Nursing Care Plan

Causes, Symptoms and Nursing Diagnosis for Septic Shock

Nursing Diagnoses 2015-17:
Definitions and Classification
(NANDA Nursing Diagnoses)

NCP Septic Shock

Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure.

Septic shock is a possible consequence of bacteremia, or bacteria in the bloodstream. Bacterial toxins, and the immune system response to them, cause a dramatic drop in blood pressure, preventing the delivery of blood to the organs. Septic shock can lead to multiple organ failure including respiratory failure, and may cause rapid death. Toxic shock syndrome is one type of septic shock.

Septic shock still remains the one of the leading causes of death in hospital patients. Barely more than 50% of the patients with severe sepsis survive their hospital admission. This unacceptable high mortality can only be reduced if there is greater awareness and understanding of the condition .and the knowledge of most effective treatment measures available. Unplanned admissions to the Intensive Care Unit (ICU) and potentially preventable deaths on wards are associated with a failure to institute early preventive conditions. Greater than 40% of the intensive Care Unit admissions are potentially preventable with improved ward care.

Septic shock causes a very low blood pressure, which causes a decrease the amount of blood and oxygen reaching the other organs, leading to multi-system organ failure (MSOF). In MSOF, the major organs, including the brain, liver, kidneys and lungs, all stop working properly. If a patient in septic shock does not receive the appropriate antibiotics, medications to support the blood pressure, and respiratory support with oxygen or a breathing machine (ventilator), it could lead to death. Sometimes, even if a patient does receive the proper treatments for septic shock, the infection may be too overwhelming for the body to be able to respond to the medications. That is why it is so important to diagnose and treat infections prior to them causing sepsis or septic shock.

Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include:
  • Cool, pale extremities
  • High or very low temperature, chills
  • Lightheadedness
  • Low blood pressure, especially when standing
  • Low or absent urine output
  • Palpitations
  • Rapid heart rate
  • Restlessness, agitation, lethargy, or confusion
  • Shortness of breath
  • Skin rash or discoloration
Septic shock is treated initially with a combination of antibiotics and fluid replacement. The antibiotic is chosen based on the bacteria present, although two or more types of antibiotics may be used initially until the organism is identified. Intravenous fluids, either blood or protein solutions, replace the fluid lost by leakage. Coagulation and hemorrhage may be treated with transfusions of plasma or platelets. Dopamine may be given to increase blood pressure further if necessary.
Respiratory distress is treated with mechanical ventilation and supplemental oxygen, either using a nosepiece or a tube into the trachea through the throat.
Identification and treatment of the primary infection site is important to prevent ongoing proliferation of bacteria.


Nursing Diagnosis for Septic Shock

1. Decreased Cardiac Output

2. Ineffective tissue perfusion

3. Fluid Volume Deficit

4. Impaired gas exchange

5. Ineffective breathing pattern

6. Imbalance nutrition: less than body requirements

7. Risk for imbalanced body temperature

8. Impaired physical mobility

9. Risk for Impaired skin integrity

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