NURSING DIAGNOSIS: Risk for infection: sepsis

related to:
  1. release of bacteria into the blood associated with:
    1. presence of infected necrotic areas or leakage of infected pseudocysts or abscesses (necrotic areas, pseudocysts, and abscesses can develop as a result of destruction of pancreatic and surrounding tissue by the activated proteolytic enzymes)
    2. peritonitis (if it occurs);
  2. decreased resistance to infection associated with decreased nutritional status
  3. break in skin integrity associated with frequent venipunctures or presence of invasive lines (e.g. intravenous catheter, hemodynamic monitoring devices).
Desired Outcome
The client will not experience sepsis as evidenced by:
  1. no further increase in temperature
  2. absence of chills and diaphoresis
  3. pulse and respiratory rate within normal range for client
  4. WBC and differential counts returning to normal
  5. negative blood culture results.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of sepsis (e.g. increase in temperature, chills, diaphoresis, tachypnea, tachycardia, increase in WBC count above previous levels and/or significant change in differential, positive blood cultures).
  2. Implement measures to prevent sepsis:
    1. perform actions to decrease pancreatic stimulation (see Diagnosis 4, action d.5) in order to reduce destruction of pancreatic and peripancreatic tissue and subsequent development of necrotic areas, pseudocysts, and abscesses
    2. perform actions to prevent and treat peritonitis (see Diagnosis 8, actions B and C in peritonitis complication)
    3. prepare client for drainage of an abscess or pseudocyst or surgical resection of necrotic tissue if planned
    4. maintain sterile technique during all invasive procedures (e.g. venous and arterial punctures)
    5. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
    6. perform actions to reduce stress (e.g. reduce pain and nausea; provide a calm, restful environment; explain diagnostic tests and treatment plan) in order to prevent an increase in secretion of cortisol (cortisol interferes with some immune responses)
    7. change intravenous line sites, tubing, and solutions according to hospital policy and maintain a closed system for intravenous infusions whenever possible
    8. anchor catheters/tubings (e.g. intravenous) securely in order to reduce trauma to the tissues and the risk for introduction of pathogens associated with in-and-out movement of the tubing
    9. administer antimicrobials as ordered.
  3. If signs and symptoms of sepsis occur, assess for and immediately report signs and symptoms of septic shock (e.g. systolic blood pressure less than 90 mm Hg; rapid, weak pulse; restlessness; agitation; confusion; urine output less than 30 ml/hour; cool, pale, mottled, and/or cyanotic extremities; capillary refill time greater than 3 seconds; diminished or absent peripheral pulses).