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Nursing Guide to Sepsis: Nursing Diagnosis, Interventions, & Care Plans

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Sepsis is a life-threatening organ dysfunction caused by inadequate oxygen delivery to tissues and cells within the body. It represents a spectrum ranging from uncomplicated infection to severe sepsis and septic shock.  

As a leading cause of morbidity and mortality globally, prompt identification and aggressive management are critical. Sepsis can result from bacterial, viral, fungal, or parasitic infections and affects all populations, in particular, neonates, older adults, and immunocompromised individuals. 

Nurses help with the early detection of sepsis, implementation of sepsis bundles, and ongoing monitoring. Timely intervention significantly improves outcomes by reducing the risk of complications and death. 

Sepsis Awareness: Key Concepts and Interventions

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Etiology and epidemiology 

Sepsis results from an overwhelming and dysregulated immune response to an invading pathogen, which may be bacterial, viral, fungal, or parasitic. This aberrant response leads to a systemic release of pro-inflammatory mediators, including tumor necrosis factor-alpha (TNF-α), interleukins, and nitric oxide. These substances cause widespread vasodilation, increased capillary permeability, and leukocyte infiltration.  

As a consequence, endothelial cells become dysfunctional, contributing to the leakage of plasma into interstitial spaces and a decline in vascular tone. Concurrently, the coagulation cascade becomes activated, often resulting in microvascular thromboses and impaired fibrinolysis, which can precipitate disseminated intravascular coagulation (DIC).  

The combined effects of hypoperfusion, coagulopathy, and inflammatory injury lead to impaired oxygen delivery to tissues and progressive organ dysfunction. Patients can develop acute kidney injury, acute respiratory distress syndrome (ARDS), liver dysfunction, and myocardial depression, ultimately increasing the risk of septic shock and death if not promptly managed. 

Common sources of infection 

  • Pneumonia 
  • Urinary tract infections 
  • Abdominal infections (e.g., peritonitis, appendicitis) 
  • Skin and soft tissue infections 
  • Device-related infections (e.g., central lines, urinary catheters) 
  • Postoperative surgical site infections 

Risk factors 

  • Age <1 year or >65 years 
  • Immunosuppression (e.g., cancer, HIV, corticosteroid use) 
  • Chronic illnesses (e.g., diabetes, renal failure, cirrhosis) 
  • Invasive procedures and indwelling devices 
  • Recent hospitalization or surgery 

Globally, sepsis contributes to approximately 20% of all deaths. It disproportionately affects underdeveloped countries and is a major cause of neonatal and maternal mortality. 

ICD-10 code 

The ICD-10-CM codes for sepsis include: 

  • A41.9 — Sepsis, unspecified organism 
    • Additional codes may include A40.x for streptococcal sepsis or A41.x for specific organisms 

Assessment 

Clinical criteria (based on Sepsis-3 definition) 

  • Infection confirmed or suspected 
  • qSOFA score: 2 or more of the following: 
    • Altered mental status (GCS <15) 
    • Respiratory rate ≥22/min 
    • Systolic BP ≤100 mm Hg 

Laboratory and diagnostic tests 

  • Blood cultures: These should be obtained prior to initiating antibiotic therapy to maximize the likelihood of identifying the causative pathogen. Two sets of blood cultures from different sites are typically recommended. 
  • CBC with differential: This assesses white blood cell count abnormalities such as leukocytosis (WBC >12,000/mm³) or leukopenia (WBC <4,000/mm³), which are indicators of systemic infection or immune suppression. 
  • Serum lactate: Elevated lactate levels (≥2 mmol/L) are indicative of tissue hypoperfusion and may signal progressing sepsis or septic shock. Serial measurements are used to monitor therapeutic response. 
  • C-reactive protein (CRP) and procalcitonin: These inflammatory biomarkers help assess the severity of infection. Procalcitonin is especially useful in distinguishing bacterial infections from other causes. 
  • Renal and liver function panels: This evaluates for organ dysfunction, including elevated creatinine (suggestive of acute kidney injury) and transaminases (indicating hepatic involvement). 
  • Coagulation profile: This includes INR, aPTT, fibrinogen, and D-dimer. These tests identify coagulopathy or evolving disseminated intravascular coagulation (DIC), common in severe sepsis. 
  • Imaging studies such as chest X-ray or CT scan: These help identify the source of infection, such as pneumonia, intra-abdominal abscesses, or obstructed urinary tracts. Point-of-care ultrasound may also aid in volume assessment and detecting fluid collections. 

