Sepsis is a potentially life-threatening condition that can be caused by an infection and lead to septic shock. Nurses often take on the responsibility of diagnosing and treating this ailment, but what exactly are the nursing diagnoses for sepsis? There are three primary nursing diagnoses: Impaired Gas Exchange, Impaired Skin Integrity, and Infection/Infestation. These nursing diagnoses can help identify possible causes of sepsis and provide insight into how it may develop or progress in an individual patient. For example, suppose a patient’s skin integrity is impaired due to excessive perspiration or lack of oxygenation (due to respiratory failure). In that case, they should also be considered at risk for developing infections that could lead to sepsis.
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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Nursing diagnoses are clinical judgments about specific health problems. Nursing diagnoses describe actual or potential health problems and the impact that these problems may have on a patient’s physical, emotional, psychological, and social well-being. They also help to identify the many factors which influence an individual’s response to illness or injury. Nurses use nursing diagnoses to formulate an individualized plan of care that meets each patient’s unique needs.
A nursing diagnosis statement is used to define the purpose of the intervention or treatment. It identifies the nurse’s plan for resolving the problem identified in the diagnosis and offers guidance to ensure that interventions are appropriate for the patient.
A nursing diagnosis statement is a sentence or phrase that describes the formulation of a nurse-diagnosed condition and guides the selection of nursing interventions that will result in an expected outcome (or resolution).
When a patient has developed sepsis, their temperature will typically be above 100.4 degrees F. They may also have lower than normal blood pressure or respiratory rate and exhibit confusion, anxiety, or restlessness. Their list of symptoms may also include pain in the abdomen or chest area and pale to blotchy skin.
The easiest way for nurses to diagnose sepsis early is by using a “suspected diagnosis” approach. This means that the patient’s symptoms present with signs of infection, so it is most logical to suspect they have developed sepsis.
When a patient exhibits just two or more of the following symptoms (fever, elevated heart rate, respiratory rate, respiratory distress, tachycardia, arrhythmias, or shock), they have a high chance of sepsis.
It is also important for nurses to diagnose sepsis during the early stages because treatment usually begins with administering antibiotics which can only be effective if administered early on in the progression of the illness. Early diagnosis also allows for any underlying conditions to be treated at the same time.
This is why it’s important for nurses, especially those in critical care units, to know how to diagnose and treat sepsis in its early stages.
Three primary nursing diagnoses describe sepsis and septic shock: impaired gas exchange, altered temperature regulation, and compromised skin integrity.
This will make it easier for the nurse to determine a care plan tailored to the individual patient and their condition.
To adequately treat patients who develop sepsis and provide insight into how it may develop or progress, nurses need to know the three main nursing diagnoses.
Here are a few examples of how these nursing diagnoses can be applied to help treat patients experiencing septic shock:
Impaired gas exchange diagnosis statement: “I-1. The patient’s respiratory rate has decreased, and their blood pressure has dropped. I-2. These changes are due to sepsis’s progression, which is compromising tissue perfusion and oxygenation in the lungs”.
Impaired gas exchange diagnosis statement: “I-1. The patient’s respiratory rate has decreased, and their blood pressure has dropped. I-2. These changes indicate that tissue perfusion in the lungs has been impaired”.
Altered temperature regulation diagnosis statement: “I-1. The patient’s temperature is elevated, and their skin has begun showing signs of warmth. I-2. These changes indicate that tissue perfusion in the internal organs has been compromised.”
Compromised skin integrity diagnosis statement: “I-1. The patient’s skin is a pale, mottled appearance, and they are exhibiting signs of altered temperature regulation. I-2. These changes indicate that tissue perfusion in the patient’s underlying organs has been compromised.”
The adult version of the “Suspected Diagnoses” approach is to treat any patient exhibiting signs of infection or inflammation with antibiotics and fluids. This is no different from treating a patient who may have developed sepsis–– except early intervention is crucial to prevent tissue damage from occurring and complications from developing and saving the life of the patient.
Impaired gas exchange is a very common nursing diagnosis that is given to patients who develop sepsis. An infection can cause this in the lungs since it interferes with the normal functioning of both the respiratory and cardiovascular systems. It can also interfere with blood circulation, impairing oxygenation and tissue perfusion.
