Nursing Care Plan for Sepsis

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Pathophysiology

Sepsis is essentially an overactive/uncontrolled immune response to an infection. The immune system kicks into overdrive, for whatever reason, and cannot be calmed down. It’s like someone turned the dial all the way up on the immune system and ripped the dial off the dashboard. As the healthcare team, we are trying to turn the immune response down as best we can… but it is VERY challenging. This is a very complex issue which affects many body systems, with an overall mortality rate anywhere from 27-36% (and higher in patients in intensive care settings). The challenge is that it can present with very subtle symptoms and progress quickly. Time is of the essence in sepsis recognition and treatment.

Etiology

Essentially, the cause of sepsis is the original infection. Examples include pneumonia, urinary tract infection, infection in the bloodstream (bacteremia), etc. It doesn’t have to be a bacterial infection, it can be a virus or a fungus as well.

Desired Outcome

Lessening the immune response, prevention cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build up, maximizing cardiac output and resolution of the condition.

Sepsis Nursing Care Plan

Subjective Data:

  • Pain
  • Difficulty breathing

Objective Data:

  • Elevated temp (over 101 F)
  • Low temp (below 96.8 F)
  • HR over 90
  • RR over 20
  • Respiratory distress
  • Decreasing urinary output
  • Hypotension
  • Decreasing platelet count
  • Edema
  • Hyperglycemia (no hx diabetes)
  • Altered LOC
  • Mental status changes
  • Increase in WBC, bands
  • Low SVO2
  • High lactic acid
  • Increasing creatinine

Nursing Interventions and Rationales

  • Prompt lab draws

 

  • Labs in sepsis diagnosis and treatment are very time sensitive. It is imperative the nurse is drawing labs promptly, as this evaluates the effectiveness of treatment and determines next steps.

 

  • Appropriate administration of IV antibiotics

 

  • Baseline blood cultures must be drawn prior to the initiation of antibiotics to ensure the appropriate pathogen is identified. Drawing the labs, then starting antibiotics as ordered is the nurse’s responsibility.

 

  • Optimize fluid-volume status

 

  • Patients suffering from sepsis usually require massive fluid resuscitation.

 

  • Assess, monitor, and optimize cardiac output

 

  • Cardiac output is typically compromised in sepsis. The nurse must communicate with the MD about this and how to treat it, as some may need more fluid, or vasopressors, or both. Non-invasive cardiac output monitoring (NICOM) or central venous pressure monitoring (CVP) are options.

 

  • Assess, monitor, and support oxygen status

 

  • Septic patients may need significant respiratory support, depending on severity. Oxygen delivery and utilization is severely impaired, therefore the nurse must assess frequently (ABG’s, SpO2) and work with medical team on interventions

 

  • Prevent infection

 

  • This patient already has a heightened inflammatory response, we don’t want to make it worse with another pathogen. Asepsis is KEY with all patient care but in particular the septic patient. Frequently septic patients will require a central venous catheter and foley catheter. These are invasive lines that can easily get infected but are necessary when a patient is that ill.

 

  • Assess, monitor, and manage body temp

 

  • Their body temp may be high or low, and we want to warm them if they’re too cold (increase room temp, warming blankets) or cool them if their fever is too high (antipyretic, cooling blanket, decrease room temp). Many septic patients with fluctuating body temps may have continuous temperature monitoring (via foley, rectal tube, or endotracheal tube)

 

  • Communicate with and educate patient and loved one

 

  • Sepsis is serious and scary. It is essential to educate the patient and their support system at every step of the way so they are able to let you know if they feel/act differently, if things change, and also to prevent them from unnecessarily worrying or interfering with very needed interventions.

 


References

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