Sepsis and Septic Shock modul

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Contents

Sepsis and Septic Shock ........................................................................................................................ 4
Pathophysiology ...................................................................................................................................... 4
Epidemiology........................................................................................................................................... 4
Causes .................................................................................................................................................... 4
Clinical Manifestations ............................................................................................................................ 5
Prevention ............................................................................................................................................... 5
Complications.......................................................................................................................................... 5
Assessment and Diagnostic Findings ..................................................................................................... 5
Medical Management.............................................................................................................................. 6
Nursing Management.............................................................................................................................. 6
Nursing Assessment ............................................................................................................................... 6
Diagnosis................................................................................................................................................. 6
Planning & Goals .................................................................................................................................... 6
Nursing Interventions .............................................................................................................................. 6
Evaluation................................................................................................................................................ 7
Discharge and Home Care Guidelines ................................................................................................... 7
Documentation Guidelines ...................................................................................................................... 7
Sepsis Nursing Care Plans ..................................................................................................................... 8
Nursing Care Plans ................................................................................................................................. 8
Risk For Infection .................................................................................................................................... 8

Nursing Diagnosis ............................................................................................................................... 8
Risk factors.......................................................................................................................................... 8
Possibly evidenced by......................................................................................................................... 8
Desired Outcomes .............................................................................................................................. 8
Risk For Shock ...................................................................................................................................... 11
Risk factors........................................................................................................................................ 11
Possibly evidenced by....................................................................................................................... 11
Desired Outcomes ............................................................................................................................ 11
Risk For Impaired Gas Exchange ......................................................................................................... 15
Nursing Diagnosis ............................................................................................................................. 15
Risk factors........................................................................................................................................ 15
Possibly evidenced by....................................................................................................................... 15
Desired Outcomes ............................................................................................................................ 15
Risk For Deficient Fluid Volume............................................................................................................ 17
Nursing Diagnosis ............................................................................................................................. 17
Risk factors........................................................................................................................................ 17
Possibly evidenced by....................................................................................................................... 17

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Desired Outcomes ............................................................................................................................ 17
Hyperthermia......................................................................................................................................... 19

Nursing Diagnosis ............................................................................................................................. 19
May be related to .............................................................................................................................. 19
Possibly evidenced by....................................................................................................................... 19
Desired Outcomes ............................................................................................................................ 19
Deficient Knowledge ............................................................................................................................. 21
Nursing Diagnosis ............................................................................................................................. 21
May be related to .............................................................................................................................. 21
Possibly evidenced by....................................................................................................................... 21
Desired Outcomes ............................................................................................................................ 21

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Sepsis and Septic Shock
One of the most common types of circulatory shock and the incidences of this disease
continue to rise despite the technology.

• Sepsis is a systemic response to infection. It is manifested by two or more
of the SIRS (Systemic Inflammatory Response Syndrome) criteria as a
consequence of documented or presumed infection.

• Septic shock is associated with sepsis. It is characterized by symptoms of
sepsis plus hypotension and hypoperfusion despite adequate fluid volume
replacement.

Pathophysiology
The pathophysiology of sepsis involves an evolving process. The following shows the
process of how sepsis works its way inside of our body.

1. Microorganisms invade the body tissues and in turn, patients exhibit an
immune response.

2. The immune response provokes the activation of biochemical cytokines and
mediators associated with an inflammatory response.

3. Increased capillary permeability and vasodilation interrupt the body’s ability to
provide adequate perfusion, oxygen, and nutrients to the tissues and cells.

4. Proinflammatory and anti-inflammatory cytokines released during the
inflammatory response and activates the coagulation system that forms clots
whether or not there is bleeding.

5. The imbalance of the inflammatory response and the clotting and fibrinolysis
cascades are critical elements of the physiologic progression of sepsis in
affected patients.

Epidemiology
Sepsis has affected a lot of people in the United States and around the world as well. The
rise in the numbers of those affected with sepsis is alarming and should be given utmost
attention.

• Annually, an estimated 750, 000 people in the United States are affected by
sepsis.

• By 2010, the rate may increase up to 1 million cases every year.
• Elderly patients are at most risk for developing sepsis because of decreased

physiologic reserves and an aging immune system.
• Gram-positive bacteria accounts for 50% of cases of septic shock.
• It is also estimated that 20% to 30% with severe sepsis may never identify the

site of infection.

