Sepsis: Nursing Care Plan & Interventions

Nurses are frequently the first healthcare professionals to observe patients when they arrive in the Emergency Department (ED), and they have a fundamental role in recognizing the physiologic changes that could indicate the onset of sepsis. Yet even the most experienced nurses may face delays in intervention if they don’t have clear protocols to act promptly when they detect early signs of this critical condition. Giving nurses the ability to initiate protocols that rapidly treat life-threatening disease improves outcomes and reduces long-term complications. In this article, we’ll explore how a structured nursing diagnosis, nurse-initiated order sets, and nursing care plans are critical to the early detection and treatment of sepsis.

Nursing Diagnosis for Sepsis

A nursing diagnosis for sepsis is a clinical judgment about how a patient is responding to infection and its complications. As sepsis is a time-critical condition that requires immediate clinical attention, early nursing diagnoses are essential to guiding care decisions. Furthermore, accurate nursing diagnoses ensure that sepsis interventions are prioritized appropriately.

Nursing assessment is the foundation of accurate diagnosis. By recognizing early signs of deterioration, nurses contribute directly to faster treatment. Research shows that each hour of delayed treatment for sepsis increases mortality by up to 8%. Nursing diagnoses informed by timely assessments help reduce that delay and improve outcomes.

NANDA International (formerly the North American Nursing Diagnosis Association-International) provides standardized nursing diagnoses that support assessment, planning, and evaluation of patients. Common NANDA-I nursing diagnoses associated with sepsis may include:

• Decreased cardiac output
• Hyperthermia
• Ineffective protection
• Risk for deficient fluid volume
• Risk for infection

These diagnoses give nurses a clear starting point for building care plans that support timely, appropriate treatment.

Nursing Care Plans

A nursing care plan for sepsis is focused on early recognition, rapid response, and ongoing monitoring. While specific components vary by institution, most share the following core elements:

Initial Nursing Assessment
Early warning indications often emerge during the initial nursing assessment of vital signs and level of consciousness. Nurses triage patients upon arrival to the ED, observing for:

• Altered mental status
• Systolic blood pressure below 100 mm Hg
• Respiratory rate greater than 22 breaths per minute
• Nurses may also assess for Systemic Inflammatory Response Syndrome (SIRS), which is defined by the presence of two or more of the following criteria:
• Temperature above 100.4 or below 96.8
• Heart rate over 90 beats per minute
• Respiratory rate over 20 breaths per minute,
• Abnormal white blood cell count

If sepsis is suspected based on these nursing assessments, nurses play a key role in initiating orders, per protocol.

Nurse-Initiated Order Sets

Nurse-initiated order sets, also known as standardized protocols or standing orders, have been used in medical care for more than 70 years. They have the potential to streamline care, improve patient safety, and enhance efficiency, while emphasizing the importance of nurses acting within their scope of practice.

In the ED, nurse-initiated protocols guide nurses to begin specific investigations for patients in need of early or urgent intervention before a physician’s assessment. ST-elevation myocardial infarction (STEMI) and stroke are two of the most commonly used protocols initiated by nurses.

Nurse-initiated order sets may include:

• Lactate level
• Blood cultures (before antibiotics are given, if possible)
• IV access and fluid resuscitation
• Oxygen therapy
• Initiation of sepsis protocol (if thresholds are met)

Communication, Escalation, and Ongoing Monitoring

Clear communication with providers is essential once sepsis is suspected. Nurses are responsible for promptly notifying the care team, and after initial interventions are in place, they continue monitoring for changes in vital signs, mental status, urine output, and overall perfusion. Reassessment is critical to timely escalation if the patient’s condition worsens, or they do not respond to treatment.

How Cytovale’s IntelliSep Can Help with Early Sepsis Detection

IntelliSep is a rapid, host-response test that analyzes immune activation in under 10 minutes using a standard blood draw. It integrates into existing triage workflows and complements nursing protocols, allowing nurses and care teams to act with greater confidence when time is critical. In a recent multi-site study, nurses called for more support in recognizing and managing sepsis—specifically asking for screening tools, formal protocols, and additional education on early signs and interventions. The IntelliSep test addresses this gap directly, providing objective, actionable data that strengthens clinical judgment, supports faster interventions, and reduces diagnostic uncertainty in the earliest stages of care.

Contact the Cytovale team to learn more.