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Planning/Implementation/Evaluation

Med/Surg Nursing Diagnosis: Risk for shock (septic) related to multiple invasive procedures
Long-Term Goal: Patient will maintain adequate tissue perfusion
Outcome
Criteria
One outcome
criteria for each
intervention.
Number each
one.
1. Patients vital
signs will remain
as follows as
assessed q4h: T
96.8-100.4, BP
<120/<80 but
>90/>50, HR
60-100 bpm and
regular rhythm,
RR 12-20/min,
SpO2 95-100%.

Interventions
Label each as
assess/monitor/independen
t/
dependent/teaching/collabo
ration
1. Assess T, HR, RR, BP,
and SpO2 cc parameters
q4h (independent).

Rationale
Answers why, how, what your interventions will help
solve, prevent,
Or lesson the stated problem specific to each
patient.
1. It is essential to monitor vital signs in the patient
who is suspected to be experiencing septic shock
because the values can indicate the presence of
septic shock as well as what further interventions
need to be implemented. The nurse should observe
for trends in vital signs that may be indicative of
septic shock: elevated temperature, elevated heart
rate, elevated respiration rate, and decreased BP
and SpO2. Early detection of abnormal vital signs in
this patient indicated that she was on her way to
develop septic shock, especially with all of her risk
factors. She was transferred to the ICU for more
specialized care to prevent Multiple Organ
Dysfunction Syndrome from occurring.

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. P
Patients vital signs
were as follows: T
98.1 , BP 140/100,
P between 90-100
bpm and irregular, RR
30-40/min, and SpO2
97% on O2 2L/min
NC.
Plan is ongoing

2. Patients
blood Lactate
level will remain
<4 mmol/L as
assessed when
resulted.

2. Monitor blood Lactate


level q6h as ordered
(dependent).

2. An elevated blood Lactate level of > 4 mmol/L is


a diagnostic indicator of early septicemia per
pathway (Upstate University Hospital Adult Sepsis
Pocket Card). When a patient is hypoxic, lactic acid
builds up as a result of the body shifting to
anaerobic metabolism because the liver does not
have the oxygen it needs to remove the lactic acid.
The blood Lactate level will be analyzed in this
patient to determine whether hypoxia is present,
especially since her SpO2 was WNL (Lewis).

2. U
Patients blood
Lactate level was not
yet resulted by the
end of our shift.
Plan is ongoing

3. Patients LOC
will improve
from her
baseline
(lethargic) when
awake as
assessed.

3. Assess level of
consciousness throughout
all interactions
(independent).

3. U
Patients mentation
status was lower than
her baseline. She was
more lethargic than
usual and was not
responsive to simple
statements and
questions.
Plan is ongoing

4. Patients WBC
count will trend
to 4,800-10,800
cells/mm 3 as
assessed when
resulted.

4. Monitor WBC count qday


as ordered (dependent).

3. An early indicator of septic shock is a change in


mentation from the patients baseline. The nurse
should be aware of the patients baseline mental
status, including alertness, orientation, and usual
response to increasing stimuli. A change in
mentation can indicate hypoperfusion to cerebral
tissue, which is a secondary effect of Systemic
Inflammatory Response Syndrome. A decreased LOC
can also indicate the need for increased
oxygenation via fluid resuscitation. This patient had
encephalopathy from previous Acute Respiratory
Distress Syndrome and Multisystem Organ
Dysfunction Syndrome. Her LOC had decreased
more, which indicated that hypoperfusion was
occurring, so foley catheter care, peri care and oral
care were performed to prevent the development of
septic shock.
4. An elevated or low WBC count is one diagnostic
criterion for sepsis. Sepsis is a systemic
inflammatory response to a known or suspected
infection, and the WBC may increase as an
inflammatory response to the infection or decrease
because the patient is immunocompromised or

4. U
This patients WBC
level was not resulted
on 10/7, but it was
12,600 cells/mm3 on
10/6.

5. Patient will
not develop
worsening or
additional
infection(s) after
maintenance of
aseptic
technique as
assessed.

5. Maintain aseptic
technique during all
dressing changes
(independent).

6. Patients CVP
will remain in
the range of 2-8
mmHg as
assessed when
resulted.

6. Collaborate with MD to
obtain order for patients
central venous pressure
(CVP) via hemodynamic
monitoring (dependent).

