Sepsis is a syndrome characterized by clinical signs and symptoms of severe infection that may progress to septicemia and septic shock. Septicemia implies the presence of an infection of the blood caused by rapidly multiplying microorganisms or their toxins, which can result in profound physiological changes and systemic sepsis. The pathogens can be bacteria, fungi, viruses, or rickettsiae. The most common causes of septicemia are Gram-negative bacteria (and endotoxins), staphylococci, and Candida. If the defense system of the body is not effective in controlling the invading microorganisms, septic shock may result, characterized by altered hemodynamics, impaired cellular function, and multiple system failure.
Patients at highest risk for bacteremia and septic shock include the elderly, infants, and immunosuppressed patients with chronic diseases (e.g., diabetes); postoperative patients; and those with ventilators, invasive lines, and catheters.
Early signs and symptoms may be vague, and sepsis can develop subtly until sudden, overwhelming septic shock is present, affecting multiple organ systems.
CARE SETTING
Although severely ill patients may require admission to an intensive care unit (ICU), this plan addresses care on an inpatient acute medical-surgical unit.
RELATED CONCERNS
AIDS
Chronic obstructive pulmonary disease (COPD) and asthma
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Peritonitis
Pneumonia, microbial
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Renal Failure: Acute
Surgical Intervention
Total nutritional support: parenteral/enteral feeding
Ventilatory assistance (mechanical)
Patient Assessment Database
Data depend on the type, location, duration of the infective process and organ involvement.
ACTIVITY/REST
May report: Fatigue, malaise
May exhibit: Mental status changes, e.g., withdrawn, lethargic
Respiration/heart rate increased with activity
CIRCULATION
May exhibit: Blood pressure (BP) normal/slightly low-normal range (as long as cardiac output remains elevated); profound hypotension (late stage)
Peripheral pulses bounding, rapid (hyperdynamic phase); weak/thready/easily obliterated, extreme tachycardia (shock)
Heart sounds: Dysrhythmias and development of S3 suggest myocardial dysfunction, effects of acidosis/electrolyte imbalance Skin warm, dry, flushed (vasodilation); or pale, cold, clammy, mottled (vasoconstriction)
ELIMINATION
May exhibit: Urinary output decreased, concentrated; progressing to oliguria, anuria
Urine cloudy, malodorous
FOOD/FLUID
May report: Loss of appetite; nausea/vomiting
May exhibit: Weight loss, decreased subcutaneous fat/muscle mass (malnutrition)
Diminished/absent bowel sounds
Extremity and generalized edema
NEUROSENSORY
May report: Headache; dizziness, fainting
May exhibit: Restlessness, apprehension, confusion, disorientation, delirium/coma
PAIN/DISCOMFORT
May report: Abdominal tenderness, localized pain/discomfort
Generalized urticaria/pruritus
RESPIRATION
May report: Shortness of breath
May exhibit: Tachypnea with decreased respiratory depth, dyspnea; rapid labored respirations
Basilar crackles, rhonchi, wheezes (presence of pneumonia; developing pulmonary complications/onset of cardiac decompensation)
SAFETY
May report: History of recent/current infection, viral illness; cancer therapies, use of corticosteroids/other immunosuppressant medications
May exhibit: Temperature: Usually elevated (101°F or higher) but may be normal in elderly or compromised patient; occasionally subnormal (lower than 98.6°F)
Shaking chills
Poor/delayed wound healing, purulent drainage, localized erythema
Mascular erythematous rash, petechiae; oozing/bleeding from invasive line sites, wounds, mucous membranes
SEXUALITY
May report: Perineal pruritus
Recent childbirth/abortion
May exhibit: Maceration of vulva, purulent vaginal drainage
TEACHING/LEARNING
May report: Chronic/debilitating health problems, e.g., liver, renal, cardiac disease; cancer, diabetes mellitus (DM), alcoholism
History of splenectomy
Recent surgery/invasive procedures, traumatic wounds
Antibiotic use (recent or long-term)
Discharge plan
DRG projected mean length of inpatient stay: 5.5 days
May require assistance with wound care/supplies, treatments, self-care and homemaker tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Cultures (wound, sputum, urine, blood): May identify organism(s) causing the sepsis. Sensitivity determines most effective drug choices. Catheter/intravascular line tips may need to be removed and cultured if the portal of entry is unknown. Note: Diagnosis does not require positive blood cultures because up to 40% of patients who develop septic shock do not display an identified bacterium by culture.
