Sepsis Nursing Diagnosis & Care Plan

Sepsis is the body’s response to an infection from either a bacterium, fungus, virus, or other pathogen. According to the Centers for Disease Control and Prevention (CDC), at least 1.7 million adults in the U.S. develop sepsis, and at least 350,000 die as a result.¹

A well-structured nursing care plan is vital for rapid assessment, timely treatment, and continuous monitoring. This article outlines the key elements of nursing care plans that help improve outcomes for patients with sepsis.

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What is Sepsis?

The body’s extreme and distinct response to a specific infection causes sepsis. When left untreated, sepsis can lead to septic shock and death. Specific signs of septic shock are persistent low arterial pressure, low tissue perfusion, and an alteration in oxygenation. 

Common Symptoms of Sepsis

Signs and symptoms of sepsis include:

• Tachycardia
• Fever
• Hypothermia
• Hypotension
• Weakness
• Low energy
• Reduced urination
• Rash
• Shortness of breath
• Chills
• Warm, clammy skin
• Confusion
• Disorientation
• Pain
• Hyperventilation
• Agitation²

Sepsis Causes

Sepsis can develop due to various reasons, but it is typically the result of bacterial, fungal, parasitic, and viral infections.

Specific causes most often related to sepsis are:

• Lung infection
• Skin infection
• Intestinal infection
• Urinary tract infection

The most common germs that develop into sepsis are:

• Staphylococcus aureus (staph)
• Escherichia coli (E. coli)
• Some types of Streptococcus³

Sepsis Risk Factors

While an infection is the primary cause, certain factors may increase the risk of sepsis, including:

• Age (below one or over 65 years old)
• Weakened immune system
• Malnutrition
• Chronic diseases
• Treatment with antibiotics in the last 3 months
• Specific medications
• Recent surgery
• Pregnancy or recently post-partum¹

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Sepsis Diagnosis

Practitioners diagnose sepsis using a variety of subjective and objective data. Blood tests that look for an infection, such as a blood or urine culture, are the most common diagnostic tool. Others include:

• Physical examination
• Vital signs
• Diagnostic imaging such as X-ray, CT, or MRI⁴

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How to Develop a Sepsis Nursing Care Plan

Developing a nursing care plan helps nurses and other healthcare professionals meet the patient’s short-term and long-term goals. When developing a sepsis nursing care plan, the first step is determining those goals. 

Although you’ll generate parts of the nursing care plan on your own, the nursing diagnosis must be on the NANDA-I-approved nursing diagnosis list.

According to the North American Nursing Diagnosis Association (NANDA),  a nursing diagnosis is “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is rooted in Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis, you’ll set goals to resolve your patient’s problems through nursing interventions determined in the next step.

NANDA-I separates nursing diagnoses into four categories:

• Problem-focused: A diagnosis based on patient problems present during a nursing assessment.
• Risk: A diagnosis based on risk factors that require intervention from a nurse or healthcare team before a real problem develops.
• Health promotion: A diagnosis that intends to improve the overall well-being of an individual, family, or community.
• Syndrome: Based on a cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions.

Determining the most important goals for the patient and the corresponding nursing diagnosis provides the basis to create an infection care plan that can best support the patient while reaching those goals.

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Sepsis Nursing Care Plan Components

A nursing care plan has several key components, including: 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales
• Evaluation

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections. Otherwise, it won’t make sense.

• Nursing diagnosis: A clinical judgment that helps nurses determine the plan of care for their patients.
• Expected outcome: The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales: Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation: Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

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Sepsis Nursing Care Plan Examples

All nursing diagnoses must be NANDA-I approved and have corresponding definitions to help guide nurses in writing a nursing care plan.

• NANDA-I Definition of Sepsis: Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.⁵ 

1. Risk for Infection

The patient is at risk for infection related to the presence of a foreign pathogen, a compromised immune system, and prolonged hospitalization, as evidenced by low blood pressure and elevated temperature.

As Evidenced By:

• Elevated white count
• Hypotension
• Hyperthermia
• Underlying cancer diagnosis 

Expected Outcome:

• The patient will remain free of infection.
• The patient’s white count will return to baseline.
• The patient’s temperature will remain within 36.5 and 37.5 degrees Celsius. 

Nursing Interventions:

• Collaborate with healthcare professionals and infectious disease providers to determine antibiotic therapy. 
• Administer antibiotic therapy as ordered.
• Send cultures as ordered. 
• Perform proper hand hygiene and adhere to infection prevention protocols. 
• Educate the patient and family on infection and prevention strategies. 
• Coordinate with oncology for the patient’s plan of care. 

2. Altered Mental Status

The patient has an altered mental status related to septic encephalopathy as evidenced by confusion, excessive sleepiness, and disorientation.

As Evidenced By:

• Confusion
• Disorientation
• Excessive sleepiness
• Increased ICP
• Delayed reaction to questions
• Forgetfulness
• Incoherent speech
• Hallucinations

Expected Outcome:

• Patient will be awake, alert, and oriented to person, place, and time (X3) throughout the shift. 
• The patient will not experience any falls during the shift. 
• The patient will work with a PT to perform activities of daily living (ADLs) throughout the shift.

Nursing Interventions:

• Perform full neurological assessments as ordered and report any changes to the medical provider. 
• Promote rest and relaxation for the patient. 
• Document the patient’s mental status and level of consciousness (LOC).
• Administer prescribed medications as ordered.
• Transport the patient to MRI, CT, or EEG as ordered.
• Obtain labs as ordered.
• Collaborate with healthcare professionals to ensure quality patient care. 

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Other Nursing Care Plans

• Hypertension Nursing Care Plan
• Acute Pain Nursing Care Plan
• Infection Nursing Care Plan
• Constipation Nursing Care Plan
• Decreased Cardiac Output Nursing Care Plan
• COPD Nursing Care Plan
• Pneumonia Nursing Care Plan
• Diabetes Mellitus Nursing Care Plan
• Fluid Volume Deficit Nursing Care Plan
• Impaired Physical Mobility Nursing Care Plan
• Risk for Falls Nursing Care Plan
• Atrial Fibrillation (AFib) Nursing Care Plan
• Heart Failure Nursing Care Plan

Resources

_{1 “Risk Factors for Sepsis | Sepsis.” CDC, 31 January 2025, https://www.cdc.gov/sepsis/risk-factors/index.html.} 

_{2 “Sepsis: Symptoms, Causes, Treatment & Prevention.” Cleveland Clinic, 19 January 2023, https://my.clevelandclinic.org/health/diseases/12361-sepsis#symptoms-and-causes.} 

_{3 “Septicemia.” Johns Hopkins Medicine, https://www.hopkinsmedicine.org/health/conditions-and-diseases/septicemia.} 

_{4 Ball, Jane W., Seidel's Guide to Physical Examination: An Interprofessional Approach. 9 ed., Elsevier, 2019.}

_{5 Herdman, T. H., Shigemi Kamitsuru, and Camila Lopes, eds. 2024. NANDA-I International Nursing Diagnoses: Definitions & Classification, 2024-2026. 13th ed. N.p.: Thieme Medical Publishers.}

Nursing Care Plan