Causes
There are several factors that can put the patient at risk for septic shock, and these include:

• Patients with immunosuppression have greater chances of acquiring septic
shock because they have decreased immune system, making it easier for
microorganisms to invade the body tissues.

• Extremes of age. Elderly people and infants are more prone to septic shock
because of their weak immune system.

• Malnourishment. Malnourishment can lower the body’s defenses, making it
susceptible to the invasion of pathogens.

• Chronic illness. Patients with a longstanding illness are put at risk for sepsis
because the body’s immune system is already weakened by the existing
pathogens.

• Invasive procedures. Invasive procedures can introduce microorganisms
inside the body that could lead to sepsis.

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Clinical Manifestations
The signs and symptoms that are associated with septic shock and sepsis include the
following:

• Since the ability of the body to provide oxygen and nutrients is interrupted,
the heart compensates by pumping faster.

• Hypotension occurs because of vasodilation.
• To compensate for the decreased oxygen concentration, the patient tends to

breathe faster, and also to eliminate more carbon dioxide from the body.
• The inflammatory response is activated because of the invasion of

pathogens.
• Decreased urine output. The body conserves water to avoid

undergoing dehydration because of the inflammatory process.
• Changes in mentation. As the body slowly becomes acidotic, the patient’s

mental status also deteriorates.
• Elevated lactate level. The lactate level is elevated because there is

maldistribution of blood.

Prevention
Before sepsis could invade a patient’s body, it is better to prevent its occurrence here are
some ways to prevent sepsis and septic shock.

• Strict infection control practices. To prevent the invasion of
microorganisms inside the body, infection must be put at bay
through effective aseptic techniques and interventions.

• Prevent central line infections. Hospitals must implement efficient programs
to prevent central line infections, which is the most dangerous route that can
be involved in sepsis.

• Early debriding of wounds. Wounds should be debrided early so that
necrotic tissue would be removed.

• Equipment cleanliness. Equipment used for the patient, especially the ones
involved in invasive procedures, must be properly cleaned and maintained to
avoid harboring harmful microorganisms that can enter the body.

Complications
Complications could happen in a patient with sepsis if it is not properly treated or not treated
at all.

• Severe sepsis. Sepsis could progress to severe sepsis with symptoms of
organ dysfunction, hypotension or hypoperfusion, lactic acidosis, oliguria,
altered level of consciousness, coagulation disorders, and altered hepatic
functions.

• Multiple organ dysfunction syndrome. This refers to the presence of
altered function of one or more organs in an acutely ill patient requiring
intervention and support of organs to achieve physiologic functioning required
for homeostasis.

Assessment and Diagnostic Findings
Early assessment and diagnosis of the infection must be established to avoid its
progression.

• Blood culture. To identify the microorganism responsible for the disease, a
blood culture must be performed.

• Liver function test. This should be performed to detect any alteration in the
function of the liver.

• Blood studies. Hematologic test must also be performed to check on the
perfusion of the blood.

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Medical Management
The current treatment of septic shock and sepsis include identification and elimination of the
cause of infection.

• Fluid replacement therapy. The therapy is done to correct the tissue
hypoperfusion, so aggressive fluid resuscitation must be implemented.

• Nutritional therapy. Aggressive nutritional supplementation is critical in
the management of septic shock because malnutrition further impairs the
patient’s resistance to infection.

Nursing Management
Nurses must keep in mind that the risks of sepsis and the high mortality rate associated with
sepsis, severe sepsis, and septic shock.

Nursing Assessment
Assessment is one of the nurse’s primary responsibilities, and this must be done precisely
and diligently.

• Signs and symptoms. Assess if the patient has positive blood culture,
currently receiving antibiotics, had an examination or chest x-ray, or has a
suspected infected wound.

• Signs of acute organ dysfunction. Assess for presence of hypotension,
tachypnea, tachycardia, decreased urine output, clotting disorder, and hepatic
abnormalities.

Diagnosis
Sepsis can affect a lot of body systems and even cause their failure, so diagnosis is an
important part of the process to establish the presence of sepsis.

• Risk for deficient fluid volume related to massive vasodilation.
• Risk for decreased cardiac output related to decreased preload.
• Impaired gas exchange related to interference with oxygen delivery.
• Risk for shock related to infection.

