NCP Sepsis / Septicimia

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.


Although severely ill patients may require admission to an intensive care unit (ICU), this plan addresses care on an inpatient acute medical-surgical unit.



Chronic obstructive pulmonary disease (COPD) and asthma

Disaster considerations

Fluid and electrolyte imbalances

Metabolic acidosis (primary base bicarbonate deficiency)


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.


May report: Fatigue, malaise

May exhibit: Mental status changes, e.g., withdrawn, lethargic

Respiration/heart rate increased with activity


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)


May exhibit: Urinary output decreased, concentrated; progressing to oliguria, anuria

Urine cloudy, malodorous


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


May report: Headache; dizziness, fainting

May exhibit: Restlessness, apprehension, confusion, disorientation, delirium/coma


May report: Abdominal tenderness, localized pain/discomfort

Generalized urticaria/pruritus


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)


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


May report: Perineal pruritus

Recent childbirth/abortion

May exhibit: Maceration of vulva, purulent vaginal drainage


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.


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.


1. Eliminate infection.
2. Support tissue perfusion/circulatory volume.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.


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.