Find out what sepsis and sepsis shock are. Learn about nursing care plans and interventions for sepsis. Understand nursing diagnoses, including the use of NANDA.
Updated: 11/21/2023
Sepsis | Diagnosis, Intervention & Protocols
Table of Contents
- What are Sepsis and Septic Shock?
- Early Sepsis Symptoms
- Advanced Sepsis Symptoms
- What are Nursing Interventions for Sepsis?
- Nursing Care Plans for Sepsis Patients
- Nursing Protocols for Sepsis Patients
- Lesson Summary
Frequently Asked Questions
What is an example of a nursing diagnosis?
A nursing diagnosis is a clinical determination or judgment about how a patient is responding to a health condition. Some examples of a nursing diagnosis for sepsis include risk for shock, risk for impaired gas exchange, and hyperthermia.
What are some interventions for sepsis?
There are several possible interventions for sepsis. These interventions include giving a tepid bath, providing a cooling blanket, administering IV fluids, giving antipyretics, and providing perineal care.
What is a NANDA-accepted nursing diagnosis?
A NANDA-accepted nursing diagnosis is: Hyperthermia related to sepsis secondary to third-degree burns as evidenced by a temperature of 101.9 degrees Fahrenheit, constantly sweaty skin, rapid heart rate, and low blood pressure. Hyperthermia refers to a body temperature that is significantly above normal levels.
Table of Contents
- What are Sepsis and Septic Shock?
- Early Sepsis Symptoms
- Advanced Sepsis Symptoms
- What are Nursing Interventions for Sepsis?
- Nursing Care Plans for Sepsis Patients
- Nursing Protocols for Sepsis Patients
- Lesson Summary
This lesson will cover information about how nurses should diagnose sepsis. Specifically, this lesson will provide information about the nursing diagnosis for septic shock, the nursing care plan for sepsis, and a septic shock nursing diagnosis.
Sepsis is a very serious, potentially life-threatening condition in which the body responds to an infection by damaging its own tissues. Normally, when a person has an infection, the immune system responds by releasing a type of protein known as cytokines. Cytokines function to regulate and control the immune system. When a person has an infection, cytokines instruct the immune system to destroy the microorganisms that caused the infection while not harming the normal, healthy tissues of the body.
However, during sepsis, cytokines do not function properly, and the body responds to an infection with a systemic immune response. A systemic immune response refers to when the immune system starts to attack the entire body including normal, healthy tissues. Sepsis has a high mortality rate with nonspecific symptoms. There are three stages of sepsis:
| Stage of Sepsis | Description |
|---|---|
| Stage 1: Sepsis | During stage 1, an infection gets into the bloodstream and spreads to other parts of the body causing widespread inflammation. |
| Stage 2: Severe Sepsis | Severe sepsis occurs when the infection becomes worse and starts to impact and damage the organs of the body. |
| Stage 3: Septic Shock | Septic shock occurs when the infection becomes very serious and widespread which leads to organ failure, hypotension (low blood pressure), hypoperfusion (low blood flow), and possibly death. |
Who is at Risk for Sepsis?
There are several groups of people who are most susceptible to sepsis. These groups include:
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- Seniors: The immune system of an elderly patient can be slower and less effective, which can lead to a higher risk of serious infections.
- Young kids: The immune system of young kids may not be developed enough to properly fight off various types of infections.
- Chronically ill: Chronic illnesses are very taxing on the body and immune system, which puts people with chronic illnesses at higher risk for serious infections.
- Immunosuppressive conditions patients: Immunosuppressive conditions refer to conditions that decrease or impair the immune system, and they include cancer, HIV/AIDS, pneumonia, and organ transplants. If the immune system is decreased or impaired, the body is more susceptible to infection and sepsis.
- Patients exposed to invasive devices: Invasive devices refer to medical equipment that is inserted directly into a blood vessel or airways such as an intravenous (IV) catheter or breathing tube. Equipment that is inserted directly into a blood vessel or airways increases the opportunity for microorganisms to enter the body and cause an infection.
How is Sepsis Diagnosed?
The North American Nursing Diagnosis Association (NANDA) is an organization that develops a list of official nursing diagnoses. A nursing diagnosis is a clinical determination or judgment about how a patient is responding to a health condition. Some NANDA nursing diagnoses for sepsis include:
- Risk for shock: Shock is a life-threatening medical condition caused by a drop in blood pressure and/or blood volume. Since a drop in blood pressure and blood volume are both symptoms of sepsis, patients with sepsis are at risk for shock.