Planning & Goals
Healthcare team members should be prepared with a care plan for the patient for a more
systematic and detailed achievement of the goals.

• Patient will display hemodynamic stability.
• Patient will verbalize understanding of the disease process.
• Patient will achieve timely wound healing.

Nursing Interventions
Nursing interventions pertaining to sepsis should be done timely and appropriately to
maximize its effectivity.

• Infection control. All invasive procedures must be carried out with aseptic
technique after careful hand hygiene.

• Collaboration. The nurse must collaborate with the other members of the
healthcare team to identify the site and source of sepsis and specific
organisms involved.

• Management of fever. The nurse must monitor the patient closely for
shivering.

• Pharmacologic therapy. The nurse should administer prescribed IV
fluids and medications including antibiotic agents and vasoactive medications.

• Monitor blood levels. The nurse must monitor antibiotic toxicity,
BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels, and
coagulation studies.

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• Assess physiologic status. The nurse should assess the patient’s
hemodynamic status, fluid intake and output, and nutritional status.

Evaluation
After implementation of the interventions, the nurse must evaluate their effectiveness.

• Patient displayed hemodynamic stability.
• Patient verbalized understanding of the disease process.
• Patient achieved timely wound healing.
Discharge and Home Care Guidelines
Even after discharge, the patient must still be taught how to establish home and community
care regimen.
• Prevent shock episodes. The nurse should instruct the patient and the

family strategies to prevent shock episodes through identifying the factors
implicated in the initial episodes.
• Instructions on assessment. The patient and the family should be taught
about assessments needed to identify the complications that may occur after
discharge.
• Treatment modalities. The nurse must teach the patient and the family
about treatment modalities such as emergency administration of medications,
IV therapy, parenteral or enteral nutrition, skin care, exercise, and ambulation.
Documentation Guidelines
Proper documentation must be established both for legal protection and data organization.
• Document individual risk factors.
• Document assessment findings.
• Document results of the laboratory tests and diagnostic studies.
• Document plan of care and teaching plan.
• Document client’s responses to treatment, teaching, and actions performed.
• Document modifications in the plan of care.

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Sepsis Nursing Care Plans

Sepsis is a systemic response to infection; it may occur after a burn, surgery, or a serious
illness and is manifested by two or more clinical symptoms: temperature of more than 38°C
or less than 36°C, heart rate of more than 90 beats per minute, respiratory rate of more than
20 breaths per minute, PaCO2 of below 32 mmHg, white blood cell count of more than
12,000 cells/mm3, less than 4,000 cells/mm3 or greater than 10% of bands or immature
cells, hyperglycemia, bleeding, and abnormal clotting.

Nursing Care Plans
The nursing care plan for clients with sepsis involves eliminating infection, maintaining
adequate tissue perfusion or circulatory volume, preventing complications, and providing
information about disease process, prognosis, and treatment needs.

Here are six (6) nursing care plans (NCP) and nursing diagnosis for patients with
sepsis and septicemia:

1. Risk For Infection
2. Risk For Shock
3. Risk For Impaired Gas Exchange
4. Risk For Deficient Fluid Volume
5. Hyperthermia
6. Deficient Knowledge

Risk For Infection

Nursing Diagnosis
• Risk For Infection

Risk factors
• Compromised immune system.
• Failure to recognize or treat infection and/or exercise proper preventive
measures.
• Invasive procedures, environmental exposure (nosocomial).

Possibly evidenced by
• [not applicable].

Desired Outcomes
• Client will achieve timely healing; be free of purulent secretions, drainage, or
erythema; and be afebrile.

Nursing Interventions Rationale

Assess client for a possible source of The most common causes of sepsis are
infection (e.g., burning urination, localized respiratory tract and urinary tract infection,
abdominal pain, burns, open wounds followed by abdominal and soft tissue infections.
or cellulitis, presence of invasive catheters, Other causes of hospital-acquired sepsis are
or lines). the use of intravascular devices.

Teach proper hand washing using Hand washing and hand hygiene lessen the risk
antibacterial soap before and after each of cross-contamination. Note: Methicillin-
care activity. resistant Staphylococcus aureus (MRSA) is
most commonly transmitted bacteria via direct
contact with health care workers who unable to
wash hands between client contacts.