Complete blood count (CBC): Hematocrit (Hct) level may be elevated in hypovolemic states because of hemoconcentration. Leukopenia (decreased white blood cells [WBCs]) occurs early, followed by a rebound leukocytosis (15,000–30,000) with increased bands (shift to the left), indicating rapid production of immature WBCs. Neutrophils (also called granulocytes, polys, or polymorphonuclear neutrophils [PMNs]) may be elevated or depressed. Counts below 500/mL indicate immune system exhaustion.
Serum electrolytes: Various imbalances may occur because of acidosis, fluid shifts, and altered renal function.
Clotting studies:
Platelets: Decreased levels (thrombocytopenia) can occur because of platelet aggregation.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): May be prolonged, indicating coagulopathy associated with liver ischemia, circulating toxins, shock state.
Serum lactate: Elevated in metabolic acidosis, liver dysfunction, shock.
Serum glucose: Hyperglycemia occurs, reflecting gluconeogenesis and glycogenolysis in the liver in response to cellular starvation/ alteration in metabolism.
Blood urea nitrogen (BUN)/Creatinine (Cr): Increased levels are associated with dehydration, renal impairment/failure, and liver dysfunction/failure.
Arterial blood gases (ABGs): Respiratory alkalosis and hypoxemia may occur early. In later states, hypoxemia, respiratory acidosis, lactic and metabolic acidosis occur because of failure of compensatory mechanisms.
Urinalysis: Presence of WBCs/bacteria suggests infection. Protein and red blood cells (RBCs) are often present.
X-rays: Abdominal and lower chest films indicating free air in the abdomen may suggest infection due to perforated abdominal/ pelvic organ.
Electrocardiogram (ECG): May show ST-segment and T-wave changes and dysrhythmia resembling myocardial infarction.
NURSING PRIORITIES
1. Eliminate infection.
2. Support tissue perfusion/circulatory volume.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
1. Infection eliminated/controlled.
2. Homeostasis maintained.
3. Complications prevented/minimized.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
Patients at highest risk for bacteremia and septic shock include the elderly, infants, and immunosuppressed patients with chronic diseases (e.g., diabetes); postoperative patients; and those with ventilators, invasive lines, and catheters.
Early signs and symptoms may be vague, and sepsis can develop subtly until sudden, overwhelming septic shock is present, affecting multiple organ systems.
CARE SETTING
Although severely ill patients may require admission to an intensive care unit (ICU), this plan addresses care on an inpatient acute medical-surgical unit.
RELATED CONCERNS
AIDS
Chronic obstructive pulmonary disease (COPD) and asthma
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Peritonitis
Pneumonia, microbial
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Renal Failure: Acute
Surgical Intervention
Total nutritional support: parenteral/enteral feeding
Ventilatory assistance (mechanical)
Patient Assessment Database
Data depend on the type, location, duration of the infective process and organ involvement.
