Nursing Care Plan for Septic Shock (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 to septic shock. Time is of the essence in sepsis recognition and treatment.

Etiology

Essentially, the cause of septic shock 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 of cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build up, maximizing cardiac output and resolution of condition.

Septic Shock Nursing Care Plan

Subjective Data:

  • Pain
  • Difficulty breathing
  • Reports of s/s infection (burning with urination, frequent cough, green mucus, etc.)

Objective Data:

  • ↑ temp (over 101° F)
  • ↓ temp (below 96.8° F)
  • HR over 90 bpm
  • RR over 20 bpm
  • Respiratory distress
  • ↓ urinary output
  • Hypotension
  • ↓ platelet count
  • Edema
  • Hyperglycemia (no hx diabetes)
  • Altered LOC
  • Mental status changes
  • ↑ WBC, bands
  • ↓ SVO2
  • ↑ lactic acid
  • ↑ creatinine

Nursing Interventions and Rationales

  • Prompt lab draws
    • CBC – WBC count
    • Lactate – ↓ O2 to tissues
    • BMP – kidney function
    • ABG – shows acidosis
    • Blood Cultures

 

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.

Blood cultures must be drawn prior to the initiation of antibiotics to ensure the appropriate pathogen is identified.

 

  • Appropriate administration of IV antibiotics

 

  • Drawing the labs, then starting antibiotics as ordered is the nurse’s responsibility.
  • The goal is to initiate broad spectrum antibiotics within 1 hour of recognition of sepsis.

 

  • Optimize fluid-volume status

 

Patients suffering from sepsis usually require massive fluid resuscitation. This helps to increase their preload and therefore their cardiac output.

  • 30 mL/kg in the first 6 hours
  • 100 kg man = 3 L fluid

 

  • Assess, monitor, and optimize cardiac output
    • MAP
    • CO
    • Signs of perfusion
    • Lactic Acid

 

Cardiac output is compromised in septic shock. 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.
  • MAP should be monitored with an arterial line when administering vasopressors
  • Lactic acid levels are elevated with decreased tissue perfusion – following lactic acid levels helps to determine if therapy is being successful.

 

  • Assess, monitor, and support oxygen status
    • SpO2
    • Lung sounds
    • SOB
    • ABG

 

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. Follow CLABSI and CAUTI protocols to prevent infection

 

  • 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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Video Transcript

All right guys, let’s work through an example Nursing Care Plan for a patient with sepsis. Now remember, sepsis can have sources from all over the body. So it was really just infection that has gone a systemic and has gotten worse. So when we start talking about this hypothetical patient, we start gathering our data. We are going to stay a little bit generic here because I don’t want to focus too much on one body system. I really just want to focus on what happens if whatever infection they had goes systemic and becomes septic. So the first bit of information we’re going to see, which really could be subjective or objective, is going to be signs and symptoms of whatever that infection source is, whether it’s respiratory, urinary, whether it’s surgical, any kind of infection that they’ve got can become sepsis if it gets worse, right? So other signs of infection, we’re looking for things like increased white blood cells.

We might see an increased heart rate, increased respiratory rate, increased temperature. Now we know with Sepsis we could also see a low temperature. It’s pretty rare, but it’s definitely possible.  We’re possibly going to see maybe some like respiratory distress or shortness of breath just depending on the source, but even once you get really bad infection, you start to have some respiratory issues no matter where the source of the infection is. And then what’s the other big thing with sepsis? When we start to get really infected, we start to have fluid issues. Certain have fluid volume issues and it starts to be depleted. So we’re going to start seeing signs of that too. We might see decreased urinary output.  we might see an increased bun and creatinine. Then we’re going to see other signs of dehydration and low fluid volume. Their skin might be warm, it might be dry.

