sepsis nursing diagnosis

Blood poisoning is a life-threatening medical condition wherein severe infection circulates within the bloodstream. It is not a medical term and the condition has nothing to do with poison, “blood poisoning” is used to describe bacteremia, septicemia, or sepsis (Cirino & Lou, 2018). Similar to the out-turns of poisoning, blood infection is a fast killer that can kill in just 12 hours.

The condition is unforeseeable and incalculable as the spread of infection is massive and rapid which can go undiagnosed, misdiagnosed, or shows poor prognosis due to its non-specific signs and symptoms. Furthermore, there is a 10% increase in the probability of poor survival for every hour of delayed treatment (Ring, 2018). These are the reasons why early diagnosis and immediate treatment are very crucial in the management of sepsis.

Sepsis is a fatal medical condition requiring immediate clinical management. Mild cases with immediate treatment have a higher recovery rate compare to severe cases that progress to septic shock whichs showed a 50% mortality rate (O’Connell & Sullivan, 2018). Moreover, statistics revealed an increased incidence rate annually due to the aging population, antibiotic resistance, and weaken immune system secondary to chronic illnesses affecting 1.7 million adults wherein 270,000 have died (roughly 1 out of 3 patients died in the hospital has sepsis) in the United States of America alone (CDC, 2020; Medical News Today, 2020).

Risk Factors for Occurrence of Infections

Prevention is better than cure and a lot way cheaper than the treatment of sepsis. The best way to prevent sepsis is to prevent infections. The following are risk factors responsible for the occurrence of infections (Doenges, et al, 2014), which includes:

  • Unsanitary and/or unhygienic practices
  • Crowded living conditions
  • Pollution and smoke
  • Poor nutrition
  • Immunosuppression
  • Chronic diseases
  • Improper use of antibiotics
  • Improper techniques of wound cleaning

High Risk of Sepsis

No one is exempted from sepsis, anyone can get the illness. However, some people are at high risk of sepsis compare to others. Those high-risk individuals are more susceptible to acquire the disease due to different medical conditions (CDC, 2020; Cleveland Clinic, 2020; Medical News Today, 2020; MedlinePlus, 2020; Cirino & Lou, 2018; O’Connell & Sullivan, 2018), such as:

  • Immunocompromised (i.e. HIV, AIDS, leukemia or receiving chemotherapy)
  • Young children
  • Geriatrics
  • Frequent intravenous medications
  • Poor dental hygiene
  • Long-term indwelling urinary catheter
  • Underwent recent surgery or dental procedures
  • Debilitated with long-term chronic illness
  • People with chronic medical diseases (i.e. diabetes, lung disease, cancer, and kidney disease)
  • Sepsis survivors
  • Prolonged hospital stay / intensive care unit
  • Device related infections (IV cannula, endotracheal tubes, IV access line for dialysis, central line, implants, orthopedic implants/screws/fixators)
  • Neonatal sepsis (related to birth process or after birth, prematurity, low birth weight)

Common Infections that Can Cause Sepsis

Sepsis most likely to occur due to current untreated infections which eventually progresses to septic shock (Cleveland Clinic, 2020; Cirino & Lou, 2018; O’Connell & Sullivan, 2018), which includes:

  • Abdominal infections (appendicitis, bowel inflammation, peritonitis, gallbladder or liver infections)
  • Central nervous system infections (brain or spinal cord infections)
  • Pneumonia / Respiratory infections / COVID-19
  • Kidney / Genito-urinary tract infection
  • Injuries / Trauma
  • Fractures / Bone infections
  • Skin infection (condition like cellulitis or inflammation of the skin’s connective tissue)
  • Infected insect bite
  • Device or implants related infections
  • Infected gums or infection post-dental extractions or procedures
  • Infected wound post-surgery
  • Burns
  • Foot gangrene or gangrenous wound (particularly diabetic wounds)
  • Infected bedsores
  • Infected wounds
  • Bloodstream infections
  • Worms / parasitic infestation
  • Drug / antibiotic resistance

What is Sepsis?

As pathogens (germs, bacteria, virus, parasites, or fungi) invades the bloodstream causing septicemia, the body’s immune system responds overactive to the circulating infection. The overload of invading microorganisms in the bloodstream makes the immune system reacts extremely releasing chemicals to fight the infection, the reaction will eventually lead to a multi-system inflammatory response called Sepsis. With the presence of infection, endotoxins and exotoxins continuously produce activating inflammatory upsurge resulting in cytokines release into the circulation to restore homeostasis during systemic inflammatory response syndrome.

The prolonged inflammatory response between the infection and chemicals of the immune system, the body’s response will get out of balance, and initiating cellular changes—this failure of the mechanism will lead to destructive response losing circulatory integrity. Inflammation may cause small blood clots to form throughout the system that can block blood and oxygen circulations to vital organs and other body parts causing tissue death (gangrene). Severe cases of sepsis may progress to septic shock, a medical emergency that can cause complications including multiple organ systems dysfunction and/or failure (Mayo Clinic, 2020; Cleveland Clinic, 2020; WebMD, 2020; MedlinePlus, 2020; NHS, 2019; O’Connell & Sullivan, 2018; Doenges et al, 2014).

