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Nursing Care Plan for Sepsis

 |  in Sepsis at  5:04 PM

Sepsis is when the immune system responds to a serious infection by attacking the body's own organs and tissues. The infection can originate in many body parts, including the lungs, intestines, urinary tract, or skin.

A bacterial infection anywhere in the body may set off the response that leads to sepsis. Common places where an infection might start include:
  • The bloodstream
  • The bones (common in children)
  • The bowel (usually seen with peritonitis)
  • The kidneys (upper urinary tract infection or pyelonephritis)
  • The lining of the brain (meningitis)
  • The liver or gallbladder
  • The lungs (bacterial pneumonia)
  • The skin (cellulitis)
A sepsis workup may be needed to help identify the location of the infection and type of microorganism causing the infection. A sepsis workup may include the following procedures:
  • Blood tests
  • lumbar puncture (Also called spinal tap.) - a special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes your child's brain and spinal cord.
  • blood cultures
  • urine culture (sometimes by suprapubic tap, insertion of a needle through the lower abdomen into the bladder)
  • culture of fluids from inside tubes and catheters that are inserted in the baby
  • x-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.


If you have sepsis, you will be admitted to a hospital, usually in the intensive care unit (ICU). Antibiotics are usually given through a vein (intravenously).

Oxygen and large amounts of fluids are given through a vein. Other medical treatments include:
  • Medications that increase blood pressure
  • Dialysis if there is kidney failure
  • A breathing machine (mechanical ventilation) if there is lung failure

Nursing Diagnosis for Sepsis

1. Risk for Infection (progression from sepsis to septic shock) related to the development of opportunistic infections.

2. Hyperthermia / Hypothermia related to an increase in metabolic rate, vasoconstriction / vasodilation of blood vessels.

3. Ineffective tissue perfusion related to the reduced supply of oxygen / breathing irregular.

4. Risk for fluid volume deficit related to fluid diarrhea, vomiting, fluid shifts from the interstitial to the vascular tissue.

5. Imbalanced nutrition, less than body requirements related to nausea, vomiting, increased metabolism.

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