7. Patients
urine output will
remain > .5
ml/kg/hr as
assessed.

7. Assess patients urine


output every hour
(independent).

lacks sufficient WBCs to fight off infection. The WBC


count is significant in this patient because it will
indicate the presence or absence of current
infection (Lewis).
5. The purpose of aseptic technique is to prevent
the spread of infection from the health care
professional to the patient. This patient has a
Peripherally Inserted Central Catheter (PICC) line
dressing and Mepilex dressings on her buttocks that
require changing. The nurse should know the proper
times for hand washing and donning PPE when
handling soiled and new dressings and a sterile field
should be maintained when applying new dressings.
Maintaining aseptic technique will prevent the
spread of microorganisms from the nurse to the
patient and will help prevent the patient from
developing septic shock.

Plan is ongoing

6. A patients CVP is measured to determine the


filling pressures of the right side of the heart as well
as his or her fluid volume status. CVP is a critical
value in patients who may be in septic shock
because it will indicate whether vital organs are
being perfused and whether fluid resuscitation has
been successful. If the CVP is below 2 mmHg, then
the patients organs are not being adequately
perfused and additional fluid resuscitation may be
indicated. CVP should be ordered for this patient to
prevent Multisystem Organ Dysfunction Syndrome
from occurring.
7. Patients who may be in or going into septic shock
should have their urine output monitored every
hour to determine if the kidneys are adequately
being perfused. The massive inflammatory response
that occurs when a patient is in septic shock causes

6. U
Patients CVP was not
ordered before
patient was
transferred to the
ICU.
Plan is ongoing

5. U
Patient did not have a
dressing changed
before being
transferred to the
ICU.
Plan is ongoing

7. U
Patients urine output
was less than .5
ml/kg/hr before she
was transferred to

8. Patients lung
sounds will
remain clear
bilaterally as
auscultated q4h.

8. Auscultate lung sounds


every 4 hours
(independent).

9. Patient will
demonstrate a
decrease in UTIcausing
bacteria,
reverse of septic
shock effects, or
no further
decline in vital
signs as

9. Administer levofloxacin
(Levaquin) in D5W
500mg/100mL IVPB q24h
over 60 minutes per MD
order (dependent).

an increase in the permeability of blood vessels,


and fluid shifts from the intravascular space to the
interstitial space. As a result less fluid is available in
the vascular space to adequately perfuse vital
organs. Inadequate perfusion to the kidneys is
indicated when urine output is below 0.5
mL/kg/hour. Renal insufficiency will cause waste
products to accumulate in the bodys tissues and
will increase infection risk. Urine output monitoring
in this patient helped to determine that her kidneys
were not being adequately perfused (Nursing Care
Plans, 8th Edition).
8. This patients lung sounds should be auscultated
in order to determine the presence of air or fluid
accumulation in her lungs. The accumulation of fluid
in the lungs can indicate pneumonia (which can
cause sepsis) or congestive heart failure. The
presence of crackles in the lungs may indicate fluid
overload and interventions should be implemented
(such as IS and TCDB when the patient is able) to
clear their lungs. Accumulation of secretions may
lead to Acute Respiratory Distress Syndrome, which
is a complication of septic shock (Nursing Care
Plans, 8th Edition).

the ICU.
Plan is ongoing

9. Levofloxacin is an anti-infective in the class of


fluoroquinolones and it acts by inhibiting the
synthesis of disease-causing bacteria. Levofloxacin
was prescribed for my patient because she had a
UTI. Levofloxacin happens to be a broad-spectrum
antibiotic, which is included in the treatment
protocol for sepsis (Upstate University Hospital
Adult Sepsis Pocket Card). When septic shock is
confirmed, a broad-spectrum antibiotic should be
administered within 1 hour. The purpose of prompt

9. U
Patient did not
receive levofloxacin
before she was
transferred to the
ICU.
Plan is ongoing

8. U
Patient had bilateral
rhonchi throughout
her lungs as
auscultated.
Plan is ongoing

assessed after
administration
of levofloxacin.

10. Patients pH,


PaCO2, and
HCO3 will remain
WNL (7.35-7.45,
35-45, and 2226, respectively)
as assessed
when resulted.

10. Interpret results of


Arterial Blood Gases (ABGs)
as ordered (dependent).

11. Patients
blood glucose
level will trend
to 70-110 mg/dL
as assessed
q6h.

11. Monitor patients blood


glucose level q6h as
ordered (dependent).

12. Patients
skin will remain
clean, dry, and
intact and her
oral cavity will
remain clean,
moist, and
intact as
assessed.

