Nursing Priorities and Interventions for Sepsis: A Case Study

This article discusses nursing priorities and interventions for sepsis using a case study. It covers impaired tissue perfusion, hypotension, normal body temperature, pain reduction, wound care, prevention of infection, and discharge plan. The article also includes references for further reading.

Introduction
Sepsis is the serious medical condition which has to be treated immediately with the support
of the evidence-based literature review helps the nurse to provide safe and quality nursing
care. The clinical scenario is about Mr. Paul peter a 45 years old presented to the with the
complaints of not feeling feel, elevated vital signs, hypotension, decreased Spo2 and infected
wound. This assessment aids in discussing the assessment, roles, and responsibilities of the
registered nurse, documentation, and evaluation. Discharge plan for Mr. Paul is also
discussed for the wellbeing of the patient.
Nursing priorities
Impaired tissue perfusion
On admission patient’s saturation level was low (Spo2 92%) which is related to sepsis.
declined saturation level indicates low oxygen level in the blood which is considered to be
the major complication of the disease condition. Decreased Spo2 causes impaired tissue
perfusion. Treating impaired gas perfusion is the main concern in the therapy for sepsis.
 Nursing interventions
Primary Nursing intervention is the assessment. The nurse has to check heart rate, respiratory
rate, temperature, and saturation continuously. Decreased Spo2 is the indication of declined
oxygen contribution to the tissues. To compensate the oxygen deficiency lungs increase the
breathing rate to ensure normal oxygen supply to the tissues. Oxygen therapy has to be
initiated as per the doctor’s order. The nurse needs to ensure humidified oxygen therapy.
Impaired gas perfusion has to be treated immediately and continuous monitoring has to be
implemented to prevent the patient from clinical deterioration.
Treat hypotension
Mr. Paul was suffering from severe sepsis. On admission patient’s blood pressure was 90/60
mmHg. Hypotension is related to sepsis. Infection in the central system causes an abrupt
discharge of cytokines which leads to vasodilatation. Vasodilatation decreases the blood
pressure and vascular resistance is also reduced. Decreased blood pressure significantly
affects the blood flow to the tissues and leads to hypoxia.

Nursing interventions
The nurse has to monitor the blood pressure continuously. The rationale for hypotension in
patients with sepsis is Hypovolemia. So both hypotension and Hypovolemia has to be treated
to prevent further complications (Asfar 2017). Fluid therapy repairs the fundamental and
marginal perfusion. The Normal circulatory blood volume alleviates the vital signs and also
makes sure the regular function of the system is restored. The nurse needs to check the vital
signs that are considered to be the key indicators of the stable condition of the body
(Malbrain 2018).
Maintain Normal body temperature
On admission patients, body temperature was elevated (39C). His vital signs are also elevated
which is related to the disease condition. Increased body temperature and the infection lead to
vasodilatation that is considered to be the major complication that is related to sepsis.
Nursing Interventions
Patient’s body temperature has to be monitored continuously. The nurse needs to apply a cold
compress and ice cap based on the temperature of the patient. Advise the patient to increase
the fluid intake (Kok 2017). Administer antipyretics to normalize the body temperature.
Elevated body temperature is due to sepsis, so infection need to be treated with antibiotics.
The nurse has to administer antibiotic as per doctor’s order (Howell 2017). Restrict visitors.
Ensure patient centered and family-centered nursing care in the treatment of sepsis.
Encourage the patient to take high protein diet which fastens the wound healing and
prevention of infection.
Pain reduction
The patient is suffering from Pain on the wound site and the pain score in the pain scale is
5/10. His wound is infected and inflamed with the green exudates. Nursing responsibility
includes pain reduction and promotion of comfort.
 Nursing Responsibilities
Primary nursing responsibility of the nurse in pain management is the pain assessment. The
nurses have to assess the intensity of pain, and location (Bloos 2017). Non- pharmacological
nursing intervention in pain management is positioning, the nurse has to position the patient

comfortably. Encourage the patient to do the deep- breathing exercise. The nurses have to
provide diversion therapy. The nurse needs to assist the patient in ambulation (Bartley 2015).
Wound dressing needs to be done twice daily. Pharmacological intervention includes
administration of analgesics.
Wound care
Wound care assessment in the case of Paul is essential to treat sepsis. The nurse has to assess
the wound for bleeding, Pus or fluid discharge, and green colored exudates present over the
left leg of the patient. Exudates in the wound site reveal that the wound is affected and needs
immediate attention Assessment reveals that the patient is suffering from a wound with green
exudates. Green color exudates show that the wound is severely infected.
 Nursing responsibilities
The nurse needs to clean the wound and do a wound dressing which fastens the recovery. The
nurse has to wash hands before and after wound dressing to prevent infection. Restriction of
visitors has to be implemented. The nurse needs to monitor the patient’s pain in the site of the
wound (Armstrong 2017). Administration of analgesics in the case of severe pain. Advice
the patient to reduce liquor drinking as it may affect wound healing. Educate the patient about
the importance of protein rick diet for wound healing. Administer antibiotics as per the
doctor’s prescription to prevent infection (Gotts 2016).
Prevention of infection
On assessment, the patient’s vital signs were abnormal and represent the level of infection
Patient’s present medical history shows that patient is feeling unwell which the typical
symptom of sepsis and suffering from the infected wound in the left leg and inflamed with
the green exudates.
 Nursing interventions
The nurse needs to monitor the patient continuously for the signs of clinical deterioration
which is considered to be a complication of sepsis. Encourage the patient to increase fluid
intake (Shetty 2018). The nurse needs to monitor the intake and output strictly because an
imbalance in the intake and output is the indication of fluid imbalance. The nurse has to
monitor the vital signs continuously (Chan 2015). Advise the patient about the importance of

taking nutritious food and encourage him to take more fruits, vegetable, and green leafy
vegetables. Educate the patient about the ways to prevent further infection and hand washing
techniques. The patient needs to be administered with antibiotics as per the doctor’s orders
(Kok 2017).
Discharge plan
In this case scenario, the patient lacks the knowledge of his disease condition and the nurse
need to plan the client education based on the level of understanding of the client. The nurse
needs to talk to the patient to know the patient’s attitude, belief, and knowledge about the
disease condition and healing process. The nurse needs to explain about the Pathophysiology
of the disease condition and the preventive measures in simple terms (Hoyer 2019). The
nurse should acknowledge that the patient understands the teaching provided by the nurse.
Ask the patient whether he has any doubt before his discharge and clear his doubts.
Educate the patient on infection prevention techniques. Demonstrate wound dressing and ask
the patient to do it. Educate the patient about the importance of wound dressing. Encourage
the patient to take a highly nutritious diet and explain how it supports wound healing.
Encourage the patient to do follow up. Explain the patient on increased fluid intake in wound
healing and hyperthermia. Advice the patient to stop smoking and explain how smoking habit
affects wound healing. Provide psychological and moral support to the patient. Teach the
patient about self-care and ask him to seek medical advice when he is unable to manage the
infection at home.
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