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Maintain sterile technique when changing Medical asepsis inhibits the introduction of
dressings, suctioning, and providing site bacteria and reduces the risk of nosocomial
care, such as an invasive line or a urinary infection.
catheter.

Investigate reports of pain out of proportion Pressure-like pain over an area of cellulitis may
to visible signs. indicate developing of necrotizing fasciitis due to
group A beta-hemolytic streptococci (GABHS),
necessitating prompt intervention.

Inspect wounds and sites of invasive Catheter-related bloodstream infections (CR-
devices daily, paying particular attention to BSIs) are increasing where central venous
parenteral nutrition lines. Document signs of catheters are used in both acute and chronic
local inflammation and infection and care settings. Clinical signs, such as local
changes in character wound drainage, inflammation or phlebitis, may provide a clue to
sputum, or urine. a portal of entry, type of primary infecting
organism (s), as well as early identification of
secondary infections.

Inspect oral cavity for white plaques. Depression of immune system and use
Investigate reports of vaginal and perineal of antibiotics increase the risk of secondary
itching or burning. infections, particularly yeast-thrush.

Encourage client to cover mouth and nose Appropriate behaviors, personal protective
with a tissue when coughing or sneezing. equipment, and isolation prevent the spread of
Place in a private room if indicated. Wear infection via airborne droplets.
mask when providing direct as appropriate.

Encourage or provide frequent position Good pulmonary toilet may reduce respiratory
changes, deep breathing, and coughing compromise.
exercises.

Limit use of invasive devices and Reduces the number of possible entry sites for
procedures when possible. Remove lines opportunistic organisms.
and devices when infection is present and
replace if necessary.

Dispose of soiled dressings and other Appropriate disposal of contaminated material
materials in a double bag. reduces contamination and spread of
organisms.

Wear gloves and gowns when caring for Prevents spread of infection and cross
open wounds or anticipating direct contact contamination.
with secretions or excretions.

Provide isolation and monitor visitors, as Body substance isolation should be used for all
indicated, infectious clients. Wound and linen isolation
and handwashing may be all that is required for
draining wounds. Clients with diseases
transmitted through air may also need airborne
and droplet precautions.

Note temperature trends and observe for Fever [101°F-105°F (38.5°C-40°C)] is the result
shaking chills and profuse diaphoresis. of endotoxin effect on the hypothalamus and

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pyrogen-released
endorphins. Hypothermia lower than 96°F
(36°C) is a grave sign reflecting advancing
shock state, decreased tissue perfusion, and
failure of the body’s ability to mount a febrile
response. Chills often precede temperature
spikes in the presence of generalized infection.

Monitor for signs of deterioration of Deterioration of a clinical condition or failure to
condition or failure to improve with therapy. improve with therapy may reflect inappropriate
or inadequate antibiotic therapy or overgrowth
of resistant or opportunistic organisms.

Obtain specimens of urine, blood, sputum, Identification of portal of entry and organism
wound, and invasive lines or tubes for causing the septicemia is crucial to effective
culture, and sensitivity, as indicated. treatment based on susceptibility to specific
medications.

Monitor laboratory studies, such as WBC The normal ratio of neutrophils to total WBCs is
count with neutrophils and band counts at least 50%; however, when WBC count is
markedly decreased, calculating the absolute
neutrophil count is more pertinent to evaluating
immune status. Likewise, an initial elevation of
band cells reflects the body’s attempt to mount
a response to the infection, whereas a decline
indicates decompensation.

Administer medications, as indicated,
for example:

• Anti-infective agents: broad spectrum Specific antibiotics are determined by culture
antibiotics, such as imipenem and and sensitivity tests, but therapy is usually
cilastatin (Primaxin), meropenem initiated before obtaining results, using broad-
(Merrem), ticarcillin and clavulanate spectrum antibiotics and/or based on most likely
(Timentin), piperacillin and tazobactam infecting organisms. Antifungal therapy may be
(Zosyn), clindamycin (Cleocin), considered in a client who has already been
vancomycin treated with antibiotics, who is neutropenic,
(Vancocin); aminoglycosides, such as receiving total parenteral nutrition (TPN), or who
tobramycin (Nebcin), gentamicin has central venous access in place.
(Garamycin); cephalosporins, such as
cefepime (Maxipime); fluoroquinolones,
such as levofloxacin (Levaquin),
ciprofloxacin (Cipro); antifungals, such
as fluconazole (Diflucan), or
caspofungin acetate (Cancidas).