Nurses need to understand that patients who develop sepsis probably have an underlying health condition that makes them susceptible to infection. Patients with immunosuppression or reduced function of the immune system are more likely to succumb to septic shock since their bodies cannot fight off the invading bacteria as effectively as a healthy person’s body would be able to.
In Pediatric patients with sepsis, the immune system has not fully developed. This causes their bodies to have weakened immune capabilities, which makes them more susceptible to infection. Children will also most likely be diagnosed before adults because their symptoms are very specific and can sometimes be subtle.
Impaired gas exchange in pediatric patients can result from a variety of different conditions. Some of these include pneumonia, respiratory failure due to an asthma attack, or a chronic lung condition.
1) Abnormal vital signs
2) Signs of infection based on patient history, physical examination, and laboratory findings
3) Biochemical findings consistent with sepsis
4) A clinical improvement after the administration of antibiotics and fluids.
Sepsis in pregnant patients is also referred to as “septicemia.” This occurs when an infection spreads through the bloodstream after traveling from one part of the body to another.
Impaired gas exchange can occur if a fetus has been infected, resulting in uterine cramping and bleeding, both of which are signs of placental infection. Suppose the mother is experiencing a high fever. In that case, this will also be detrimental to a fetus and cannot be corrected until the patient becomes afebrile (no longer running a fever).
The “Draeger Sepsis Act Early” initiative, which was created by the Draeger company and launched in 2007, can be used to help nurses identify patients who are at risk for developing sepsis and determine if they have it. This test is a portable tool that can record blood gas analysis measures such as oxygen levels, carbon dioxide levels, and respiratory rates.
The test can also be used to measure blood pressure, temperature, pulse oximetry levels (which indicates how much oxygen a patient is receiving), heart rate, and perfusion index (a measurement of cardiac output).
In the first few days of life, sepsis can result from bacterial colonization in a neonatal patient’s lungs or umbilical cord. This type of infection is usually caused by staphylococcus or streptococcus and will likely cause dissemination throughout the baby’s body unless it is diagnosed and treated right away.
– Umbilical cord blood culture. The infant’s specimen will then be tested for hemolysis and elevated nitric oxide levels to determine the type of infection which is more likely to cause neonatal sepsis.
If a patient exhibits any of the following signs or symptoms, they may be suffering from sepsis. They should immediately seek medical attention to prevent organ damage or death:
– Fever (if the temperature is over 103˚F)
– Decreased alertness, lethargy, confusion
– Difficulty breathing or shortness of breath
– Labored breathing
– Abdominal pain
– Decreased urine output – cold and clammy skin; pale and cool to the touch (cyanosis)
In addition to these symptoms, a patient may also experience organ dysfunction as a result of sepsis:
– Decreased blood pressure
– Low heart rate
– Low respiratory rate
– Cold and clammy skin
– Rapid breathing (tachypnea)
– Thoroughly clean any open wounds, especially if there is any risk or exposure to MRSA
– Wash your hands before and after administering any medical care; using an alcohol-based hand sanitizer is also recommended
– If you discover that you have contracted a bacterial infection, don’t delay in seeking medical attention because the longer you wait after the initial onset of symptoms to treat the condition, the more damage will be done to your body
– If you have diabetes, take care not to injure or infect any open wounds that may appear on your body
– Vaccination to prevent infections caused by Streptococcus, Neisseria meningitides (meningitis), and Haemophilus influenzae
– Early treatment of respiratory tract infections, such as croup, bronchiolitis, or pneumonia
– Prompt immunization to ward off pneumococcal infections
– Monitoring for fever and infections to prevent diphtheria, tetanus, or rubella
If a person exhibits any of the following five symptoms, then sepsis may be considered:
1. Temperature greater than or equal to 38.3°C (101°F) OR less than 36°C (96.8°F)
2. Heart rate greater than 90 beats per minute
3. Respiratory rate greater than 20 breaths per minute
4. Leukocyte count less than 4,000/mcL OR greater than 12,000/mcL
5. White blood cell count less than 4000/mcL OR greater than 12,000/mcL AND any of the following:
-The patient is hypothermic (low body temperature)
-The patient is hypotensive (low blood pressure), with systolic arterial pressure less than 90 mm Hg
The following physical findings may also be observed:
1. Absence of bowel sounds (or hypoactive bowel sounds)
2. Decreased urine output or dark, tea-colored urine
3. Fever (often steadily rising)
4. Hypotension (low blood pressure), with systolic arterial pressure less than 90 mm Hg
5. Jaundice or bleeding from the IV site
6. Marked pallor or cyanosis (bluish discoloration of the patient’s skin, lips, or nail beds) in patients with circulatory shock
7. Rapid respiratory rate (more than 20 breaths per minute) and dyspnea (shortness of breath)
8. Tachycardia (rapid heart rate)
9. Tachypnea (rapid breathing, more than 20 breaths per minute)
-Bacterial infections, virus or viral infections, fungal infection, and parasitic infection. When any of these infective agents enter the bloodstream and attack the human body in some way/form, it can lead to sepsis. The typical infectious agents include Escherichia coli, Staphylococcus aureus, Streptococcus pneumonia, and Klebsiella species.
