Urosepsis: Building Margaret’s Nursing Care Plan
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Margaret’s story did not end when her deterioration was recognised.
In the original scenario, Margaret was admitted with urinary symptoms, reduced oral intake and worsening weakness. She then became drowsier and developed a pattern of fever, tachycardia, hypotension, increased respiratory rate, reduced urine output and altered mental state. The immediate priority was an A–E assessment, urgent escalation and treatment for suspected sepsis.
This continuation moves from recognising deterioration to planning, delivering and evaluating Margaret’s nursing care. It is a worked educational example, not a care plan to copy into clinical documentation.
Read Margaret’s original urosepsis scenario first
Margaret after urgent review and initial treatment
During urgent review, Margaret’s observations were respiratory rate 27 breaths/min, SpO₂ 93% on room air, heart rate 119 bpm, blood pressure 86/52 mmHg, temperature 39.0°C and GCS 14 with new confusion. Her NEWS2 placed her in a high-risk group requiring an emergency clinical response under the local deterioration pathway.
Blood tests showed a lactate of 3.2 mmol/L and creatinine of 176 micromol/L, compared with a documented baseline of 84 micromol/L. Urea was 15.1 mmol/L and white cell count 18 × 10⁹/L. Blood cultures and an appropriate urine specimen were obtained without delaying treatment. The clinical team diagnosed suspected sepsis from a urinary source with acute kidney injury.
Margaret received oxygen to a documented target, broad-spectrum intravenous antibiotics and carefully assessed intravenous fluid treatment under the local sepsis pathway. Her regular medicines are being reviewed by the prescriber because hypotension, dehydration and acute kidney injury can change their safety.
Four hours later, Margaret remains on the Acute Medical Unit. Her current observations are:
- Respiratory rate: 22 breaths/min
- SpO₂: 96% on 2 L/min oxygen
- Heart rate: 101 bpm
- Blood pressure: 104/62 mmHg
- Temperature: 38.2°C
- GCS: 15, with intermittent disorientation to time and place
- Blood glucose: 8.9 mmol/L
Her circulation has improved, but she has passed only 20 mL of concentrated urine since admission. She feels nauseated and has managed only a few sips. Margaret says she wants staff to explain what is happening slowly and would like her daughter contacted. Her daughter confirms that Margaret is normally orientated, lives independently and manages her own medicines.
Before you see the worked plan
Which needs would you prioritise now?
- Which findings remain an immediate threat to Margaret’s safety?
- What suggests that her kidneys may have been affected?
- How should her fluctuating confusion change communication and safety planning?
- How will you know whether fluid treatment is helping or causing harm?
- What matters to Margaret beyond the observations?
Margaret’s circulation and response to infection remain the first priorities. Reduced urine output and acute kidney injury require close attention, followed by delirium risk, hydration and nutrition, mobility, skin integrity and recovery planning.
Worked care plan
Priority 1: Severe infection with impaired circulation
Assessed need or nursing problem
Margaret has suspected sepsis from a urinary source with evidence of impaired perfusion. Her blood pressure has improved after initial treatment, but tachycardia, fever and ongoing physiological abnormality mean that deterioration remains possible.
Evidence
- Initial blood pressure 86/52 mmHg and heart rate 119 bpm
- Initial lactate 3.2 mmol/L
- Fever, increased respiratory rate and altered mental state
- Reduced urine output and acute rise in creatinine
- Current heart rate 101 bpm and temperature 38.2°C
Agreed outcome
Margaret will show a sustained improvement in perfusion and physiological observations following treatment. Prescribed antimicrobials and other treatment will be administered safely and on time, and any failure to improve will trigger immediate reassessment and escalation.
Nursing actions and rationale
- Continue A–E reassessment, NEWS2 observations and escalation at the frequency determined by the responsible clinical team and local policy. A temporarily improved blood pressure does not mean that the risk has passed.
- Administer prescribed intravenous antibiotics promptly after checking identity, allergies, medicine, dose, route, timing and relevant clinical information. Monitor for adverse reactions and document the actual administration time. Antimicrobial choice and later review must follow local guidance, microbiology results and prescriber assessment.
- Monitor blood pressure, heart rate, respiratory rate, temperature, capillary refill, peripheral perfusion, cognition and urine output as a connected picture. Escalate clinical concern even if an isolated value appears acceptable.
- Support prescribed blood tests, repeat lactate and microbiological investigations within competence. Blood cultures and urine specimens may inform later treatment, but obtaining them must not cause harmful delay to urgent antibiotics.
- Support prescribed intravenous fluid treatment and reassessment. Fluid management must be individualised, particularly in older adults and people with renal or cardiac impairment.
- Observe for signs of fluid overload, including increasing breathlessness, new oxygen requirement, crackles, peripheral oedema or worsening oxygen saturation, and escalate promptly.
Monitoring and evaluation
Trend Margaret’s NEWS2, perfusion, lactate, mental state and response to treatment. The plan is progressing if blood pressure and heart rate stabilise, cognition improves and urine output begins to recover without signs of fluid overload. Persistent hypotension, rising lactate, increasing oxygen requirement, reduced consciousness or other deterioration requires urgent senior review.