• Recombinant human activated protein Administration of recombinant activated protein
C (rhAPC) or Drotrecogin alpha C inhibits thrombosis and inflammation,
(Xigris). promotes fibrinolysis, and may reduce mortality
in adult clients with severe sepsis. Drotrecogin
alfa (activated) is the first FDA-approved
treatment for severe sepsis

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Assist with or prepare for procedures, such Removal of infection sources promotes healing.
as removal of infected devices, incision and
drainage of abscess, or debridement of
infected wounds, as indicated.

Prepare for hyperbaric therapy, as Exposing wounds to high ambient oxygen
appropriate. tension therapy may be done to fight anaerobic
infections.

Risk For Shock
Shock: is a life-threatening condition that occurs when the body is not getting enough blood
flow. This can lead to damage to multiple organs.

Risk factors
• Reduction of arterial/venous blood flow: selective vasoconstriction, vascular
occlusion–intimal damage, micro emboli.
• Relative or actual hypovolemia.

Possibly evidenced by
• [not applicable].

Desired Outcomes
• Client will display adequate perfusion as evidenced by stable vital signs,
palpable peripheral pulses, skin warm and dry, usual level of mentation,
individually appropriate urinary output, and active bowel sounds.

Nursing Interventions Rationale

Monitor trends in blood pressure (BP), Hypotension develops as circulating
especially noting progressive hypotension and microorganisms stimulate release and
widening pulse pressure. activation of chemical and hormonal
substances. These endotoxins initially
cause peripheral vasodilation, decreased
systemic vascular resistance (SVR), and
relative hypovolemia. As shock progress,
the cardiac output becomes severely
depressed due to major alterations in
contractility, preload, and/or afterload, thus
producing profound hypotension.

Monitor heart rate and rhythm. Note Tachycardia occurs because of sympathetic
dysrhythmias. nervous system stimulation secondary to
stress response and to compensate for the
relative hypovolemia and hypotension.
Cardiac dysrhythmias can occur because of
hypoxia, acid-base and electrolyte
imbalance, and/or low-flow perfusion state.

Note quality and strength of peripheral pulses. Initially, the pulse is strong and bounding
because of increased cardiac output. Pulse
may become weak and thready because of
sustained hypotension, decreased cardiac
output, and peripheral vasoconstriction if the
shock state progresses.

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Assess respiratory rate, depth, and quality. Increased respirations occur in response to
Note onset of severe dyspnea. direct effects of endotoxins on the
respiratory center in the brain, as well as
developing hypoxia, stress, and fever.
Respirations become shallow as respiratory
insufficiency develops, creating the risk of
acute respiratory failure.

Assess skin for changes in color, temperature, Vasodilation results in the warm, dry, pink
and moisture. skin characteristic of hyperperfusion in
the hyperdynamic phase of early septic
shock. If shock state progresses,
compensatory vasoconstriction occurs,
shunting blood to vital organs, reducing
peripheral blood flow, and creating a cool,
clammy, pale and dusky skin.

Assess for changes in sensorium (confusion, Changes in mentation reflect alterations in
lethargy, personality changes, stupor, delirium, cerebral perfusion, hypoxemia, and/or
and coma). acidosis.

Auscultate bowel sound. Reduce blood flow to the mesentery
(splanchnic vasoconstriction)
decrease peristalsis and may lead to
paralytic ileus or possibly trigger multiple
organ failure syndrome.

Measure hourly urine output; record urine Decreasing urinary output with high specific
specific gravity. gravity indicates diminished renal perfusion
related to fluid shifts and selective
vasoconstriction. There may be transient
polyuria during the hyperdynamic phase,
while cardiac output is elevated, but this
may progress to oliguria.

Hematest gastric secretions and stools for Stress of illness and use of steroids
occult blood. increases the risk of gastric mucosal erosion
and bleeding.

Monitor for signs of bleeding; oozing from Coagulopathies such as DIC may occur,
puncture sites or suture lines, petechiae, related to accelerated clotting in the
ecchymoses, hematuria, epistaxis, hemoptysis, microcirculation reflecting activation of
and hematemesis. chemical mediators, vascular insufficiency,
and cell destruction creating a life-
threatening hemorrhagic situation and
multiple emboli.

