Sepsis Care Plan (2018)

Here’s your step-by-step guide to writing an AMAZING sepsis care plan in nursing school.

If you’re struggling with how to write nursing care plans, you will definitely want to watch this video all the way through.

I’ll walk you through, step-by-step, how to write a sepsis care plan for nursing school, including the nursing assessment, signs and symptoms of sepsis, and sepsis nursing interventions.

Thanks for watching this sepsis care plan video! Now go become a nursing ROCK STAR! 🙂

Make sure to download your free nursing care plan template with 3 sample care plans here.

VIDEO TRANSCRIPT

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Hello hello! My name is Christina Rafano from nursingsos.com and in this video we are going to walk through an example nursing care plan and, more specifically this is going to be a sepsis care plan. Now, if you haven’t watched the Nursing Care Plan Template video that we’ve got for you, you’ll want to check that out first, because I’ll be building off of that video here. And of course, if you want more care plan examples, you don’t want to miss out on the care plan database that I’ve got for you inside the NursingSOS Membership Community. I’ll pop a link in the description below for you to check that out. Now, let’s dive into the sepsis care plan.

Alrighty, so the nursing care plan is divided up into 5 main parts: assessment, diagnosis, planning, implementation, and evaluation. And I’ve actually got a free nursing care plan template for you to follow along with for this video. There’s a link down below for you to download that. And there’s also some more free sample care plans I threw in there as well for you too. So check that out!

So to start, you’ll go to clinical, and you’ll assess your patient. So while you’re assessing them, you’re documenting as you go, writing down the subjective and objective data you collect, and making sure you assess everything you need to assess. I’ve got a whole other video all about subjective and objective data if you want a deep dive into that. I’ll put a link in the description if you want to check that out.

Now this subjective and objective data will go in the first column of your nursing care plan template. And you can even get fancy and separate the 2 if you want into subjective data and objective data, so those will just go there in the first column.

So, let’s say for sepsis as an example, our patient has a pulse rate of 110 beats per minute, respiratory rate of 24 breaths per minute, a blood pressure of 90/50, a temperature of 102 degrees Fahrenheit, a urine output of 25mL per hour, diminished peripheral pulses, and the patient is stating that they feel cold and weak. Okay, so all of that is not so good, right? So we want to help this patient. And all of that assessment data will go in that first column, the assessment column.

And then once you’ve done your assessment and collected your subjective and objective data, you’ll look through your care plan book to find a NANDA® nursing diagnosis that fits that patient and their situation. And my FAVORITE care plan book is the Nursing Diagnosis Handbook by Ackley and Ladwig, it’s AMAZING, and you shouldn’t live without it in nursing school, it basically writes your care plans for you. So if you want to check that out, I’ll put an affiliate link down below in the description, and if you do decide to purchase that book through my link, I will receive a small commission, just a little disclaimer there, so thanks for that, I really appreciate your support, thank you so much.

So this nursing diagnosis should be something of priority for them, something that you really want to fix with your nursing interventions. So in this second column, you’ll write down your NANDA® nursing diagnosis that you think fits your patient the best. Now, for example here, we’re going to make up a nursing diagnosis of “Impaired Perfusion.” Now, this is not a real nursing diagnosis, those do change, so you need to make sure you have an up-to-date book with the current standardized nursing diagnoses. So for this video, we’re going to use “Impaired Perfusion” as a made up example, but you can look in your textbook and find the closest one about impaired perfusion if you’d like, there should be several in there that relate to decreased perfusion.

So, why did I choose impaired perfusion to focus on? Well, that blood pressure is low, but mostly it’s because of that urine output. Urine output should be at least 30mL per hour if the kidneys are healthy and functioning properly, but right now, they are having some trouble, which tells me that they might not be getting as much blood as they need, which means impaired organ perfusion. And this is a priority nursing diagnosis for sepsis, keeping the organs perfused is high on the list. So if you were curious, that’s why.

