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Nursing care plan sepsis septicemia

Written by ncp nursing care plan on April 25th, 2012

I. Pathophysiology (Cunha, 2008; Kleinpell, 2006; Sharma &
Mink, 2007; Wood & Lavieri, 2007)
a. Presence of a systemic inflammatory response to documented
or presumed infection, which may progress along a continuum
i. Systemic inflammatory response syndrome (SIRS)
1. Infection with release of endo- or exotoxins activating
the inflammatory cascade—local release of cytokines
into the circulation in attempt to restore homeostasis
2. Failure of mechanism leads to destructive response
with loss of circulatory integrity
3. Criteria (two or more)—fever greater than
100.4ºF/38ºC or less than 96ºF/36ºC; heart rate greater
than 90 beats per minute; respiration greater than
20/min or PaCO2 less than 32 mm Hg; white blood
cell (WBC) count greater than 12,000/μL, less than
4,000/μL, or greater than than 10% of bands or
immature cells
ii. Severe sepsis—presence of known or suspected infection
and two or more SIRS criteria; associated with organ
dysfunction, hypoperfusion, hypotension with alteration
of mental status, hypoxemia, lactic acidosis, and/or
oliguria
iii. Septic shock—characterized by hemodynamic changes
and persistent hypotension, development of perfusion
abnormalities, and impaired cellular function that fails to
respond to adequate fluid resuscitation
iv. Multiple organ dysfunction syndrome (MODS)—organ
dysfunction leading to organ failure with inability to
maintain homeostasis

II. Etiology
a. Multiple microorganisms associated with sepsis
i. Bacteria, fungi, viruses, or rickettsiae
ii. Common pathogens: Streptococcus pneumoniae or
Staphyloccocus aureus, Candida, Salmonella,
Escherichia coli, Legionella, Klebsiella, Pseudomonas
b. Common origin of infections
i. Abdomen: appendicitis, bowel problems (perforated
diverticuli), infection of the abdominal cavity, and
gallbladder or liver infections
ii. Central nervous system: infections of the brain or the
spinal cord, such as encephalitis, meningitis
iii. Lungs: pneumonia
iv. Skin: wounds or cellulitis; punctures, such as from
intravenous (IV) lines, intravascular devices, or
catheters inserted into the body to administer or drain
fluids
v. Urinary tract: kidneys or bladder (glomerulonephritis,
pyelonephritis, cystitis), prostatic obstruction
c. Risk factors: unsanitary and/or crowded living conditions,
pollution, poor nutrition, immunosuppression, chronic
health conditions, improper use of antibiotics

III. Statistics (Angus et al, 2001)
a. Morbidity: A reported 751,000 cases of severe sepsis occur
annually in the United States.
b. Mortality: Dependent on progression of condition and
degree of organ failure, presence of comorbidities, and age;
in 2001, the rate was 28.6%.
c. Cost: Averages $22,100 per case, with approximately
$16.7 billion spent annually.

Care Setting
Although severely ill individuals will likely receive care in
the intensive care unit (ICU), this plan addresses care on an
inpatient acute medical-surgical unit.

Related Concerns
Acquired immunodeficiency syndrome (AIDS)
Chronic obstructive pulmonary disease (COPD) and asthma
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis—primary base bicarbonate deficiency
Peritonitis
Pneumonia
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Renal failure: acute
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Ventilatory assistance (mechanical)

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

Discharge Goals
1. Infection eliminated or controlled.
2. Homeostasis maintained.
3. Complications prevented or minimized.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

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Source Credits: Nursing Care Planning Guides: For Adults in Acute, Extended and Home Care Settings by S. P. Ulrich and S. W. Canale BSN MSN / Nursing Care Plans by M. Doenges MF Moorehouse Alice Murr