Evaluate lower extremities for local tissue Venous stasis, changes in the coagulation
swelling, erythema, and positive Homan’s processes, and infection may result in the
development of thrombosis.
sign (calf pain at dorsiflexion of the foot).

Maintain bedrest and assist with care activities. Preventing overexertion decreases
myocardial workload and oxygen

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consumption, thus maximizing the
effectiveness of tissue perfusion.

Maintain sequential compression devices These preventive measures for a bedfast
(SCDs), as indicated. client to reduce lower extremity stasis
complications.

Administer parenteral fluids. Parenteral fluid therapy helps maintain
tissue perfusion and expand circulating
volume.

Administer medications, as indicated:

• Corticosteroids Low-dose steroids may be given for the
(prednisone). potential advantages of decreasing capillary
permeability, increasing renal perfusion, and
inhibiting microemboli formation.

• Histamine 2-receptor blockers, Histamine receptor blockers prevent or treat
such as famotidine (Pepcid), stress ulcers.
cimetidine (Tagamet), ranitidine
(Zantac), and nizatidine (Asid).

• Inotropic agents and Inotropic agents and vasopressors may be
vasopressors, such as needed to improve organ perfusion and to
norepinephrine maintain blood pressure during and after
(Levophed), dopamine (Intropin), fluid treatment.
and vasopressin (Pitressin).

• Low-molecular-weight-heparin, Low-molecular-weight-heparin prevents or
such as dalteparin (Fragmin), treats deep vein thrombosis (DVT).
enoxaparin (Lovenox), and
tinzaparin (Innohepp); and
unfractionated heparin.

Note drug effects, and monitor for toxicity. Massive doses of antibiotics have potentially
toxic effects in clients with compromised
renal and/or hepatic function.

Monitor laboratory studies, such as ABGs and Circulatory collapse reduces tissue
lactate levels. perfusion. Inadequate renal perfusion alters
filtration, reabsorption, and secretion of
various substances resulting in fluid and
electrolyte imbalance and anaerobic
metabolism. Respiratory or metabolic
acidosis indicates weakened compensatory
mechanism. Lactic acid accumulation is due
to inadequate oxygenation and thus
accumulation of anaerobic by-products or
lactate.

Maintain stable body temperature, using Temperature elevations increase metabolic,
adjunctive aids as necessary. and oxygen demands beyond cellular

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Provide supplemental oxygen. resources, hastening tissue ischemia, and
cellular destruction.
Prepare for and transfer to critical care setting,
as indicated. Supplemental oxygen improves cellular
oxygenation.

Progressive deterioration requires more
aggressive therapy including hemodynamic
monitoring and vasoactive drug infusions.

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Risk For Impaired Gas Exchange

Nursing Diagnosis
• Risk for Impaired Gas Exchange

Risk factors
• Altered oxygen supply–effects of endotoxins on the respiratory center in the
medulla (resulting in hyperventilation and respiratory alkalosis);
hypoventilation.
• Altered blood flow (changes in vascular resistance), alveolar-capillary
membrane changes–increased capillary permeability leading to pulmonary
congestion.
• Interference with oxygen delivery and utilization in the tissues (endotoxin-
induced damage to the cells and capillaries).

Possibly evidenced by
• [not applicable].

Desired Outcomes
• Client will display ABGs and respiratory rate within the normal range, with
breath sounds clear and chest x-ray clear or improving.
• Client will experience no dyspnea or cyanosis.

Nursing Interventions Rationale

Monitor respiratory rate and depth. Note use Rapid, shallow respiration occur because of
of accessory muscles or work of breathing. hypoxemia, stress, and circulating endotoxins.
Hypoventilation and dyspnea reflect ineffective
compensatory mechanisms and are
indications that ventilatory support is needed.

Auscultate breath sounds. Note for crackles, Respiratory distress and the presence of
stridor, wheezes, and areas of decreased or adventitious sounds are indicators of
absent ventilation. atelectasis, interstitial edema, and pulmonary
congestion.

Assess for changes in sensorium (confusion, Cerebral function is very sensitive to decrease

lethargy, personality changes, stupor, in oxygenation such as hypoxemia, or reduced

delirium, and coma). perfusion.