- Risk for impaired gas exchange: Gas exchange in the body depends on proper blood flow. The blood exchanges oxygen for carbon dioxide with the lungs. Since sepsis is associated with reduced blood volume and blood pressure, it can also impair gas exchange between the blood and the lungs.
- Hyperthermia: Hyperthermia is a condition in which the body's temperature increases significantly above normal levels, and patients with sepsis are at increased risk of hyperthermia.
An example of a NANDA-accepted nursing diagnosis is Hyperthermia related to sepsis secondary to third-degree burns as evidenced by a temperature of 101.9 degrees Fahrenheit, constantly sweaty skin, rapid heart rate, and low blood pressure.
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Nurses have a pivotal role in the early identification of sepsis. Early symptoms of sepsis include:
- Fever (temperature above 100.4 degrees Fahrenheit)
- Rapid pulse (heart rate above 100 beats per minute)
- Rapid breathing (more than 20 breaths per minute)
- Unusual sweating
- Confusion
- White blood cell count over 12,000
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Symptoms of advanced sepsis include:
- Abrupt mental changes
- Difficulty breathing
- Abdominal pain
- Decreased urine output
- Decreased platelets
- Severe weakness
- Bluish color of skin
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A nursing intervention refers to the actions a nurse will perform to take care of their patient, and these actions include treatments, medical procedures, and educating the patient. Nursing interventions for sepsis include:
- Timely identification by monitoring vital signs and spotting abnormalities
- Enactment of protocols
- Provision of prescribed treatment measures
- Reporting the patient's responses to treatment
It should be noted that nurses are not responsible for ordering medications used to treat sepsis. Doctors are responsible for ordering the medications, and nurses are responsible for administering the medications to the patients.
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Nursing care plans and nursing interventions are used interchangeably. Additional nursing sepsis care plans include:
- Tepid baths: A tepid bath refers to baths with water that is slightly lower than the body's temperature, and they can be used for patients who have hyperthermia.
- Giving antipyretics: Antipyretics are medications that function to reduce a person's temperature.
- Cooling blankets: A cooling blanket can be used for sepsis patients who have hyperthermia.
- IV fluids: IV fluids can be used to increase blood volume and blood pressure.
- Aseptic techniques: Aseptic techniques refer to procedures that reduce the transmission of infectious microorganisms such as sterilizing surgical equipment.
- Perineal care: Perineal care refers to keeping the rectal and genital areas clean. This type of care is important for preventing infections and maintaining the comfort of a patient.
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A nursing protocol refers to a standard set of nursing procedures used to treat a specific condition. Examples of sepsis protocols for nursing include:
- Obtain labs for serum lactate levels and blood cultures within three hours of positive sepsis assessment
- Administer broad-spectrum antibiotics within one hour of positive sepsis assessment
- Start IV fluid bolus within one hour of positive sepsis assessment and complete this IV bolus within three hours of positive sepsis assessment
Following standard protocols for nursing sepsis is key to increasing the likelihood of patient survival. If nurses can detect sepsis early and make a timely intervention, they can prevent clinical deterioration.
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Sepsis is a life-threatening condition in which the immune system responds to an infection by damaging the body's healthy, normal tissues, and it requires early and aggressive treatment. There are three stages of sepsis which include sepsis, severe sepsis, and septic shock. A nursing diagnosis for sepsis includes risk for shock, risk for impaired gas exchange, and hyperthermia. People who are at increased risk for sepsis include young children, seniors, immunosuppressed conditions (ex: cancer and pneumonia), and patients exposed to invasive devices. Symptoms of sepsis include fever (temperature over 100.4), hypotension, hypoperfusion, rapid pulse (heart rate above 100), rapid breathing (more than 20 breaths per minute), mental changes, severe weakness, bluish skin, and white blood cell count above 12,000.
A nursing intervention and a nursing care plan for sepsis include monitoring vital signs, giving a tepid bath, providing a cooling blanket, administering IV fluids, giving antipyretics, and giving perineal care. Nursing protocols refer to a standard set of nursing procedures used for a specific condition, and nursing protocols for sepsis include obtaining serum lactate levels and blood cultures, giving IV fluids, and administering antibiotics. Nurses do not order medications used to treat sepsis. Doctors order these medications, and nurses administer the medication.
Medical Disclaimer: The information on this site is for your information only and is not a substitute for professional medical advice.
