NANDA-I 2024-2026 edition · Reviewed November 2, 2026 by the editorial team
What happens in sepsis and where nursing comes in
The body's response to infection dilates the blood vessels and damages tissues: blood pressure drops, heart rate rises, oxygenation fails and confusion may set in. Nursing catches deterioration early, gives the ordered fluids and treatment, and monitors the response.
What to assess
- Mean arterial pressure, heart rate and capillary refill.
- Temperature and likely source of infection.
- Hourly urine output and intake and output.
- Respiratory rate and oxygen saturation.
- Mental status: new confusion or drowsiness.
- Lactate and other labs as ordered.
NANDA-I 2024-2026 nursing diagnoses for sepsis
| Code | Diagnosis | When it applies |
|---|---|---|
| 00205 | Risk for shockRisk | Infection can lead to hypotension and poor organ perfusion. |
| 00007 | HyperthermiaProblem-focused | Fever from the inflammatory response. |
| 00421 | Inadequate fluid volumeProblem-focused · former code 00027 | Hypotension, tachycardia and oliguria from low effective circulating volume. |
| 00030 | Impaired gas exchangeProblem-focused | Hypoxemia from lung involvement. |
| 00173 | Risk for acute confusionRisk | Sepsis is a common cause of delirium, especially in older adults. |
How to prioritize them
Perfusion and volume first (00205 and 00421), then oxygenation, fever and delirium prevention. Your assessment makes the final call: anything that threatens life (airway, breathing, circulation) comes first.
Sample nursing diagnosis statements
Risk for shock related to poor fluid intake over the previous three days and uncontrolled hyperthermia, in a patient with urosepsis (associated condition).
Hyperthermia related to dehydration and exposure to a hot environment as evidenced by axillary temperature of 39.2 °C (102.6 °F), hot flushed skin and heart rate of 118 bpm.
Inadequate Fluid Volume related to unreplaced losses from vomiting and no oral intake for 24 hours as evidenced by HR 118 bpm, BP 96/60 mmHg, urine output of 0.25 mL/kg/h over the last 4 hours, dry oral mucosa, and capillary refill of 3 seconds.
Impaired gas exchange related to shallow breathing from pleuritic pain and prolonged supine positioning as evidenced by SpO2 of 86% on room air, drowsiness and PaCO₂ of 55 mmHg on ABG.
Risk for acute confusion related to sleep deprivation, dehydration, uncontrolled pain, and sensory deprivation from missing glasses and hearing aid, in an 82-year-old patient with urosepsis (associated condition).
Fictional cases written by our team. Adapt them to your patient with the PES statement generator.
Nursing care plan summary
Main goals and interventions for the priority diagnoses. Each diagnosis page has the full plan, with rationales and a case study.
Risk for shock (00205)
Goals
- Maintains a MAP of 65 mmHg or higher throughout monitoring.
- Maintains urine output of at least 0.5 mL/kg/h every hour during the first 24 hours.
Interventions
- Take vital signs with MAP every 15 to 30 minutes at first, then space them out as the patient stabilizes.
- Calculate the shock index and use your facility's early warning score.
- Secure two large-bore peripheral IVs and give the prescribed fluids at the ordered rate.
- If sepsis is suspected, draw the ordered cultures before the first antimicrobial dose, then give it without delay.
Hyperthermia (00007)
Goals
- Temperature drops below 38 °C (100.4 °F) within 2 hours of starting the ordered measures.
- Urine output stays above 0.5 mL/kg/h in adults or 1 mL/kg/h in children.
Interventions
- Check temperature every 1 to 4 hours depending on the trend.
- Give prescribed antipyretics and reassess in 30-60 minutes.
- Remove excess clothing and keep the room cool and well ventilated.
- Apply cooling measures such as lukewarm compresses if indicated. Do not use alcohol or ice water.
Inadequate fluid volume (00421)
Goals
- Patient maintains urine output of at least 0.5 mL/kg/h in each of the next 12 hours.
- Heart rate drops below 100 bpm and systolic BP stays above 100 mmHg within 24 hours.
Interventions
- Start a large-bore peripheral IV and administer the prescribed IV fluids at the ordered rate.
- Measure and record urine output every hour while the patient is unstable.
- Keep strict intake and output, including emesis, drains and stools.
- Check heart rate, blood pressure and capillary refill every 1 to 2 hours at first, then as the patient's condition dictates.
Build the full care plan as a table with the generator.
Frequently asked questions
What is the nursing diagnosis for sepsis?
Risk for shock (00205) is the priority. If hypotension or hypoperfusion is already present, address the actual problems, such as Inadequate fluid volume (00421).
Is there a NANDA diagnosis for "septic shock"?
No. Shock is a medical problem; nursing uses Risk for shock (00205) and diagnoses for the patient's responses.
Which nursing diagnosis fits confusion in a septic patient?
Risk for acute confusion (00173) if risk factors are present but confusion has not appeared yet; Acute confusion (00128) if it is already present.
Other conditions
Study material: the diagnosis selection, sample statements and care plans were written by our editorial team using the NANDA-I 2024-2026 classification. They do not replace clinical judgment or your facility's protocols.
Classification sources: NANDA-I 2024-2026, Thieme supplement · Elsevier summary of changes. Reviewed November 2, 2026.