Note for a presence of circumoral cyanosis. Circumoral cyanosis indicates inadequate
central oxygenation and hypoxemia.

Note cough and purulent sputum production. Pneumonia is a common nosocomial infection
that occurs by aspiration of oropharyngeal
organisms or spread from other sites.

Reposition client frequently. Encourage Good pulmonary toilet is important for
coughing and deep-breathing exercises. minimizing ventilation/perfusion imbalance and
Suction, as indicated. for mobilizing and facilitating removal of
secretions to maximize gas exchange.

Maintain client airway. Place client in a Elevating the head of bed enhances lung
position of comfort with the head of bed expansion and reduces respiratory effort.
elevated 30 to 45°.

Monitor ABGs and pulse oximetry. Hypoxemia is related to decreased ventilation
and pulmonary changes (i.e. atelectasis,

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interstitial edema and pulmonary shunting) and
increased oxygen demands caused by fever or
infection. Respiratory acidosis (ph below 7.35
and PaCO2 higher than 40 mm Hg) happens
due to hypoventilation and ventilation-
perfusion imbalance. As septic condition
worsens, metabolic acidosis (ph below 7.35
and HCO3 less than 22-24 mEq/L) develops as
a result of build up of lactic acid from
anaerobic metabolism.

Review serial chest x-rays. Changes on x-ray reflect progression or
resolution of pulmonary complications, such as
infiltrates and edema.

Administer red blood cells (RBCs), as May be required to improve available oxygen
indicated. to treat sepsis-induced hypoperfusion, or when
the hematocrit falls below 30%.

Provide supplemental oxygen via appropriate Supplemental oxygen is important for

route: nasal cannula, mask, or high-flow correction of hypoxemia with failing respiratory

rebreathing mask. effort or progressing acidosis.

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Risk For Deficient Fluid Volume

Nursing Diagnosis
• Risk for Deficient Fluid Volume

Risk factors
• Capillary permeability with fluid leaks into the interstitial space (third spacing).
• Marked increase in vascular compartment, massive vasodilation.

Possibly evidenced by
• [not applicable].

Desired Outcomes
• Client will maintain adequate circulatory volume as evidenced by vital signs
within client’s normal range, palpable peripheral pulses of good quality, and
individually appropriate urinary output.

Nursing Interventions Rationale

Measure and record urinary output and Decreasing urinary output with a high specific
specific gravity. Note cumulative intake and gravity suggests relative hypovolemia
output (I&O) imbalances (including associated with vasodilation. Continued positive
insensible losses), and correlate with daily fluid balanced with corresponding weight gain
weight. Encourage oral fluids, as indicated. may indicate third spacing and tissue edema,
suggesting a need to alter fluid therapy.

Assess for dry mucous membranes, poor Hypovolemia and third spacing of fluid give rise
skin turgor, and thirst. to signs of dehydration.

Observe for dependent or peripheral edema Fluid losses from the vascular compartment into

in the sacrum, scrotum, back, and legs. the interstitial space create tissue edema.

Monitor blood pressure and heart rate. Reduction in the circulating fluid volume reduces
Measure central venous pressure (CVP) if BP and CVP, initiating compensatory
used. mechanism of tachycardia to improve cardiac
output and increase systemic blood pressure.

Palpate peripheral pulses. Weak, easily obliterated pulses suggest
hypovolemia.

Monitor laboratory values:

• Hematocrit and red blood Evaluates changes in hydration/blood viscosity.
cell count.

• Blood urea nitrogen The BUN/Cr ratio could indicate dehydration or
and creatinine. renal dysfunction and failure.

Monitor cardiac output, as indicated. Cardiac output, and other functional parameters
such as cardiac index, preload, afterload,
contractility, and cardiac work, can be measured
noninvasively using thoracic electrical
bioimpedance (TEB) technique. Cardiac output
determination is useful in determining
therapeutic needs and effectiveness.

Administer IV fluids, such as isotonic Fluid therapy is most effective early in the
crystalloids (D5W normal saline [NS], course of severe sepsis because as the

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lactated ringer’s [LR] and colloids (albumin, condition worsens, there is greater dysfunction
fresh frozen plasma), as indicated. at the cellular level. Large volumes of fluid may
be required to overcome relative hypovolemia or
peripheral vasodilation, and replaced losses
from increased capillary permeability (e.g.,
sequestration of fluid in the peritoneal cavity)
and increased insensible sources such as fever
and diaphoresis.