12. Provide frequent


catheter care, peri care and
oral care (independent).

antibiotic therapy in my patient is to kill as many


disease-causing organisms as quickly as possible to
prevent the spread of infection to other areas of the
body and reverse the effects of septic shock
(Nursing Care Plans, 8th Edition).
10. Analysis of ABGs provides the healthcare team
with information about the patients oxygenation
and ventilation status and acid-base balance. An
early clinical manifestation of septic shock is
hyperventilation, and interpretation of the patients
ABG usually indicates respiratory alkalosis. ABG
analysis is an important intervention for this patient
because it will help to determine if she is hypoxic
and if she needs more oxygen or a different form of
oxygen (Lewis).
11. This patient has diabetes, so it is important to
monitor and control her blood glucose levels while
she is hospitalized, especially when she is
suspected to have sepsis. It is recommended that
blood glucose levels be maintained below 150
mg/dL for patients experiencing shock. Controlled
hyperglycemia in this patient will promote improved
immune function and increased oxygen perfusion to
the areas of heart muscle that are ischemic (Lewis).
12. This patient requires the nurse to perform
frequent care to her catheter, peri area, and oral
cavity because she is too weak to perform these
actions herself. With decreased perfusion to her
tissues, her C. diff, and a foley catheter, she has an
increased risk of infection and skin breakdown. This
patient also has very low PO intake, so her oral
cavity is often very dry, and her impaired
swallowing makes it possible for secretions to
accumulate in the oral cavity. By performing
frequent care to these areas of concern, the

10. P
Patients pH was 7.5,
PaCO2 was 33, and
HCO3 was 25.2,
indicating partially
compensated
respiratory alkalosis.
Plan is ongoing

11. M
Patients blood
glucose levels were
133 mg/dL at 0608
and 125 mg/dL at
1220.
Plan is ongoing

12. M
Patients skin
remained clean, dry,
and intact and her
oral cavity remained
clean, moist, and
intact as assessed.
Plan is ongoing

13. Patient will


have
nondistended,
nontender
abdomen with
normoactive
bowel sounds in
all 4 quadrants
as assessed
q4h.

14. Patient will


show no
physical signs or
symptoms of
malnutrition and
her electrolyte
and protein
laboratory
values will trend
toward normal
limits as
assessed when
resulted.

15. Patient will


verbalize 3 of
her risk factors
for sepsis and 3

patients risk for infection (and eventual sepsis) will


decrease.
13. Perform abdominal
13. A thorough abdominal assessment, including
assessment, including
inspection, auscultation, and palpation is crucial in
bowel sounds every 4 hours the patient with suspected sepsis because the
(independent).
findings may indicate bowel obstruction or
perforation. Signs and symptoms of a bowel
obstruction include increased abdominal distention,
nausea, and hypoactive bowel sounds.
Hypoperfusion will likely occur as a result of a bowel
obstruction and prompt treatment may prevent the
development of sepsis and septic shock. This
patients abdominal assessment is especially
important because she had a recent small bowel
obstruction and bowel resection so it is possible that
she has a perforated bowel.
14. Administer amino acids 14. My patient has an order for total parenteral
5%-lytes-CA-D15W (C1)
nutrition (TPN) because she has trouble swallowing
parenteral solution IV 1and she is not tolerating feedings well via her
2L/day at 83 mL/hr & MVI cc nasogastric (NG) tube. Her problems with
vit K 10 mL and fat
swallowing have resulted in her eating/drinking
emulsion IV 250mL at
almost nothing PO. She has been vomiting and
21mL/hr per MD order.
having frequent liquid stools after her NG tube
feedings. TPN is administered through a designated
port in her PICC line to provide her with the calories,
proteins, fats, and electrolytes that she needs in
order for her body to function. Adequate nutrition
will help to improve her immune system function
and to deliver oxygen to her vital organs, both of
which will decrease her risk of developing septic
shock.
15. Teach patient about risk 15. This patient has the following risk factors for
factors for sepsis and early septic shock: decubitus ulcers on her buttocks, PICC
signs and symptoms of
line, advanced age, foley catheter, small bowel
sepsis when she is stable
resection, and continuous illnesses. Early signs and

13. P
Patients abdomen
was obese, tender in
the RLQ when
palpated, and bowel
sounds were
normoactive in all 4
quadrants.
Plan is ongoing

14. M
Patient showed no
physical signs or
symptoms of
malnutrition and her
electrolyte and
protein laboratory
values were WNL as
assessed on 10/7/14.
Plan is ongoing

15. U
Patient was not
stable or alert
enough for teaching

early symptoms
of sepsis by
discharge.

and alert.

symptoms of septic shock include elevated


temperature, heart rate, and respiration rate,
shortness of breath, and a decreased level of
consciousness. All of these signs and symptoms
may indicate hypoperfusion, so if the patient is
aware of them and able to report them to the nurse
in a timely manner, multisystem organ dysfunction
syndrome can be prevented (Lewis).

to take place during


our shift.
Plan is ongoing