Types of Sepsis (Signs and Symptoms)

There are three stages of sepsis: sepsis, severe sepsis, and septic shock (O’Connell & Sullivan, 2018).

  1. Sepsis

During the first stage of sepsis, the patient may manifest either hyperthermia (above 38ºC) or hypothermia (below 36ºC), tachycardia (>90 beats per minute heart rate), and tachypnea with hyperventilation (>20 breaths per minute breathing rate) with PaCO2 of <32mm Torr and white blood cell (WBC) of more than 12,000/ul or less than 4,000/ul (O’Connell & Sullivan, 2018; Doenges, et al, 2014).

The presence of infections affecting the thermo-regulating center of the brain may sparks a rise of temperature resulting in chills, cold clammy perspirations, and even febrile convulsion. High readings such as hyperthermia, tachycardia, tachypnea, and leukocytosis are the compensatory mechanism of the body to maintain equilibrium which happens during the early stage of sepsis. As the sepsis progresses to the late stage, the body functioning drops indicating that the immune system may be weakened and/or can no longer fight the circulating overloads of infection.

  1. Severe sepsis

As the systemic inflammatory response progresses, poor circulation,  hypoperfusion, and hypoxemia will lead to organ dysfunction and failure (Doenges, et al, 2014). Poor oxygenation circulating in the brain due to hypoxemia shows altered mental status such as changes in mental ability and decrease level of consciousness. Impaired blood-gas exchange causing lactic acidosis may manifest breathing problems and abnormal heart functions. An increase in serum lactate (lactic acid in the blood) indicates that cells are not using oxygen properly (Mayo Clinic, 2020).

The vascular inflammation triggers platelet aggregation which takes place during thrombotic events resulting in thrombocytopenia or decreased platelet level (Dewitte, et al., 2017); this process may lead to thrombus formation or formation of blood clots which eventually impaired circulation and blocks blood vessels. Poor blood circulation causing hypoperfusion in the kidney shows signs of decreased urination and/or oliguria. As the disease process continues, the body’s compensatory mechanism engages in faulty use of energy resulting in fatigue and extreme weakness.

  1. Septic shock

Septic shocks occur when the body’s systemic functions fail to compensate. Prolonged perfusion abnormalities may result in drops of blood pressure, critical oxygen saturation level (SPO2), and a deteriorating level of consciousness (Glasgow Coma Scale) indicating that sepsis progressed to septic shock. This is the state when the body uses energy in a more abnormal way resulting in changes in the circulatory system (Mayo Clinic, 2020).

Impaired cellular function and altered fluid exchange may cause failure to respond to fluid resuscitation (and eventually leads to fluid shifts such as edema and/or anasarca. Prolonged altered blood circulation caused by systemic inflammation and thrombotic events worsen the hypoxemic state of the body with the inability to maintain adequate tissue perfusion and oxygenation can lead to multiple organ system dysfunction and failure (Doenges, et al, 2014). Unresolved septic shock is most likely to cause death.

Nursing Diagnoses for Sepsis

(NANDA International, Inc., 2018; Doenges, et al., 2014)

The chance of survival from sepsis depends on the early detection of problems and accurate diagnosis to formulate an efficient timely nursing care plan and implement immediate life-saving interventions.


Presence of infection / Fever / Tachycardia / Tachypnea / Leukocytosis / Thrombocytopenia / Presence of WBC and microorganisms in the urine, drains, sputum, swab, CSF culture / Elevated C-reactive proteins and procalcitonin / Presence of infection as revealed in diagnostic tests


– Invasion and multiplication of pathogenic microorganisms at the site of infection; and/or circulating in the bloodstream.


Nursing Diagnosis

Risk / Actual for infection (progression; opportunistic; hospital-acquired)



Fever or hypothermia / Cold clammy perspiration / Chills / Flushed skin or pallor / tachypnea or bradypnea / Tachycardia or bradycardia / Signs of dehydration / Slow capillary refill / Skin cool or warm to touch / Seizure or convulsion


– Temperature fluctuation between hyperthermia and hypothermia due to presence of circulating pathogens affecting the thermoregulating center of the brain.


Nursing Diagnosis

Ineffective thermoregulation



Alteration in mental status / Poor skin turgor / Decrease blood pressure / Tachypnea or bradypnea / Tachycardia or bradycardia / Fever or hypothermia / Increase hematocrit level / Increase urine concentration / Edema / Anasarca / Fluid collection / Presence of drainage / Decrease urine output or oliguria / Deranged clotting profile results / abnormal renal function test results / electrolytes imbalance


– Impaired cellular function / altered fluid exchange resulted from massive vasodilation due to to systemic inflammation.

– Capillary permeability with fluid leaks into the interstitial space.

– Decreased intravascular, interstitial, and/or intracellular fluid due to dehydration, water loss alone without change in sodium.

– Decrease blood circulation due to thrombotic events.

– Impaired cellular metabolism.

– Insufficient fluid intake.

– Compromised regulatory mechanism.

– Deviations affecting fluid absorption.

– Renal dysfunction.