So, now that we have our nursing diagnosis, we need to figure out the related-to factor. So our nursing diagnosis is impaired perfusion, and so what is CAUSING this? Well we could choose a lot of things, but for this care plan let’s say that it’s due to vasodilation secondary to sepsis. So vasodilation meaning the blood vessels are dilating, so the blood just can’t get to the organs as well as it should.

Now, I did throw in that “secondary to” component in there, you don’t have to do that if you don’t want to, but it does help to clarify exactly what’s going on. That “secondary to” part should be the disease or disorder that’s causing whatever you wrote about in the “related-to” part of the nursing diagnosis statement.

And finally, the last part of the nursing diagnosis is the “as evidenced by” part, or the “aeb.” So here you list your assessment evidence that supports why you chose your nursing diagnosis. So here, we could really re-write all of the assessment things we originally wrote, because they all have something to do with perfusion, but for simplicity, we’ll stick the the 4 main ones: the blood pressure, the urine output, the peripheral pulses, and the patient feeling weak.

So that gives us our whole nursing diagnosis statement: Impaired perfusion related to vasodilation secondary to sepsis, as evidenced by a blood pressure of 90/50, urine output of 25mL per hour, diminished peripheral pulses, and the patient states she feels weak.

So, now that you’ve got your nursing diagnosis statement written, let’s move onto the next column in the sepsis care plan: planning. So here is where you will write your patient goals. And you’ll need to make sure they are SMART goals, and that they are written as what the patient will do. And if you need a refresher on how to write SMART patient goals, you’ll definitely want to check out the How To Write Care Plan video that I’ve got for you. So, we’ll start our patient goal with, “The patient will…” and then we’ll write what we want them to achieve to help improve. So for this example sepsis care plan, we’ll say that our goal is, “The patient will have a blood pressure above 100 milimeters mercury by 1700 tomorrow.” This goal follows the SMART framework, because it’s specific, measurable, achievable, relevant and time-bound, and it is patient centric because we have written it as what the PATIENT will do.

And now, let’s create some nursing interventions to solve the underlying problem, the vasodilation and sepsis. So for this example sepsis care plan, we could write some nursing interventions such as: “The nurse will draw labs and take blood cultures.” “The nurse will assess the patient’s vital signs frequently (per facility policy).” “The nurse will give fluids as prescribed.” “The nurse will give vasopressors, oxygen, and other medications as prescribed.”

So all of these nursing interventions help to solve the underlying problem. It’s important that when you do and write your nursing interventions, you’re not just trying to put a band-air over the signs and symptoms, we want to fix the underlying condition. So all of these nursing interventions help to solve that underlying problem of sepsis and vasodilation, and in turn, they help the patient reach that goal of having a blood pressure above 100 milimeters mercury.

And for most nursing schools, they’ll want you to find an evidenced based rationale for each nursing intervention you use. So go through your textbook and find where they talk about the disorder or about the intervention you choose, and figure out why that nursing intervention is important.

And finally, you’ll need to evaluate your patients progress. Did they meet that goal or not? If they did meet their goal, you will need to set a new goal and do this whole process over again with a brand new goal. If they didn’t meet their goal, write down what changes need to be made in order to help them get there.

So with this example sepsis care plan, if our patient didn’t meet their goal of having a blood pressure above 100 milimeters mercury, we would write what we could change in the care plan: things like, “Consult with the healthcare team to choose the best course of action,” “Continue to assess and monitor the patient,” “Recommend an increase in fluids to the healthcare team.”

So if the goal was not met, make sure you give some recommendations to help them meet that goal.

And that is your sample sepsis care plan! I really hope that helped to clarify the care plan process for you. And if you want more sample care plans, you will definitely want to jump into the NursingSOS Membership Community where we’ve got a ton of them for you.

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Thank you so much for watching, friend, now go become the nurse that God created only YOU to be. And I’ll see you right back here next time on the nursing school show, take care.

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