Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is followed by suppression of the immune system. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection. The very young, old, and people with a weakened immune system may have no symptoms of a specific infection, and the body temperature may be low or normal instead of having a fever. Severe sepsis causes poor organ function or blood flow. The presence of low blood pressure, high blood lactate, or low urine output may suggest poor blood flow. Septic shock is low blood pressure due to sepsis that does not improve after fluid replacement.
Sepsis - Nursing Diagnosis and Interventions
1. Ineffective breathing pattern related to apnea
Outcomes :
- No cyanosis and dyspnoea, demonstrating an effective cough and clear breath sounds.
- Demonstrate a patent airway (no abnormal breath sounds).
- Vital signs within normal range.
Nursing Interventions and Rationale :
a. Place the patient in a semi-powler's position.
Rationale: The position of the semi-powler can maximize ventilation.
b. Auscultate breath sounds, noting any additional breath sounds.
Rationale: Additional breath sounds can be a sign of an inadequate airway.
c. Monitor respiration and O2 status, vital signs.
Rationale: In sepsis, respiratory disorders and O2 status are often found, which causes vital signs not to be within normal range.
d. Apply a moist Nacl gauze humidifier.
Rationale: Reduce the number of locations that can be a place of entry of organisms.
e. Teach effective cough, suction, postural drainage.
Rationale: To remove secretions in the airways to create a patent airway.
2. Risk for Infection related to invasive procedures
Outcomes :
- Temperature within normal limits.
- The progress of the client's status improved during the therapy period.
Nursing Interventions and Rationale :
a. Provide isolation or monitor visitors as indicated.
Rationale: Isolation / restriction of visitors is needed to protect immunosuppressed patients and reduce the risk of possible infection.
b. Wash hands before and after activities, even if using sterile gloves.
Rationale: Reduce cross-contamination.
c. Encourage frequent changing positions, deep breaths/coughs.
Rationale: Good lung clearance prevents pneumonia.
d. Limit use of invasive devices/procedures where possible.
Rationale: Reduce the number of locations that can be a place of entry of organisms.
e. Inspect the wound / side of the invasive device every day.
Rationale: Noting signs of local inflammation or infection, changes in the character of wound drainage or sputum and urine. Prevents ongoing infection.
f. Use sterile technique at all times when changing dressings or suctioning or administering care.
Rationale: Prevents entry of bacteria, reduces the risk of nosocomial infections.
g. Monitor the trend of temperature, if fever give warm compresses.
Rationale: Fever (38.5oC - 40oC) is caused by the effects of endotoxin on the hypothalamus and endorphins that release pyrogens. Hypothermia (<36 oC) are critical signs indicating a state of shock or decreased tissue perfusion.
h. Observe for chills and diaphoresis.
Rationale: Shivering often precedes the peak temperature in the presence of infection.
i. Monitor for signs of condition deviation or failure to improve during the course of therapy.
Rationale: May indicate inappropriate or inadequate antibiotic therapy or overgrowth of resistant organisms.
j. Inspect the oral cavity for white plaque or canker sores, also investigate the presence of itching.
Rationale: Immune system depression and use of antibiotics may increase the risk of secondary infection.
k. Collaboration in the administration of antibiotics. Pay attention to the effects of drug administration.
Rationale: Treatment therapy is very helpful in healing during treatment therapy.
3. Hyperthermia related to impaired temperature control secondary to infection or inflammation
Outcomes :
- Body temperature is within normal limits (Normal temperature 36.5°-37o C)
- Pulse and respiratory rate within normal limits.
Intervention and Rationale:
a. Monitor vital signs every two hours and monitor skin color.
Rationale: Significant changes in vital signs will affect regulatory or metabolic processes in the body.
b. Observe for seizures and dehydration.
Rationale: Hyperthermia has the potential to cause seizures which will further worsen the patient's condition and can cause the patient to lose an unknown amount of fluid by evaporation and can cause the patient to enter a state of dehydration.
c. Give a compress with warm water on the axilla, neck and groin, avoid using alcohol to compress.
Rationale: Compress on the axilla, neck and groin there are large basic vessels that will help reduce fever. The use of alcohol is not done because it will cause a decrease and increase in heat drastically.
Collaboration:
d. Give antipyretics as needed if fever does not go down.
Rationale: Administration of antipyretics is also necessary to reduce fever immediately.
4. Ineffective peripheral tissue perfusion related to hypovolemia
Outcomes :
- Oxygen saturation >90%
- Adequate muscle contraction for movement
- The rate of blood flow through the small vessels of the extremities and maintains tissue function
Intervention and Rationale:
a. Maintain bed rest.
Rationale: Reduces micard workload and oxygen consumption.
b. Monitor changes in blood pressure.
Rationale: Hypotension will develop along with microorganisms attacking the bloodstream.
c. Monitor heart rate and rhythm, noting dysrhythmias.
Rationale: Cardiac dysrhythmias may occur as a result of hypoxia.
d. Assess breath frequency, depth, and quality.
Rationale: Increased respiration occurs in response to the direct effects of endotoxin on the respiratory center in the brain.
e. Record hourly urine output and specific gravity.
Rationale: Decreased urine output indicates decreased kidney function.
f. Assess for changes in skin color, temperature, humidity.
Rationale: Knowing the state of shock that continues.
5. Imbalanced Nutrition: Less Than Body Requirements related to food/drink intolerance
Outcomes :
- There is an increase in body weight in accordance with the goal
- Ideal body weight according to height
- No signs of malnutrition
- No significant weight loss
Intervention and Rationale:
a. Monitor for weight loss.
Rationale: Anorexia or intolerance to food or drink can cause weight loss.
b. Identify the client's favorite food.
Rationale: Increase the client's appetite for food or drink.
c. Instruct the client to perform oral hygiene before eating.
Rationale: Reduces nausea of food.
d. Monitor fluid intake and nutrition.
Rationale: Lack of fluids can cause dehydration and hyperthermia. Lack of nutrients can lead to weight loss.
e. Make sure the diet that eat is also high in fiber.
Rationale: Lack of fiber can cause constipation.
f. Collaboration with nutritionists to determine the number of calories the patient needs.
Rationale: Identify nutritional problems in treatment therapy.