Nursing Diagnosis

Deficient fluid volume



Alteration in mental status / Poor skin turgor / Decrease blood pressure / Tachypnea or bradypnea / Tachycardia or bradycardia / Increase hematocrit level / Increase urine concentration / Edema / Anasarca / Fluid collection / Presence of drainage / Decrease urine output or oliguria / Abnormal renal function test results / Electrolytes imbalance


– Insufficient fluid volume.

– Compromised regulatory system.

– Renal dysfunction.


Nursing Diagnosis

Risk for electrolytes imbalance



Abnormal arterial blood gases / Abnormal arterial pH / Abnormal breathing pattern / Abnormal skin color / Confusion / Decrease in carbon dioxide (CO2) level / Diaphoresis / Dyspnea / Hypercapnia / Hypoxemia / Hypoxia / Decrease SPO2 level / Irritability / Restlessness / Somnolence / Tachycardia / Adventitious breath sounds clear / Cyanosis / High serum lactate / Acid-base imbalance / Electrolytes imbalances / Pulmonary infection or edema in chest x-ray or chest CT scan / Low hemoglobin level


– Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

– Ventilation-perfusion imbalance.

– Alveolar-capillary membrane changes—increased capillary permeability leading to pulmonary congestion.

– Altered O2 supply—effects of endotoxins on the respiratory center in the medulla (resulting in hyperventilation and respiratoryalkalosis); hypoventilation.

– Interference with oxygen delivery and utilization in the tissues    (endotoxin-induced damage to the cells and capillaries).


Nursing Diagnosis

Impaired gas exchange



Fatigability / Weakness / Powerlessness / Loss of muscle strength / Altered mental status / Decreased range of motion


– Limitation in independent, purposeful movement of the body or of one or more extremities.

– Fatigue and weakness.

– Immobility or prescribed movement restrictions.

– Activity intolerance.

– Disuse syndrome.

– Decrease muscle control, mass and strength.

– Reluctance to initiate movement.


Nursing Diagnosis

Impaired physical mobility



Tachypnea with hyperventilation (>20 breaths per minute breathing rate) with PaCO2 of <32mm Torr / Decrease SPO2 / Abnormal blood gases /Cyanosis / Acid-base imbalance / Increase serum lactate / Low hemoglobin   level / Abnormal breathing pattern / Dyspnea / Tachypnea or bradypnea / Altered chest excursion / Nasal flaring / Pursed-lip breathing / Fatigability


– Inspiration and/or expiration that does not provide adequate ventilation due to compensatory mechanism / impaired ventilation-perfusion process / respiratory muscle weakness or fatigability.


Nursing Diagnosis

Ineffective breathing pattern



Tachycardia or bradycardia / Abnormal ECG readings / Decrease central  venous pressure / Edema or anasarca / Low SPO2 level / Fatigue / Heart murmur / Jugular vein distension / Cold clammy skin / Dyspnea / Decrease peripheral pulses / Decrease urine output or oliguria / Adventitious breath sounds / Decrease ejection fraction


– Inadequate blood pumped by the heart to meet the metabolic demands of the body.

– Poor blood circulation due to increased blood coagulation / thrombotic events.

– Loss of vascular / circulation integrity due to inflammatory process.

– Decrease blood volume.


Nursing Diagnosis

Decreased cardiac output



Altered mental status / Tachycardia or bradycardia / Tachypnea or bradypnea / Increase in C-reactive protein / Low SPO2 level / Decrease capillary refill time / Decrease blood pressure / Deranged clotting results / weak or absence of peripheral pulses / Edema / Extremity pain / Femoral bruit / Intermittent claudication / Paresthesia / Skin color pales with limb elevation / Decrease urine output or oliguria / Abnormal renal function test / Abnormal blood gases / Low hemoglobin level / Thrombocytopenia


– Impaired blood circulation, hypoperfusion, and hypoxemia due to inflammatory process and/or thrombotic events.


Nursing Diagnosis

Ineffective (cerebral; cardiac; kidney; peripheral) tissue perfusion.


Taking precautionary measures to prevent the occurrence of other infections and suprainfections, and receiving prompt management can reduce the risk of sepsis and improve prognosis. The four target goals in the management of sepsis are: (1.) eliminate infection, (2.) improve circulation and tissue perfusion, (3.) prevent complications, and (4.) health education about the sepsis disease process, prognosis, and treatment needs (Doenges, et al., 2014).

Hospital stay, recovery, and rehabilitation from sepsis vary according to the severity of complications and pre-existing medical conditions. A rigid rehabilitation program is required for those with serious neurological complications and damage brought about by depleted oxygenation, poor circulation, and debilitating condition. Many patients who survive will recover completely for an average of 18 months before the survivor returns to an old healthy self. However, it was reported that 50% of sepsis survivors suffer from post-sepsis syndrome (PSS) with long-term effects brought by damaged organs such as insomnia, nightmare, disability, muscle/joints pains, chronic fatigue, poor concentration, impaired cognitive functions, low self-esteem, and post-traumatic stress disorder or PTSD (Medical News Today, 2020; O’Connell & Sullivan, 2018).


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