Management 

Early goal-directed therapy (within one hour of recognition): 

  • Administer broad-spectrum IV antibiotics. These should be given immediately, ideally within the first hour of sepsis recognition. Empiric choices depend on suspected infection source, local resistance patterns, and patient risk factors. Timely administration is associated with reduced mortality. 
  • Begin fluid resuscitation with 30 mL/kg crystalloids. Initial boluses of isotonic saline or lactated Ringer’s solution are essential to restore intravascular volume and improve tissue perfusion. Fluid responsiveness should be assessed frequently, using dynamic and static parameters, such as pulse pressure variation or ultrasound. 
  • Obtain blood cultures before antibiotics. Two sets of cultures should be drawn from separate sites to enhance the likelihood of identifying the pathogen. However, treatment should not be delayed more than 45 minutes for culture collection. 
  • Monitor serum lactate levels. Elevated lactate indicates hypoperfusion and cellular metabolic stress. Serial lactate measurements help evaluate response to therapy and guide ongoing resuscitation efforts. 
  • Consider vasopressors (e.g., norepinephrine). Initiated if hypotension (MAP <65 mm Hg) persists after adequate fluid resuscitation. Norepinephrine is the first-line agent, titrated to target MAP. Other agents, like vasopressin or epinephrine, may be added if needed. Continuous hemodynamic monitoring is recommended. 
  • Use oxygen therapy and mechanical ventilation. Administer supplemental oxygen to maintain SpO2 ≥94%. Mechanical ventilation with lung-protective strategies (e.g., low tidal volume, PEEP) is indicated in patients with respiratory failure or ARDS. Close monitoring of oxygenation and ventilation parameters is essential. 
  • Practice source control. Rapid identification and elimination of the infection source is crucial. This may involve draining abscesses, debriding infected tissue, removing or replacing catheters and prosthetics, or performing surgical intervention. Timing and method depend on clinical stability and location of the infection. 
  • Provide glucose control, DVT, and ulcer prophylaxis. Maintain blood glucose between 140–180 mg/dL with insulin therapy as needed. Implement venous thromboembolism prophylaxis using low molecular weight heparin or mechanical devices. Provide stomach ulcer prophylaxis using proton pump inhibitors for patients with risk factors such as mechanical ventilation or coagulopathy. 

Nursing care plan 

A nursing care plan for sepsis is critical for early recognition, rapid intervention, and ongoing management of this life-threatening condition. Sepsis can progress quickly, leading to organ dysfunction and septic shock if not promptly treated.  

The care plan emphasizes close monitoring of vital signs, timely administration of antibiotics and fluids, oxygen support, and patient education. By identifying risk factors and initiating appropriate nursing interventions, nurses help improve survival rates and minimize long-term complications. 

Nursing considerations 

Effective nursing care in the management of sepsis relies on vigilant and continuous assessment. Nurses must consistently monitor vital signs, including heart rate, blood pressure, respiratory rate, and temperature, alongside oxygen saturation levels to detect early signs of deterioration.  

Close observation of urine output is essential for evaluating renal perfusion, while regular neurological assessments help identify altered mental status, a key indicator of worsening sepsis. Fluid status should be reassessed frequently using clinical indicators such as capillary refill, skin turgor, central venous pressure (if applicable), and overall fluid balance. Open and timely communication with the interdisciplinary healthcare team is critical to ensure rapid adjustments to the care plan based on evolving clinical findings. 

 Additionally, maintaining strict aseptic technique during invasive procedures and adhering to robust infection control practices are imperative in preventing secondary infections and ensuring patient safety. 

Assessment 

  • Vital signs: Monitor for fever, tachycardia, hypotension, tachypnea. 
  • Neurological status: Evaluate for confusion, lethargy. 
  • Intake/output: Assess renal perfusion via urine output. 
  • Skin: Look for mottling, cyanosis, delayed capillary refill. 
  • Lab trends: Watch for rising lactate, creatinine, and declining platelets. 

Nursing diagnosis/risk for 

  • Ineffective tissue perfusion related to systemic inflammatory response 
  • Risk for shock 
  • Risk for acute renal failure 
  • Altered mental status 
  • Hyperthermia or hypothermia 

Interventions

Domain Intervention 
Monitoring vital signs and response to therapy 

Frequent assessment of BP, HR, RR, body temperature, and SpO2, as well as lactate clearance. Maintain normothermia using blankets or cooling measures. 

  

Fluid management Monitor intake/output, assess for fluid overload or dehydration. 
Antibiotic therapy Administer as ordered, check for allergies, monitor for adverse reactions. 
Oxygenation Maintain SpO2 ≥94% with oxygen support or ventilation as needed. 
Infection control Practice proper hand hygiene, aseptic technique, proper line and catheter care. 
Communication Collaborate with the healthcare team and escalate care promptly if the patient declines.  
Nutritional status Support nutritional needs and prevent complications. 
Patient education Teach early signs of infection/sepsis and prevention strategies. 

Expected outcomes 

  • Stabilized hemodynamic parameters (blood pressure and heart rate) 
  • Improved organ perfusion and urine output 
  • Infection source identified and managed 
  • Patient and caregivers demonstrate understanding of prevention 

Individual/caregiver education 

  • Recognize early signs of sepsis: fever, fast breathing, confusion. 
  • Stress the importance of completing prescribed antibiotics. 
  • Encourage vaccination and hygiene to prevent infections. 
  • Reinforce follow-up care and when to seek emergency help. 

FAQs

Resources 

References 

Erin Devine, BSN, RN

Erin Devine, BSN, RN

Erin Devine, BSN, RN, is a healthcare recruiter with a solid foundation in clinical nursing. Since earning her Bachelor of Science in Nursing in 2013, she has worked in med-surg, cardiac, progressive care, and long-term care settings. Today, she draws on that experience to match healthcare professionals with roles that align with their skills and career aspirations.