Some of the common risk factors or causes that may lead to sepsis can include:
1. Age greater than 65 years old
2. Being in a hospital or long-term care facility
3. Recent surgery, especially abdominal surgery (for example, having a tube put into the abdomen)
4. Heart failure or chronic lung diseases such as emphysema, COPD, and asthma
5. History of alcohol abuse or drug addiction. 6. History of chronic kidney disease
7. History of diabetes
8. Immunosuppression such as HIV, AIDS, or taking medications that may affect the immune system (such as cancer chemotherapy)
9. Recent viral infections such as flu or chickenpox, especially in children and infants
10. Severe burns or sunburns, especially of the skin covering the face, hands, and arms (known as a full-thickness burn)
11. Shock or severe blood loss
12. Severe sepsis in the past, such as having had it before OR you’d been diagnosed with it in the hospital within one to two weeks before being evaluated for it now
13. Surgical wounds and intubations, especially within the last year (and that’s especially true if you’re in the hospital for a long time)
14. Use of urinary catheter or a feeding tube, especially within the last year
15. Weakened immune system, such as having had an organ transplant or being on medications to suppress your immune system because of cancer treatment
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Some of the common types of sepsis include:
1. Bloodstream infections: This includes the most severe type called septic shock, which is a life-threatening condition in which your blood pressure drops too low and the circulatory system (blood vessels, heart) can’t circulate enough oxygen to tissues
2. Skin and soft tissue infections: This includes cases in which your body’s skin or soft tissues become infected
3. Pneumonia: Pneumonia is a breathing condition in which the lungs become inflamed, filled with mucus, and hard to breathe normally
From the Health & Wellness Tracking Assessment and Teaching Planner, this care plan allows educators to track a student’s progress in completing the required nursing/health assessments and interventions to provide safe health care to neonatal patients in an acute care hospital setting. Helps students learn to assess and plan care that fosters optimal neonatal outcomes.
The Care Plan provides a template for generic protocols used in measuring clinical outcomes and documentation of patient assessment data related to neonatal sepsis.
Nursing students must understand how protocols are used by physicians, nurses, and patients as a guide for treating pediatric basic procedures or illnesses. The care plan focuses on infant and maternal needs when delivering safe care to newborns. It includes newborn assessment forms and related nursing care protocols used for therapeutic drug monitoring.
The template is customizable in terms of medications, medical equipment, laboratory tests, and diagnostic procedures to suit your students’ clinical setting needs. It can be modified as needed to reflect local care patterns or patient populations. The Neonatal Sepsis Care Plan includes assessment checklists for special care needs of newborns, formulas to determine drug dosages based on the patient’s weight (i.e., dosing calculations), and guidelines related to determining the stage of labor and patient admission status.
Sepsis can occur anywhere from a few hours to 72 hours after exposure. After this period, identifying the cause and treatment may be difficult because many signs are also present in the person’s normal state.
About 3% to 5% of people with sepsis die from the infection. About another 20% or more may have long-term complications, such as organ damage or disability. These most frequently include brain damage, kidney disease, and lung problems. Risk factors for developing these complications include age greater than 65 (older people are more likely to have such complications); a low albumin level in the blood; and an infection that follows surgery.
If sepsis is suspected, treatment may begin while test results are being found. Toxins produced by bacteria in the bloodstream (septicemia) can be reduced by antibiotics, intravenous fluids, and sometimes oxygen given through a tube inserted into the windpipe.
Surgical techniques may also be used to remove infected tissue from affected organs or to repair damaged tissue. In addition, a central line may be inserted into the large vein in the neck to give antibiotics and other medications as needed through a tube that runs directly into the heart or bloodstream.