Priority 2: Acute kidney injury and reduced urine output
Assessed need or nursing problem
Margaret has an acute rise in creatinine and oliguria in the context of infection, hypotension and poor intake. She is at risk of worsening acute kidney injury, electrolyte disturbance, medicine accumulation and fluid imbalance.
Evidence
- Creatinine 176 micromol/L compared with baseline 84 micromol/L
- Urea 15.1 mmol/L
- Only 20 mL concentrated urine passed since admission
- Recent hypotension, reduced intake and suspected sepsis
Agreed outcome
Margaret’s renal function and fluid status will be monitored closely. Reversible contributors will be addressed by the clinical team, nephrotoxic and renally cleared medicines will be reviewed by the appropriate prescriber, and worsening oliguria or biochemical abnormality will be escalated promptly.
Nursing actions and rationale
- Maintain accurate fluid balance, recording what Margaret actually drinks, prescribed intravenous intake, urine output and other losses. Avoid estimating when measurement is possible.
- Measure urine output at the frequency set by the clinical team. NICE identifies urine output below 0.5 mL/kg/hour as oliguria requiring recognition and response, but the trend must be interpreted with Margaret’s weight, fluid status and overall condition.
- Report persistent oliguria, anuria, worsening creatinine, electrolyte abnormalities, increasing nausea, drowsiness, oedema or breathlessness.
- Check whether Margaret has passed urine naturally and assess for bladder distension, discomfort or possible retention within competence. Reduced output is not always caused by renal hypoperfusion.
- If urinary catheterisation is clinically required for accurate monitoring or another indication, support insertion and catheter care only within competence and local policy. Review the ongoing need daily because catheters increase infection risk.
- Ensure the registered nurse and prescriber are aware of the acute kidney injury so medicines, doses and monitoring can be reviewed. A student nurse must not independently stop Margaret’s regular medicines.
Monitoring and evaluation
Review hourly or scheduled urine output, cumulative fluid balance, creatinine, urea, electrolytes, weight where indicated and clinical signs of hydration or overload. Improvement is shown by recovery of urine output and stabilising renal markers alongside improved circulation. Continued oliguria or worsening blood results requires escalation rather than simply giving more fluid.
Priority 3: Acute confusion and possible delirium
Assessed need or nursing problem
Margaret has an acute, fluctuating change from her usual cognition. Severe infection, impaired perfusion, dehydration, renal dysfunction, medicines, pain and the unfamiliar environment may all contribute.
Evidence
- Initial GCS 14 with drowsiness and new confusion
- Current GCS 15 with intermittent disorientation
- Daughter confirms that Margaret is normally orientated and independent
- Acute infection, fever, dehydration and acute kidney injury
Agreed outcome
Margaret will remain safe, calm and involved in her care. Reversible contributors will be assessed and treated, cognition will be monitored against her usual baseline and communication will support orientation and decision-making.
Nursing actions and rationale
- Document that the change is acute and different from Margaret’s baseline. Use the organisation’s approved delirium assessment process when requested and within competence.
- Continue to assess potential contributors including hypoxia, infection, pain, dehydration, glucose disturbance, constipation, urinary retention, medicines and sleep disruption.
- Introduce yourself, explain care in short steps and gently reorientate Margaret. Make sure glasses, hearing aids, clocks and familiar items are available if she uses them.
- Reduce avoidable ward moves and unnecessary overnight disturbance where possible while maintaining essential monitoring and treatment.
- Involve Margaret’s daughter with Margaret’s agreement. Family knowledge can help establish baseline cognition and support communication.
- Do not assume that confusion means Margaret lacks capacity for every decision. Capacity is decision-specific and time-specific. Follow the applicable legal framework and local policy if her ability to make a particular decision is uncertain.
Monitoring and evaluation
Record orientation, attention, behaviour, sleep, distress and fluctuation. Improvement means Margaret is moving towards her normal cognition and can engage more consistently. New agitation, worsening drowsiness, reduced GCS or inability to protect her airway requires immediate reassessment.
Priority 4: Fluid, nutrition and symptom support
Assessed need or nursing problem
Margaret’s infection, nausea, weakness and confusion are limiting oral intake. She needs individualised support without encouraging intake that is unsafe or ignoring the risk of fluid overload.
Evidence
- Reduced intake before and after admission
- Nausea and only a few sips taken
- Concentrated urine and acute kidney injury
- Fatigue and intermittent confusion
Agreed outcome
Margaret will receive safe support with hydration, nutrition, mouth care and nausea. Intake and tolerance will be recorded accurately, and concerns will be escalated to the appropriate registered professional or multidisciplinary team.
Nursing actions and rationale
- Complete local nutrition and hydration screening and ask Margaret about food and drink preferences.
- Offer small, manageable amounts when clinically safe, provide mouth care and position her upright for drinks and meals.
- Assess for coughing, choking, altered voice or reduced alertness that could make oral intake unsafe. Stop and escalate concerns rather than continuing automatically.
- Administer prescribed antiemetic and analgesic medicines safely and evaluate their effect.
