Nursing care
Nursing care plan for sepsis: ranked diagnoses, measurable goals and rationales
Written and reviewed by Nicole Ramirez, BSN, RN, CMSRN · 5 min read · Updated November 2026
Short answer
A nursing care plan for sepsis ranks risk for shock, or ineffective tissue perfusion, first, because sepsis is organ dysfunction from the body's response to infection. Next come the infection itself, impaired gas exchange, acute confusion and temperature or glucose problems. Goals use numbers the nurse can measure: a mean arterial pressure of 65 mm Hg or more and urine output near 0.5 mL/kg/hour.
Sepsis care plan table: five problems in the order they kill
Labels follow NANDA-I as the source taxonomy; editions differ, so use your program's wording. Fluids, antibiotics and vasopressors are prescribed treatments, so the interventions column describes what the nurse monitors, sequences and reports.
| Nursing diagnosis or problem | Goal or outcome | Nursing interventions | Rationale |
|---|---|---|---|
| 1. Risk for shock related to infection-driven vasodilation and capillary leak | MAP 65 mm Hg or higher and urine output near 0.5 mL/kg/hour | Frequent vital signs and MAP, hourly urine output, give prescribed fluids promptly, report falling pressure or rising lactate | Septic shock is sepsis needing vasopressors to keep MAP at 65 with lactate above 2 despite fluids |
| 2. Infection related to the source, such as lungs, urine or a wound | Cultures collected before the first antibiotic dose; antibiotic started without delay | Draw ordered cultures, then hang the first dose as soon as it arrives, assess lines and wounds | Antibiotics are given as soon as possible after cultures are taken, so the cause of the infection can still be identified |
| 3. Impaired gas exchange related to a rising respiratory rate and lung involvement | Respiratory rate and oxygen saturation within the ordered range | Count respirations for a full minute, monitor saturation, raise the head of bed, report work of breathing | Tachypnea is one of the core sepsis signs and is easy to miss on a rushed count |
| 4. Acute confusion related to poor brain perfusion | Client stays oriented or returns to baseline mental status | Compare with baseline, reorient, keep fall precautions, report new confusion | Altered mental status is a sign of organ dysfunction, not just age |
| 5. Hyperthermia or hypothermia and risk for unstable glucose | Temperature trending toward normal; glucose within the ordered range | Monitor temperature and glucose as ordered, cooling comfort measures, report a low temperature | Hypothermia can be a sign of sepsis; MSD lists a glucose target of 110 to 180 mg/dL |
A plan written for a client already on vasopressors should state decreased cardiac output or ineffective peripheral tissue perfusion as an actual problem, with the cues as evidence, rather than a risk.
Why perfusion leads and the infection comes second
Infection is the usual wrong first pick, because sepsis starts with one. The plan ranks by what will cause death soonest. MSD Manuals puts mortality at about 25 to 30 percent for sepsis and 40 to 60 percent for septic shock, and the step from one to the other is a perfusion failure. Warm skin early can turn into cool, mottled extremities as shock develops.
The infection row still drives the clock. CDC estimates that about 1.7 million US adults develop sepsis each year and at least 350,000 die in hospital or are discharged to hospice. The nursing contribution is speed and sequence: cultures first, then the antibiotic as soon as it is ready, without waiting for the culture results.
Bedside cues that move a client up the list
CDC lists clammy or sweaty skin, confusion, extreme pain, fever or feeling very cold, a high heart rate or weak pulse, and shortness of breath. MSD adds oliguria and hypothermia. A client with pneumonia whose respiratory rate climbs from 18 to 26 while the pressure is still normal is showing the early cue students miss.
Urine output is the cue that turns perfusion into a number. For a 70 kg client, about 0.5 mL/kg/hour is roughly 35 mL an hour, so two hours of 15 mL each is a report, not a note to recheck later. Lactate trends belong in the same conversation: a level above 2 mmol/L with low pressure despite fluids is part of the septic shock definition.
Writing the statement and goals for a hypothetical client
Practice case, not a real patient: a 74-year-old man two days after a urinary catheter was placed, now confused, temperature 35.8 C, heart rate 118, respiratory rate 24, blood pressure 92/54, MAP about 67, and 40 mL of dark urine in two hours. He weighs about 70 kg.
Statement: Ineffective peripheral tissue perfusion related to sepsis-driven vasodilation, as evidenced by MAP near 65, urine output below 0.5 mL/kg/hour, tachycardia and new confusion. A measurable goal: within 6 hours the client maintains MAP at or above 65 and urine output of at least 0.5 mL/kg/hour on hourly checks. Note the low temperature: a sepsis plan that only lists hyperthermia misses clients like this one.
Evaluation: reassessing after each intervention
Sepsis evaluation happens in hours, not at discharge. After each fluid bolus, recheck pressure, heart rate, breath sounds and urine output. Rising pressure with clear lungs supports the plan; crackles and falling saturation after fluids mean the gas exchange row has moved up and needs reporting.
Mark-downs on sepsis plans include writing a prescribed fluid volume as a nursing intervention, listing hyperthermia as the top problem in a hypotensive client, goals without a time frame, and missing the cultures-before-antibiotics sequence. The comparison of sepsis and septic shock on the linked page covers the definitions in more depth.
Sources and further reading
Sepsis and Septic Shock - Critical Care Medicine - MSD Manual Professional Edition. Definitions of sepsis and septic shock with MAP 65 and lactate above 2, signs including hypothermia, tachypnea, altered mental status and oliguria, warm then cool skin, urine output target, antibiotics after cultures, glucose range, mortality figures.
About Sepsis | Sepsis | CDC. Sepsis as a medical emergency, warning signs, annual US adult cases and deaths.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
What is the priority nursing diagnosis for sepsis?
Risk for shock or ineffective tissue perfusion. Sepsis kills through falling perfusion to organs, so maintaining a MAP of 65 mm Hg or more and adequate urine output comes before the infection, temperature or comfort problems.
What are nursing interventions for sepsis?
Frequent vital signs with MAP, hourly urine output, drawing ordered cultures before the first antibiotic dose, starting prescribed antibiotics and fluids without delay, monitoring respirations and oxygen saturation, comparing mental status with baseline, and reporting falling pressure or rising lactate.
How do you write a care plan for sepsis?
Rank problems by threat to life, write each diagnosis with a related factor and, for actual problems, the measured cues as evidence. Make goals numeric and time-bound, such as MAP at or above 65 within 6 hours, and evaluate after each intervention rather than once a shift.
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