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Hyperthermia

Nursing Diagnosis
• Hyperthermia

May be related to
• Dehydration.
• Direct effect of circulating endotoxins on the hypothalamus, altering
temperature regulation.
• Increased metabolic rate, illness.

Possibly evidenced by
• Flushed skin, warm to touch.
• Increased in body temperature higher than the normal range.
• Increased respiratory rate, tachycardia.

Desired Outcomes
• Client will experience no associated complications.
• Client will demonstrate temperature within normal range and be free of chills.

Nursing Interventions Rationale

Monitor client temperature–degree and Temperature of 102°F to 106°F (38.9°C- 41.1°C)
pattern. Note shaking chills or profuse suggest acute infectious disease process. Fever
diaphoresis. pattern may help in the diagnosis. Sustained or
continuous fever curves lasting more than 24
hours indicates pneumococcal pneumonia,
scarlet, or typhoid fever; remittent fever varying
only a few degrees in either direction reflects
pulmonary infections; and intermittent curves or
fever that returns to normal once in 24-hour
period suggest septic episode, septic
endocarditis, or tuberculosis (TB). Chills often
precede temperature spikes.

Monitor environmental temperature. Limit Room temperature and linens should be altered

or add bed linens, as indicated. to maintain near-normal body temperature.

Provide tepid sponge baths. Avoid use of Tepid sponge baths may help reduce fever. The
alcohol. use of alcohol may cause chills, elevating
temperature, and skin dehydration.

Provide cooling blanket, or hypothermia Used to reduce fever, especially when higher
therapy as indicated. than 104°F to 105°F (39.9°C–40°C), and

when seizures or brain damage are likely to

occur.

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Administer antipyretics, such as Antipyretics reduce fever by its central action on
acetylsalicylic acid (ASA) (aspirin) or the hypothalamus; fever should be controlled in
acetaminophen (Tylenol). clients who are neutropenic or a splenic.
However, fever may be beneficial in limiting the
growth of organisms and enhancing auto
destruction of infected cells.

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Deficient Knowledge

Nursing Diagnosis
• Deficient Knowledge

May be related to
• Cognitive limitation.
• Lack of exposure or recall information misinterpretation.

Possibly evidenced by
• Inaccurate follow-through of instructions, development of preventable
complications.
• Questions, request for information, statement of misconception.

Desired Outcomes
• Client will verbalize understanding of disease process, prognosis, and
potential complications.
• Client will verbalize understanding of therapeutic needs.
• Client will participate in the treatment regimen.
• Client will initiate necessary lifestyle changes.
• Client will correctly perform necessary procedures and explain the rationale
for the actions.

Nursing Interventions Rationale

Review disease process and future Discussing the disease and clinical expectations
expectations. provides a knowledge base from which client
can make informed choices.

Review individual risk factors, mode of Awareness of means of infection transmission
transmission, and portal of entry of provides an opportunity to plan for and institute
infections. preventive measures.

Review necessity of personal hygiene and Personal hygiene and environmental cleanliness
environmental cleanliness, proper cooking lessen the exposure to pathogens.
techniques, and food storage.

Discuss need for a good nutritional intake or Good nutrition is necessary for optimal healing,
balanced diet. immune system enhancement, and general
well-being.

Discuss proper use of avoidance of Superabsorbent tampons or infrequent tampon
tampons with menstruating women, as changing increases the risk of Staphylococcus
indicated. aureus infection.

Provide information about drug therapy, Sufficient and appropriate information promotes
interactions, side effects, and the understanding and enhances compliance with
importance of compliance with the treatment or prophylaxis, and reduces the risk of
treatment regimen. recurrence and complications.

Identify signs and symptoms requiring Early recognition of developing infection will
medical evaluation: persistent high fever, allow a timely intervention and reduces the risk
increased heart rate, syncope, rashes of of life-threatening complications.
unknown origin,
unexplained fatigue, anorexia, increased
thirst, and changes in bladder function.

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Stress the importance of prophylactic Prophylactic vaccines and antibiotics prevent
immunizations and antibiotic therapy, as the occurrence of infection, especially in high-
needed. risk groups such as those of extreme ages or
with chronic illness and a history of infective
heart disease and immunosuppression.

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