Sepsis is a life-threatening condition that arises when the body’s response to an infection becomes dysregulated, causing injury to its own tissues and organs. This widespread inflammatory response leads to organ dysfunction, which defines this medical emergency. When a patient is admitted for care, healthcare professionals use specialized terminology to describe and manage the situation. A doctor defines the illness differently than how a nurse formally describes the patient’s immediate needs and reactions.
Medical Diagnosis Versus Nursing Diagnosis
Sepsis is categorized as a medical diagnosis, which focuses on the pathology of the disease itself. This diagnosis identifies the specific illness, which is the systemic organ dysfunction caused by an infection. A physician or advanced practice provider establishes the medical diagnosis, which remains constant throughout the course of the illness. It provides the foundation for determining the disease process that requires treatment, such as administering antibiotics.
A nursing diagnosis, conversely, is a clinical judgment about an individual’s actual or potential response to a health condition. This assessment focuses on the patient’s reactions and needs that a nurse can independently manage or address. The standardized language for these clinical judgments is provided by NANDA International (NANDA-I). NANDA-I allows nurses to communicate patient care needs clearly and consistently across different healthcare settings. The nursing diagnosis is dynamic, changing as the patient’s condition evolves, rather than focusing solely on the underlying disease.
Key Nursing Diagnoses Related to Sepsis
Since sepsis is the medical diagnosis, the nurse applies specific NANDA-I diagnoses that reflect the patient’s bodily responses to the systemic infection. A common concern is the Risk for Shock, which recognizes the patient’s vulnerability to dangerously low blood pressure and inadequate blood flow to organs. This risk is high because the inflammatory cascade causes widespread vasodilation and capillary leakage, reducing effective circulating blood volume.
Another high-priority nursing diagnosis is Ineffective Tissue Perfusion, related to decreased cardiac output and altered blood flow distribution. This diagnosis directs the nurse to assess for signs of poor oxygenation, such as changes in mental status, cool extremities, or decreased urine output. Because sepsis involves a systemic inflammatory response, the nursing diagnosis of Hyperthermia or Hypothermia is often applicable. These diagnoses address the patient’s inability to maintain a stable body temperature, a direct sign of the body’s dysregulated response.
The Nursing Process in Sepsis Management
The nursing diagnoses established for a patient with sepsis guide rapid and targeted care. Nurses use continuous and focused assessments to identify early signs of deterioration, such as a respiratory rate greater than 22 breaths per minute or a sudden change in mental status. Early recognition is valuable because mortality rates for sepsis increase with each hour that treatment is delayed.
The nurse is responsible for the rapid implementation of time-sensitive interventions outlined in sepsis protocols. These actions include obtaining blood cultures before administering broad-spectrum antimicrobials to help identify the causative organism. Nurses initiate fluid resuscitation by administering prescribed intravenous crystalloids to restore tissue perfusion and counteract vasodilation. Continuous monitoring of vital signs, urine output, and serum lactate levels allows the nurse to track the patient’s response and promptly communicate any lack of improvement.