Step-by-Step Guide: Nursing Assessment & Diagnosis for Sepsis

When an infection, typically bacterial, enters in bloodstream, it causes a systemic disease with an extreme immune reaction. Early intervention is necessary to avoid septic shock, which can cause organ failure or death. Licensed practical nursing schools help to enhance the clinical practice and make your nursing career successful.

If not treated aggressively, Sepsis can develop very quickly. It has a high mortality rate if it is not diagnosed and treated in long-term care facilities. Sepsis is most common in infants and older adults, as well as those with chronic illnesses or weakened immune systems.

Nursing Assessment for Sepsis

The health care team gathers physical, psychological, emotional, and diagnostic information in the first step. This section will discuss objective and subjective data that are related to sepsis.

Systematic Review of Health History

1.The following general symptoms characterize sepsis.

Temperature increase or decrease
Chills
Changes in mentation
Rapid Breathing
Cool or flushed skin
Hypertension

2.What is the cause of Sepsis?

Any infection, including viruses, bacteria, and fungi, can cause Sepsis. Sepsis can be caused by infection from the following:

Lung (pneumonia)
Kidney, bladder, and urinary system
Gastrointestinal system
Blood
Invasive devices
Burns or Wounds

3.Identify risk factors

The following factors increase bacterial sepsis:

Age 65 and older
Infancy
Immune system compromised
Comorbidities include diabetes and kidney disease.
Longer hospital stays
Invasive lines such as central venous or urinary catheters
Antibiotic therapy and fluid shift therapy that was unsupervised and prolonged within the past 90 days
Use of corticosteroids or other immunosuppressants

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4. Examine the medical history

The following conditions can cause sepsis:

Existing infection
Undiagnosed infection
Untreated infection
Immune system compromised (such as HIV or cancer ).
Chronic diseases (such as diabetes or COPD ).
Recent surgical procedures
Implantable devices such as pacemakers and ports
Organ transplant complications

5.Check the critical care patient’s medication list

Take note of corticosteroids or other immunosuppressive drugs that may lower the immune response. Assess for antibiotic usage. The following factors can cause drug-resistant bacteria:

Refusing antibiotics without a prescription
Antibiotics are not necessary
Frequent antibiotic use
No access to medication
Poor quality medication
Incorrect drug prescribing

Physical Assessment

1. Check your vital signs of infection

The initial changes that are seen in the vital signs of septic patients with sepsis include:

Hyperthermia or hypothermia?
Tachycardia
Tachypnea

2. Conduct a systemic evaluation

Without interventions for sepsis, Sepsis can progress to severe sepsis or septic shock and organ dysfunction. Watch for these changes:

Alteration in mental state
Respiratory: Hypoxia, cough, chest discomfort, Dyspnea
Cardiovascular reduced capillary refill
Gastrointestinal: Ileus Perforation abscess, abdominal pain
Genitourinary reduced (oliguria or anuria) or absence (anuria).
Integumentary: flushed skin, cyanosis, pallor, skin mottling

3.Assess the progression of shock

Hypotension and decreased perfusion of the organs are symptoms that may be seen as septic shock advances.

Cool extremities
Delayed capillary filling (>3 seconds).
Thready peripheral pulses
Pale skin
Diaphoresis
Confusion
Reduced level of awareness

4.Look for intravenous lines

Any signs of sepsis (infection) or thrombophlebitis, such as redness, swelling, or drainage, should be observed at the IV site. Sepsis and bacteremia are often associated with central venous lines.

5.Incisions and wounds may show symptoms of sepsis

Abscesses, cellulitis, or wound infections can cause pain, purulent discharges, erythema, or swelling. Document and closely monitor changes to wounds and incisions. Learn how to do wound nursing care by enrolling in licensed practical nurse programs near me (practical nursing programs)

Nursing Care Plan & Diagnostic Procedures

1.Samples for laboratory tests are collected

These tests can be used to nursing diagnosis for sepsis and determine the cause.

A complete blood count will reveal high or low WBCs, neutropenia, and thrombocytopenia.
Kidney Function Tests may indicate poor renal perfusion.
Site-specific cultures can be used to determine the cause of Sepsis.
Urinalysis and culture Further investigate the cause of infection.
Biomarkers, such as procalcitonin or prosaposin, help nursing diagnosis for sepsis earlier.
Lactate Levels >2mmol/L are associated with poor organ perfusion. Levels over four mmol/L indicate septic shock.
C reactive protein should be elevated.
Results that are elevated in INR and PTT indicate abnormalities of coagulation.