And then what’s the other problem? When you get sepsis, you have an infection, the infection goes systemic, gets worse, you end up with sepsis. What happens when the sepsis gets worse, right? What are they at risk for? Well, at that point they’re at risk for progressing all the way into septic shock, right? Signs of septic shock, decreased blood pressure. That’s actually one of the later signs of shock. We’re going to have a decreased LOC, they’re going to get really confused. We’re going to see a lactic acid start to go really high and they’re going to start having a significant perfusion issues, significant fluid volume issues.  And we’re going to start seeing that get really, really bad. So our goal here, anytime we have any kind of infection, so if you look at the pneumonia care plan, the UTI care plan, we’re talking about preventing sepsis.

Well, at this point we’ve got sepsis. Now we’ve got to prevent septic shock. Makes Sense? So we’ve gathered all of our information. There’s probably a lot of them that other information we can gather on this patient, but we’re just going to focus on the relevant information in clinical practice. When you’re doing this, that’s what you’ll do in your analyze phase and analyze. You’ll take everything you’ve got and you’ll focus just on the relevant information. So now we look at, we go, okay, what’s the problem? Well, the number one problem here is we have a systemic system wide infection that’s definitely going to cause problems all over the body. That’s a huge, huge issue here.  And again we probably have some fluid volume issues that could be improved. We could definitely give them some fluid. And the biggest problem, like I said, is really that risk for shock, that risk for septic shock.

If we don’t do something about this infection that overwhelming process that’s happening in their body is going to send them into shock. So the biggest priority here is we’ve got to treat that infection. We’ve got to treat the cause, treat the source, get rid of that source of infection so that we can prevent shock and get our patients better going home. So ask our how questions, how do we know it was a problem? This is where we just link our data, we go back and we say, well we have these signs of infection and we had these lab values change. So that’s how we know things are problem. So how are we going to address it with the kinds of things are we going to do for this patient? Well we know there’s infection happening, right? So we have to make sure we got cultures.

If we haven’t already gotten cultures, we’ve got to get cultures cause then we can start antibiotics, cultures first than antibiotics all the time. We’re probably gonna give some IV fluids. Again, when you get into Sepsis, you definitely start having some fluid volume issues for sure. What are we going to monitor? We’re gonna Monitor all of our vital signs, right? Heart rate, blood pressure, temperature, respiratory rate. All of this is going to be able to tell us how we’re doing. We’re also going to want to monitor labs. Like we set lab values, we’ve got bun and creatinine is going to tell you how our fluid status is doing. Lactate’s gonna tell us whether or not we’re shifting into septic shock, whether we’ve got some of those perfusion issues. Right. And we could also potentially monitor an ABG or a blood gas because a lot of times patients who have sepsis or developing septic shock are going to end up in some sort of metabolic acidosis usually because of the lactic acid. So definitely something we want to monitor. 

And then of course we want to monitor all of our signs and symptoms, whatever infection we had, we want to watch that, make sure that starting to get better. So again, how do I know if it’s getting better? I linked that back to my data. I say, how did I know it was a problem? Because what I need to see is those things get better. So I’m going to see decreased signs of infection. I’m going to see no progression to shock, right? I’m going to see them keep their vital signs. Everything’s going to look good. I’m going to see decreased signs of poor hydration, right? We’re going to see decreased signs of low fluid volume, or we’re going to see signs of improved fluid volume. Either way. Same thing. So again, we look back at the data. This is what told me it was a problem.

So this is how I know it’s better. Next step, translate, get it into terms that you need. Depending on how you’re using this. This might just be as simple as writing a couple of words on paper or it might be you having to use a nursing diagnosis, whatever it is. Personally, we prefer these high level nursing concepts because it helps you really generally look at what’s going on with your patient. So what do we say the number one problem was for this patient infection control, we have got to get that infection under control. Second problem, I think that risk for shock needs to be our number two priority. After treating the infection, we have to watch that blood pressure, watch that lactic acid watch for those signs of altered Loc tends to be one of the first signs that shock is developing.  So definitely watch those things.

