825/

  3. Mahapatra, S., & Heffner, A.C. (2022, June 21). Septic shock. StatPearls. Retrieved February 21, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK430939/

  4. Marik, P. E., & Taeb, A. M. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4), 943-945. https://doi.org/10.21037/jtd.2017.03.125

  5. MD+CALC. (n.d.). Sequential organ failure assessment (SOFA) score. February 21, 2023, from https://www.mdcalc.com/calc/691/sequential-organ-failure-assessment-sofa-score

  6. Rhee, C., Jones, T.M., Hamad, Y., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Netw Open, 2(2), e187571. doi:10.1001/jamanetworkopen.2018.7571

  7. Barton, J.R., & Sibai, B.M. (2012). Severe Sepsis and Septic Shock in Pregnancy. Obstetrics & Gynecology, 120(3), 689-706. DOI: 10.1097/AOG.0b013e318263a52d 

  8. Ackley, B. J., Ladwig, G. B., MSN, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2016). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.

  9. Gulanick, M., & Myers, J.L. (201o). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby.

  10. Pascoal, L. M., Lopes, O., Resende Chaves, D. B., Beltrão, B. A., da Silva, V.M., & Magalhães Monteiro, F. P. (2015). Impaired gas exchange: Accuracy of defining characteristics in children with acute respiratory infection. Revista Latino-Americana de Enfermagem, 23(3), 491-499. https://doi.org/10.1590/0104-1169.0269.2581

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Wendy Sutas

About Wendy Sutas, BSN, RN

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Specializes in Med-Surg/Tele, ER.

I'm confused, you have a patient with sepsis and you are using impaired social interaction and impaired comfort as your nursing diagnosis? You might want to pick a higher priority nursing dx.

Look up sepsis and learn what it is, then find your nursing diagnosis. I personally think these are inappropriate for a potentially life threatening condition. just my

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Yes I choose those because we have to have a total of 10 nursing diagnosis with 10 interventions each and those are the last 2 I need help with!

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I changed social interaction impaired to impaired verbal communication r/t psychological barriers which would be my pt's depression and for my interventions I put: allow body contact such as touching to show you care and your presence, limit the number of people in the room at bedside so you don't overwhelm the pt and do not push communication.

I worked on the impaired comfort and got ten!

My priority nursing dx is: infection r/t microorganism invasion into the body. Do you think this is a good one? I looked in my nurses pocket guide Ed 12 and they only have risk for infection not just infection by itself. Is this still nanda approved?

Thank you!

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Specializes in IMCU.

Infection is not a nursing diagnosis according to NANDA's most recent publication.

Do you have any assessment data?

What are their vital signs? With sepsis you could have everything from depressed temp. to elevated temp. Oxygenation? BP (usually low BP is a symptom of sepsis)?

You get my point. You are assessing the patient as a whole. So a medical diagnosis in itself can point you in the right direction for what complications you need to monitor, but you, the nurse, still need to assess. You know the patient is depressed so I bet you know much more.

Their impaired VERBAL communication will be r/t the alteration of the CNS then you need to add the defining characteristics: aphasia perhaps? None the less it is unlikely that the impaired verbal communication is going to be in your top few NDs.

If you are looking for priority NDs then you should always consider ABCs -- you should always consider these anyway. If you post some of your assessment data we could probably help you more.

As for looking up conditions Google "family practice notebook", Mayo Clinic or Cleveland Clinic. Still your nursing textbook often have the NDs for conditions listed.

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Specializes in IMCU.

ooooooooh I just got that you are on your last 2. Not enough coffee this morning. Still more data needed. What are your first 8 for this patient?

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Specializes in Med-Surg/Tele, ER.

I don't know if infection is NANDA approved,it's not in my older book but in by nursing dx book, under sepsis it lists Deficient fluid volume RT vasodilation of peripheral vessels, leaking capillaries

Imbalanced nutrition less than body requirements RT anorexia, generalized weakness

ineffective tissue perfusion RT decreased systemic vascular resistance

and under septic shock is deficient fluid volume RT abnormal loss of fluid through capillaries, pooling of blood in peripheral circulation

and

ineffective protection RT inadequately functioning immune system

Don't know if they pertain to your pt, but some interventions I have in my book are

Use presence. Spend time with the pt, allow time for responses and make the call light readily available

Listen carefully. Validate verbal and nonverbal expressions

Use simple communication, speak in a well modulated voice, smile and show concern for the pt.

recognize behavioral cues for pain

assess whether a person is averse to touch

maintain eye contact at the pt. level

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Here's my assessment data! Bp: 108/64, temp: 96.7 pulse: 70 resp: 14

decreased cardiac output, impaired skin integrity, social interaction impaired, chronic confusion, risk for injury, risk for dehydration, imbalanced nutrition, ineffective protection

my priority nursing dx was infection rt microorganism in the body but I have to change infection to something nanda improved!

Any thoughts on what that could be?

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Specializes in Med-Surg/Tele, ER.

Take note of the temperature, I didn't see hypothermia in your list. Your priority dx can be determined by Maslow's needs. List all of them and find out which one is highest according to Maslow and you should be fine.

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So could sepsis cause an alteration in the cns?

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Specializes in Med-Surg/Tele, ER.

Sepsis can affect many different body systems. If you think about what controls body systems like the inflammation response, how thermoregulation works, etc. you'll have your answer...sorry I'm being vague, but people get really upset if we do homework for students, besides, I want you to work it out in your mind because If I just tell you, then you won't remember or truely understand and this is important.

I will however tell you a little something about sepsis that took me years to figure out. During nursing school one thing that was stressed to us about sepsis is the risk for DIC (Disseminated Intravascular Coagulation) and that the one of the treatments for DIC was heparin. I could never figure out why, if someone was bleeding out, you would treat them with heparin!

So, the way I broke it down to myself (and this is in simple terms, so read the indepth explanation in your book also) We know that sepsis can interfere with the clotting cascade and cause all these clots to start forming everywhere (blocking blood flow to kidneys, heart, lungs, etc), so in my mind I was picturing them turning into a solid, (hence the heparin) but if they are a solid, how can they be bleeding out?? The problem is that all these clots forming everywhere are using up all the normal platelets and clotting factors in the blood and eventually the places where you are normally clotted to keep the blood in your body, don't have enough clotting factors and you start bleeding from your mouth, nose, puncture sites etc!

pinkfan said:
So could sepsis cause an alteration in the cns?

yes, think of the S&S. decreased blood pressure means a decrease in cardiac output, and a decrease in oxygenated blood throughout your body, including your brain...

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Try decreased tissue perfusion r/t decreased BP secondary to vasoldilation caused by bacterial endotoxin release as evidence by: low cardiac output, decreased urinary output, or MODS if your pts has any of these symptoms... is your patient having any S&S of shock?

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