Nursing diagnosis for sepsis in order of priority

Sepsis is a serious response to infection that can disturb the work of several organs. A nurse assesses alertness, breathing, skin colour, pulse, blood pressure, temperature, urine output and new weakness. The order can change quickly: immediate threats to the airway, breathing or circulation come first, followed by tests and treatment aimed at the infection.

Possible sources include pneumonia, a urinary tract infection or cellulitis. Fever, chills and feeling generally unwell can occur, but symptoms vary. A nurse may record trends rather than relying on one observation, because a changing pattern can show that urgent treatment is needed.

Expect repeated observations, questions about recent illness and medicines, and checks for hydration and urine. The clinical team may arrange blood tests, cultures or scans, give oxygen or fluids when indicated, and start prescribed treatment for the suspected infection. Tell staff about reduced urination, confusion, breathlessness, rash, recent procedures and any antibiotics already taken.

Seek emergency help for confusion, fainting, severe breathlessness, blue or grey lips, cold clammy skin, very little urine, or rapidly worsening illness. Do not wait for a fever. Sepsis needs urgent assessment, especially when infection is suspected and the person is becoming unusually weak or difficult to wake.

Ask which infection source is suspected, what observations are being followed, which warning changes should be reported immediately, and when the treatment plan will be reviewed.