Sepsis is the body's extreme response to an infection, and it can quickly cause organ damage and shock. Early recognition and fast action, meaning cultures, antibiotics, and fluids, save lives.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Risk for Shock
Related to
- Widespread vasodilation from infection
- Fluid shifting out of the blood vessels
As evidenced by
- Fever or low temperature
- Heart rate over 90 and respiratory rate over 20
- Lactate above 2
- New confusion
Short-term goals
- MAP of 65 or higher within the first hours of treatment
- Urine output of at least 0.5 mL/kg/hr
Long-term goals
- Client is free of organ damage and returns to baseline mental status
- Vital signs and MAP frequently
- Lactate, repeated if the first is high
- Urine output hourly
- Mental status and skin perfusion
| INTERVENTION | RATIONALE |
|---|---|
| Draw blood cultures before antibiotics, without delaying them | Cultures identify the organism so therapy can be targeted. |
| Give broad-spectrum antibiotics as soon as ordered | Each hour of delay raises the risk of death. |
| Give the ordered IV fluid bolus (often 30 mL/kg of crystalloid) | Fluid restores circulating volume and perfusion. |
| Prepare for vasopressors if BP stays low after fluids | Vasopressors raise MAP when fluids are not enough. |
EVALUATION
- MAP stays at 65 or higher
- Repeat lactate is falling
- Urine output meets the goal
- Client is alert and oriented
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Hyperthermia
Related to
- Infection and inflammatory response
As evidenced by
- Temperature above 38.3 °C (101 °F)
- Warm, flushed skin
- Tachycardia
Short-term goals
- Temperature returns toward normal within the ordered time
Long-term goals
- Client remains afebrile after the infection is treated
- Temperature at least every 4 hours and with any change
- Signs of dehydration
| INTERVENTION | RATIONALE |
|---|---|
| Give antipyretics as ordered | They lower temperature and improve comfort. |
| Encourage fluids or give IV fluids as ordered | Fever increases fluid loss. |
| Use cooling measures like light linens | These help release body heat without causing shivering. |
EVALUATION
- Temperature is trending down
- Client reports feeling more comfortable
Quick answers
What is the first priority in sepsis?
Recognize it early. Then draw cultures, start antibiotics, give fluids, and check lactate as fast as possible.
Why repeat the lactate?
A falling lactate shows that perfusion is improving with treatment.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.