ACTIVITY/REST
May report: Fatigue, malaise
May exhibit: Mental status changes, e.g., withdrawn, lethargic
Respiration/heart rate increased with activity
CIRCULATION
May exhibit: Blood pressure (BP) normal/slightly low-normal range (as long as cardiac output remains elevated); profound hypotension (late stage)
Peripheral pulses bounding, rapid (hyperdynamic phase); weak/thready/easily obliterated, extreme tachycardia (shock)
Heart sounds: Dysrhythmias and development of S3 suggest myocardial dysfunction, effects of acidosis/electrolyte imbalance Skin warm, dry, flushed (vasodilation); or pale, cold, clammy, mottled (vasoconstriction)
ELIMINATION
May exhibit: Urinary output decreased, concentrated; progressing to oliguria, anuria
Urine cloudy, malodorous
FOOD/FLUID
May report: Loss of appetite; nausea/vomiting
May exhibit: Weight loss, decreased subcutaneous fat/muscle mass (malnutrition)
Diminished/absent bowel sounds
Extremity and generalized edema
NEUROSENSORY
May report: Headache; dizziness, fainting
May exhibit: Restlessness, apprehension, confusion, disorientation, delirium/coma
PAIN/DISCOMFORT
May report: Abdominal tenderness, localized pain/discomfort
Generalized urticaria/pruritus
RESPIRATION
May report: Shortness of breath
May exhibit: Tachypnea with decreased respiratory depth, dyspnea; rapid labored respirations
Basilar crackles, rhonchi, wheezes (presence of pneumonia; developing pulmonary complications/onset of cardiac decompensation)
SAFETY
May report: History of recent/current infection, viral illness; cancer therapies, use of corticosteroids/other immunosuppressant medications
May exhibit: Temperature: Usually elevated (101°F or higher) but may be normal in elderly or compromised patient; occasionally subnormal (lower than 98.6°F)
Shaking chills
Poor/delayed wound healing, purulent drainage, localized erythema
Mascular erythematous rash, petechiae; oozing/bleeding from invasive line sites, wounds, mucous membranes
SEXUALITY
May report: Perineal pruritus
Recent childbirth/abortion
May exhibit: Maceration of vulva, purulent vaginal drainage
TEACHING/LEARNING
May report: Chronic/debilitating health problems, e.g., liver, renal, cardiac disease; cancer, diabetes mellitus (DM), alcoholism
History of splenectomy
Recent surgery/invasive procedures, traumatic wounds
Antibiotic use (recent or long-term)
Discharge plan
DRG projected mean length of inpatient stay: 5.5 days
May require assistance with wound care/supplies, treatments, self-care and homemaker tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Cultures (wound, sputum, urine, blood): May identify organism(s) causing the sepsis. Sensitivity determines most effective drug choices. Catheter/intravascular line tips may need to be removed and cultured if the portal of entry is unknown. Note: Diagnosis does not require positive blood cultures because up to 40% of patients who develop septic shock do not display an identified bacterium by culture.
Complete blood count (CBC): Hematocrit (Hct) level may be elevated in hypovolemic states because of hemoconcentration. Leukopenia (decreased white blood cells [WBCs]) occurs early, followed by a rebound leukocytosis (15,000–30,000) with increased bands (shift to the left), indicating rapid production of immature WBCs. Neutrophils (also called granulocytes, polys, or polymorphonuclear neutrophils [PMNs]) may be elevated or depressed. Counts below 500/mL indicate immune system exhaustion.
Serum electrolytes: Various imbalances may occur because of acidosis, fluid shifts, and altered renal function.
Clotting studies:
Platelets: Decreased levels (thrombocytopenia) can occur because of platelet aggregation.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): May be prolonged, indicating coagulopathy associated with liver ischemia, circulating toxins, shock state.
Serum lactate: Elevated in metabolic acidosis, liver dysfunction, shock.
Serum glucose: Hyperglycemia occurs, reflecting gluconeogenesis and glycogenolysis in the liver in response to cellular starvation/ alteration in metabolism.
Blood urea nitrogen (BUN)/Creatinine (Cr): Increased levels are associated with dehydration, renal impairment/failure, and liver dysfunction/failure.
Arterial blood gases (ABGs): Respiratory alkalosis and hypoxemia may occur early. In later states, hypoxemia, respiratory acidosis, lactic and metabolic acidosis occur because of failure of compensatory mechanisms.
Urinalysis: Presence of WBCs/bacteria suggests infection. Protein and red blood cells (RBCs) are often present.
X-rays: Abdominal and lower chest films indicating free air in the abdomen may suggest infection due to perforated abdominal/ pelvic organ.
Electrocardiogram (ECG): May show ST-segment and T-wave changes and dysrhythmia resembling myocardial infarction.
NURSING PRIORITIES
1. Eliminate infection.
2. Support tissue perfusion/circulatory volume.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
1. Infection eliminated/controlled.
2. Homeostasis maintained.
3. Complications prevented/minimized.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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