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Additional Info
A Serious Illness
Amanda is a new graduate nurse who has reported for duty on her first day at her new job in the intensive care unit. She is assigned to train with Donna, a registered nurse with over fifteen years of experience. They get reports in the morning and sit down to plan their day. One of the patients in their assignment is Dan, a 43-year-old gentleman who was admitted for sepsis after a cut he sustained at work became infected. Amanda wonders how a simple cut could lead to Dan's being admitted to the intensive care unit. Let's discuss what happened to land Dan in this condition.
What Is Sepsis?
Sepsis is the body's devastating response to an infection, and it can be life-threatening as the chemicals the body uses to fight the infection provoke severe reactions in the body itself. Sepsis can happen quickly and if left untreated or not treated in a timely manner, it may lead to tissue damage, organ failure, and even death. There are over a million diagnoses of sepsis each year in the United States, and it kills just over 250,000 people annually. Although anyone can develop sepsis, the very young, very old, and immune-compromised are at the highest risk.
Signs and symptoms of sepsis include:
- Fever
- Chills
- Elevated heart rate (over 100 beats per minute)
- Fast breathing (over 20 breaths per minute)
- Nausea, vomiting, or diarrhea
- Muscle aches
- Poor appetite
- Fatigue
- Recent or current infection
The most important sign is the presence of a current or recent infection. These signs and symptoms can also be related to other healthcare conditions; thus, it is important to determine if infection is present or was recently present.
Diagnosis and Treatment of Sepsis
Sepsis can be broken down into three stages: sepsis, severe sepsis, and septic shock. When left untreated or undertreated, sepsis can develop into septic shock, the most severe and deadly stage of sepsis. A fourth stage that is sometimes included in the sepsis cascade is systemic inflammatory response syndrome (SIRS). SIRS, like sepsis, is the body's response to an insult; however, SIRS may develop secondary to trauma, ischemia or inflammation, as well as infection. Determination of the stage of sepsis depends on the symptoms that are present.
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Donna tells Amanda how important their nursing assessment is in identifying sepsis as early as possible. Donna teaches her about each stage of sepsis and stresses the importance of notifying the physician as soon as sepsis is suspected so that treatment can begin. Amanda is starting to put the pieces together to better understand Dan's illness. She asks Donna what treatment for sepsis may include.
Donna begins to explain the treatment process. Treatment for sepsis must begin as early as possible and should be aggressive to avoid progression of the condition or organ damage. Treatment is multi-factorial and several elements must often occur concurrently to ensure that every component is timely. Current sepsis treatment guidelines recommend:
- Drawing blood cultures and lactate level within three hours of sepsis identification.
- Administering broad spectrum antibiotics within three hours of sepsis identification.
- If the blood pressure is low or lactate level elevated, administering intravenous fluids (at least 30 mL/kg).
- If blood pressure remains low after fluids, beginning intravenous vasopressor (blood pressure support) therapy.
- Ongoing monitoring and treatment of symptoms to maintain blood pressure and tissue perfusion.
Donna stresses the importance of these tasks because they are all actions carried out by the nurse, although they require physician orders. Nurses are also responsible for:
- Helping to identify signs and symptoms of sepsis early.
- Notifying the physician as soon as sepsis is suspected.
- Anticipating orders for treatment and preparing to draw labs and immediately administer ordered medications.
- Assessing the patient frequently to identify any signs of progression of sepsis or organ dysfunction.
- Monitoring the patient's responses to treatment, and again notifying the physician if treatments are not effective.
- Collaborating and communicating with practitioners in other healthcare disciplines (such as respiratory therapy and lab personnel) to ensure that all of the patient's needs are being met in a timely manner.
Amanda now feels well prepared to care for Dan and begins her shift.
Lesson Summary
Sepsis is the body's severe reaction to an infection, and it can be categorized as one of three stages: sepsis, severe sepsis, and septic shock. SIRS is sometimes grouped with sepsis because it can be a predecessor; however SIRS is not only caused by infection, but can be caused by trauma, inflammation, or ischemia as well. Competent and timely nursing care is essential in helping to prevent progression of the condition from sepsis to severe sepsis or septic shock. Many people who develop sepsis will recover completely, but others may suffer from chronic complications related to tissue or organ damage. Early, aggressive treatment is vital in preventing long-term complications related to sepsis. Nurses play a critical role in the identification, treatment and ongoing care of patients who suffer from sepsis.
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Sepsis | Diagnosis, Intervention & Protocols
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