- Record intake, urine and other losses accurately. Review this alongside the intravenous fluid plan rather than treating oral and intravenous intake as separate issues.
- Refer or escalate for dietetic or speech and language therapy review when screening or clinical findings indicate this is needed.
Monitoring and evaluation
Review what Margaret actually manages, nausea, swallowing safety, mouth condition, fluid balance and clinical response. Revise the plan if oral intake remains inadequate or signs of overload, aspiration risk or worsening kidney injury appear.
Priority 5: Reduced mobility, skin integrity and recovery planning
Assessed need or nursing problem
Margaret is normally independent but is temporarily weak, hypotensive and intermittently confused. This increases her risks of falls, pressure damage, deconditioning and loss of confidence.
Evidence
- Acute severe illness and weakness
- Recent hypotension and fluctuating confusion
- Reduced intake and time in bed
- Usual baseline of independent living
Agreed outcome
Margaret will avoid preventable harm and regain mobility as her condition allows. Her usual independence and home circumstances will remain central to recovery and discharge planning.
Nursing actions and rationale
- Complete and review local falls, pressure-ulcer and venous thromboembolism risk assessments as her condition changes.
- Keep the call bell and essential items accessible and provide appropriate help with transfers and toileting.
- Assess skin and pressure areas while preserving dignity. Support individualised repositioning and pressure relief based on risk, comfort and ability.
- Encourage safe movement and mobilisation when clinically stable, with physiotherapy or occupational therapy input if required.
- Administer prescribed venous thromboembolism prophylaxis after appropriate checks and monitor for bleeding or contraindications.
- Discuss baseline mobility, medicine management, continence, hydration and support at home with Margaret and, with consent, her daughter. Do not treat temporary dependence as permanent.
Monitoring and evaluation
Record the assistance Margaret requires, symptoms during activity, falls concerns, skin condition and progress towards baseline mobility. Recovery goals should advance as her circulation, cognition and strength improve.
How Margaret remains part of the plan
Margaret wants explanations to be slow and clear, and she wants her daughter involved without decisions being taken away from her.
Person-centred care therefore means:
- speaking directly to Margaret and checking what she understands
- allowing time for responses when she is tired or confused
- asking permission before sharing information with her daughter, unless another lawful basis applies
- checking preferences rather than assuming what an older adult wants
- recognising her normal independence and existing routines
- reviewing continence, hydration, medicines and support without assuming that a positive urine result explains every symptom
What can the student nurse contribute?
Under appropriate supervision and within competence, a student nurse may contribute by:
- performing and reporting observations and elements of A–E assessment
- recognising trends and escalating deterioration
- maintaining accurate fluid balance and urine-output records
- monitoring cognition, comfort, skin, intake and mobility
- supporting prescribed medicines, fluids and investigations in accordance with programme, placement and local requirements
- helping Margaret communicate and remain orientated
- documenting care actually provided and sharing priorities at handover
The registered nurse remains accountable for assessing nursing needs, coordinating and evaluating care, delegating appropriately and responding to deterioration. Diagnosis, prescribing and independently changing treatment are not student-nurse responsibilities.
Evaluation later in the shift
Eight hours after admission, Margaret’s respiratory rate is 20 breaths/min, SpO₂ is within her prescribed target on room air, heart rate is 92 bpm, blood pressure is 112/68 mmHg and temperature is 37.8°C. She is orientated to person and place and is less drowsy. Her urine output has begun to improve but remains below her usual pattern, and repeat renal blood results are awaited.
This is encouraging, but the care plan is not complete. Margaret still needs:
- continued monitoring for recurrent deterioration
- timely antimicrobials and review against culture results
- ongoing urine-output, fluid-balance, renal-function and electrolyte monitoring
- repeat delirium assessment and support
- nutrition, mobility, skin and falls review
- planning for medicines, continence, hydration and support after discharge
The plan must be revised whenever Margaret’s condition, renal function, response, priorities or independence changes.
Documentation example
“16:10. Care plan reviewed with Margaret following initial treatment for suspected sepsis from a urinary source and acute kidney injury. RR 22, SpO₂ 96% on 2 L/min oxygen, HR 101, BP 104/62, temperature 38.2°C, GCS 15 with intermittent disorientation. Only 20 mL concentrated urine passed since admission; RN and medical team informed. Fluid balance and urine-output monitoring continued. Margaret requests slow explanations and agrees that her daughter may be updated. Ongoing physiological, renal and cognitive monitoring planned. Falls, pressure-area, nutrition and VTE risks reviewed with supervising RN. Continue reassessment and escalate deterioration or persistent oliguria.”
Documentation must record what was assessed, agreed, provided and escalated. Do not document an intervention before it occurs or copy a generic plan without checking that it applies to the patient.
Reflection questions
- Why does an improved blood pressure not mean Margaret’s sepsis has resolved?
- What information suggests acute kidney injury?
- Why might giving more fluid be unsafe without reassessment?
- How does fluctuating cognition affect communication and decision-making?
- Which findings would require immediate re-escalation?
- How does Margaret’s normal independence influence recovery planning?
References and further reading
Royal College of Physicians (2017). National Early Warning Score (NEWS) 2.