Nursing Diagnosis and Nursing Intervention for Sepsis
Risk for Infection
Nursing Intervention for Sepsis
1. Examine client for possible source of infection, such as sore throat, sinus pain, burning with urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines. Rationale: Respiratory tract and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections. The use of intravascular devices is also a well-known cause of hospital-acquired sepsis.
2. Investigate reports of pain out of proportion to visible signs.
Rationale: Pressurelike pain over area of cellulitis may indicate development of necrotizing fasciitis due to group A beta hemolytic streptococci (GABS), necessitating prompt intervention.
3. Maintain sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. Rationale: Medical asepsis prevents or limits introduction of bacteria and reduces the risk of nosocomial infection.
4. Wash hands with antibacterial soap before and after each care activity, even when gloves are used.
Rationale: Hand washing and hand hygiene reduce the risk of crosscontamination. Note: Methicillin-resistant Staphylococcus aureus (MRSA) is most commonly transmitted via direct contact with healthcare workers who fail to wash hands between client contacts.
5. Encourage client to cover mouth and nose with tissue when coughing or sneezing. Place in private room if indicated. Wear mask when providing direct care as appropriate. Rationale: Appropriate behaviors, personal protective equipment, and isolation prevent spread of infection via airborne droplets.
6. Encourage or provide frequent position changes, deep-breathing, and coughing exercises.
Rationale: Good pulmonary toilet may reduce respiratory compromise.
7. Provide isolation and monitor visitors, as indicated.
Rationale: BSI should be used for all infectious clients. Wound and linen isolation and hand washing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions. Reverse isolation and restriction of visitors may be needed to protect the immunosuppressed client.
8. Limit use of invasive devices and procedures when possible. Remove lines and devices when infection is present and replace if necessary.
Rationale: Reduces number of possible entry sites for opportunistic organisms.
9. Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral nutrition lines. Document signs of local inflammation and infection and changes in character of wound drainage, sputum, or urine.
Rationale: Catheter-related bloodstream infections (CR-BSIs) are increasing where central venous catheters are used in both acute and chronic care settings. Clinical signs, such as local inflammation or phlebitis, may provide a clue to portal of entry, type of primary infecting organism(s), as well as early identification of secondary infections.
Nursing Intervention for Sepsis
1. Examine client for possible source of infection, such as sore throat, sinus pain, burning with urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines. Rationale: Respiratory tract and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections. The use of intravascular devices is also a well-known cause of hospital-acquired sepsis.
2. Investigate reports of pain out of proportion to visible signs.
Rationale: Pressurelike pain over area of cellulitis may indicate development of necrotizing fasciitis due to group A beta hemolytic streptococci (GABS), necessitating prompt intervention.
3. Maintain sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. Rationale: Medical asepsis prevents or limits introduction of bacteria and reduces the risk of nosocomial infection.
4. Wash hands with antibacterial soap before and after each care activity, even when gloves are used.
Rationale: Hand washing and hand hygiene reduce the risk of crosscontamination. Note: Methicillin-resistant Staphylococcus aureus (MRSA) is most commonly transmitted via direct contact with healthcare workers who fail to wash hands between client contacts.
5. Encourage client to cover mouth and nose with tissue when coughing or sneezing. Place in private room if indicated. Wear mask when providing direct care as appropriate. Rationale: Appropriate behaviors, personal protective equipment, and isolation prevent spread of infection via airborne droplets.
6. Encourage or provide frequent position changes, deep-breathing, and coughing exercises.
Rationale: Good pulmonary toilet may reduce respiratory compromise.
7. Provide isolation and monitor visitors, as indicated.
Rationale: BSI should be used for all infectious clients. Wound and linen isolation and hand washing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions. Reverse isolation and restriction of visitors may be needed to protect the immunosuppressed client.
8. Limit use of invasive devices and procedures when possible. Remove lines and devices when infection is present and replace if necessary.
Rationale: Reduces number of possible entry sites for opportunistic organisms.
9. Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral nutrition lines. Document signs of local inflammation and infection and changes in character of wound drainage, sputum, or urine.
Rationale: Catheter-related bloodstream infections (CR-BSIs) are increasing where central venous catheters are used in both acute and chronic care settings. Clinical signs, such as local inflammation or phlebitis, may provide a clue to portal of entry, type of primary infecting organism(s), as well as early identification of secondary infections.
