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.
Updated:
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
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!
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.
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
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?
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...
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:
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 SepsisAlthough 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:
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
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 SepsisThere 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.
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.
TreatmentTreatment 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:
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
Nursing Care Plans for SepsisNursing 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
Care Plan Goals and Expected Outcomes
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
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
Care Plan Goals and Expected Outcomes
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
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
Nursing Interventions and Rationale
Next Gen NCLEX Review Questions with RationalesReview 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:
Vital signs on admission: Temperature 39.0 C, Heart rate 113, Respirations 24, Blood pressure 113/76, O2 Sat 89%
Answer
AnecdotalThe 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.
ConclusionFrom 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:
References
Mahapatra, S., & Heffner, A.C. (2022, June 21). Septic shock. StatPearls. Retrieved February 21, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK430939/
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
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
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
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
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.
Gulanick, M., & Myers, J.L. (201o). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby.
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
About Wendy Sutas, BSN, RN
Share this post
Share on other sites