Nursing care plan for Septic Shock
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Sepsis is the body’s response to infection, and occurs when an infectious agent such as a virus or bacteria spreads throughout the body. The term “sepsis” is often used interchangeably with “septicemia,” which refers to blood poisoning. Show
Sepsis is also considered a systemic inflammatory response syndrome that results from an infection. Sepsis can trigger a “cytokine storm” – cytokines are chemical messengers that help regulate the immune system’s response to infection. When cytokines get out of control, they cause the body’s immune system to attack itself, making it difficult for a client’s organs to function normally. Sepsis is a serious condition that can lead to organ failure and death if not treated quickly. If these symptoms persist for more than six hours without improvement, or if they worsen after seventy-two hours, it is likely that the client is becoming septic and requires emergency treatment. Remember: Sepsis is life-threatening. Risk Factors
Rationale:Premature infants are extremely susceptible to sepsis, due to an underdeveloped immune system. Children also can become septic because manifestations (signs and symptoms) look different in children vs. adults. Children have less cardiac reserve than adults and may present differently. Older adult clients are more susceptible to contracting infectious pathogens due to their declining immune system. In addition, other age-related changes and co-morbidities (chronic health problems, e.g., diabetes, cardiovascular disease, etc) impact the resistance to pathogens. The elderly often present with different manifestations (signs and symptoms) than other populations which makes it more difficult to diagnose sepsis. Clients who are immunocompromised or have comorbidities (chronic illness) do not have the ability to fight infection as do healthy individuals. Women in the third trimester of pregnancy tend to have a decreased immune system, thus increasing the risk for infection and sepsis. Fluid replacement therapy directly affects sepsis factors (adequate urine output, changes in mental state, and stability of vital signs). Causes
Subjective (Client May Report)
Objective
Symptoms & Signs of Sepsis
Nursing Diagnosis for SepsisWhen diagnosing a client with (possible) sepsis, look for signs of infection (e.g., fever, chills) AND either evidence of systemic inflammation or hypoperfusion. AssessmentThe client has three or more of the following clinical criteria:
Nursing Interventions for SepsisSepsis is a complex condition involving inflammation and dysfunction of the immune system. Nursing interventions for sepsis are focused on monitoring and managing the client’s response to infection. However, it’s important to recognize that sepsis can result in morbidity and mortality in clients even if they receive appropriate treatment. Early detection and treatment of sepsis is key. When blood is infected with bacteria, the body recruits white blood cells to fight them off. However, this process can be prolonged or excessive, which leads to an inflammatory response that can damage tissues and organs throughout the body. AssessmentFor signs and symptoms of sepsis, monitor the client for changes in condition (after assessment). Cardiac Function
Respiratory function
Neurologic and Sensory Functions
Visual Appearance & Labs
Nursing Actions & Care Note for SepsisNurses are the first point of contact for clients with sepsis, and their actions can greatly impact a client’s recovery. The initial treatment for sepsis is the same for all clients, regardless of age or medical history. This includes taking a detailed history and performing a physical exam to evaluate the client’s overall health and determine if they are at risk for developing sepsis. Perform
Provide
Avoid
Administer
Monitor
EncourageNurses should encourage clients upon discharge or for home care to eat a healthy diet and maintain their normal fluid intake. They should be encouraged to take their temperature daily as well as keep track of how much water they consume each day. Clients should also stay hydrated, avoid becoming overly fatigued and stressed, and try to get rest. Nurses need to encourage clients to follow their prescribed treatment plan and avoid any over-the-counter medications or remedies that may interfere with their treatment. Goals and Outcomes
Sepsis NCLEX QuestionAn older adult client diagnosed with sepsis becomes angry at the unlicensed assistive personnel (UAP) and refuses oral care. The UAP reports this incident to the registered nurse (RN). Which response by the RN is appropriate? Answer: “We will talk to the client about the issue together.” Rationale: The angry client must be allowed to express concerns openly. It’s appropriate to approach the situation with an unbiased attitude of acceptance and openness. Find our other Nursing Care Plans here Sourceshttps://alraziuni.edu.ye/uploads/pdf/Nursing-Care-Plans-Edition-9-Murr-Alice-Doenges-Marilynn-Moorehouse-Mary.pdf What are nursing interventions for septic shock?Nursing Interventions. Infection control. All invasive procedures must be carried out with aseptic technique after careful hand hygiene.. Collaboration. ... . Management of fever. ... . Pharmacologic therapy. ... . Monitor blood levels. ... . Assess physiologic status.. What is the most important nursing goal for a patient in septic shock?The management of septic shock is best done with an interprofessional team that includes ICU nurses. The key is early diagnosis and resuscitation to maintain end-organ perfusion. The type of fluid for resuscitation has little bearing on outcomes but the key is to maintain adequate perfusion pressure.
What are some nursing diagnosis for septic shock?Here are six (6) nursing care plans (NCP) and nursing diagnosis for patients with sepsis and septicemia:. Risk For Infection.. Risk For Shock.. Risk For Impaired Gas Exchange.. Risk For Deficient Fluid Volume.. Hyperthermia.. Deficient Knowledge.. What is the first intervention for septic shock?Fluid resuscitation is the initial treatment for hypotension in patients with septic shock. Vasopressor therapy should be initiated in patients with sepsis when fluid resuscitation fails to restore mean arterial pressure (greater than 65 mm Hg) or continued organ hypoperfusion.
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