And then again, fluid volume fluid and electrolyte balance that absolutely plays a role when it comes to sepsis and septic shock. All right, so we’ve got our top priorities, right? So what’s the last step? Get it on paper. Transcribe. This is just a way for us to linearly look, okay, this was my problem. This is how I knew it was a problem. This is what I’m going to do about it and why and what my expected outcomes are. So we set our top priorities are infection control perfusion because of that risk for shock and then fluid and electrolyte balance. So let’s go across here. Let’s see what we can link together. So signs and symptoms of the source of my infection. So whatever that was, whether it was a UTI, whether it was pneumonia,  whether it was, maybe they had some sort of wound infection that went septic.

I’m going to see evidence of that infection. I’m going to see other signs of infection like increased white blood cells, temperature, heart rate, respiratory rate, all of those things can be increased if you’ve got an infection. So what am I going to do? I’m going to get cultures, I’m going to get antibiotics and I’m going to monitor those vital signs and labs that are specific to infection. So again, we do cultures first so that we can actually identify the source of the organism. We give antibiotics to treat the infection itself. And of course we need to be able to track progression. Are they getting better? If we don’t know if they’re getting better than we don’t know if anything’s working. So what are my expected outcomes? Well, I want all of this to go away. So decreased signs and symptoms of infection. All right, so perfusion, here’s the big thing here again, is that risk for shock.

Okay. Signs and symptoms of shock, hypotension, increased lactate, altered LOC, all of those are things that can actually cause problems with perfusion or show evidence of problems with perfusion. So what am I going to do? Well, I’m going to monitor, I need to make sure I don’t see, you know, their heart rate starts to go up a little bit more or maybe even starts to fall or blood pressure starts to go down. That’s a problem. But a monitor, those labs, again, the lactate, ABG and I’m going to keep an eye on those signs of infection. I can also do a neuro exam,  and make sure that that patient is not having that altered LOC. Cause, like I said, a lot of times that’s the first thing we see. The whole goal here is to be able to identify development of shock early so that we can treat it early. Early treatment or early detection, early treatment all the time. 

So our goal is no signs and symptoms of shock. No evidence of poor perfusion. That would be our goal, that we catch things early.  Or that we treat things fast enough that we don’t actually end up with all these perfusion issues. So let’s look at fluid and electrolyte balance, signs of poor fluid balance, decreased urine output, increased bun and creatinine. And then any other signs and symptoms of fluid volume deficit. You could have dry skin, you could have dry mucous membranes, all of those things that’ll tell you that there’s a fluid volume problem. So what are we going to do? We’re going to monitor those labs and we’re probably going to give IV fluids because we really need to take them up and make sure that they have good circulating fluid volume. So again, we do labs so that we can detect these signs and symptoms and detect problems and we give a fluids because we can prevent some of those perfusion issues and address that fluid deficit, expected outcomes, no signs and symptoms of volume deficit and no development of any kind of electrolyte abnormalities.

Remember, if they go into septic shock and they end up in this lactic acidosis, they can actually end up with a high potassium to right. So we just want everything to be nice and pretty and wrapped up in a nice little bow and not have any problems with this patient. And again, the more we can monitor and and assess for those possible problems that we have like shock, the sooner we detect it, the sooner we treatment treat it and we can prevent some of those complications. 

So let’s just review your five step process. Again, this was a hypothetical patient with Sepsis as their only main issue. Remember, you’re going to get all of your assessment data in that first step. You’re going to assess everything, good, bad, ugly, indifferent, everything. Then you analyze it, you pick out what’s important. Pick out what tells you that there is a problem and choose your priorities.

Then you ask your how questions, how did I know it was a problem?  how am I going to address it? And how do I know it’s better? Again, you’re, how do I know it better? Always comes back to that assessment data, translate it, get it in the terms that you need, and then get it on paper. Use whatever form or template you prefer. You could use ours. You can use one from school. You can just literally use a blank piece of paper. Whatever works for you. Just get it on paper. All right guys, I hope that was helpful for a nursing care plan for a patient with sepsis. Remember, some of the details depend on what your source of Sepsis was, right? So make sure that you check out all of the rest of the examples within this course, as well as our nursing care plan library. Now go out and be your absolute best selves today, guys, and as always, happy nursing.

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