Prioritized Nursing Diagnosis Care Plan

Student: Ashlee Martinez

Nursing Diagnosis Risk for infection r/t altered peristalsis & inadequate secondary defenses, secondary to Crohns.
Long Term Goal Patient will be free of infection.

Outcome Criteria Nursing Actions Scientific Rationale Evaluation

Outcome 1 Intervention 1
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI
Patient’s systolic pressure pneumonia d/t being immunocompromised, as well as, many other types of Met: BP 110/70-
will remain between 110- infections. She is a high risk for becoming septic. Trending her VS allows us 120/78, AP 68-
effectively treat her, and know if she is heading towards becoming septic. Sepsis is 93/reg. RR 16
130mm/Hg, and diastolic
Assess BP, AP, RR, a serious bodywide response to bacteremia or another infection. Usually, sepsis
easy, Temp 36.5-
will remain between 70- results from certain bacterial infections, often acquired in a hospital. Having certain
Temp, & O2 sat 37.37.1 oral, O2
85mmHg, AP 60-100 reg, conditions, such as Crohns, a weakened immune system, increases the risk.
q4h. Initially, people have a high (or sometimes low) body temperature. As sepsis sat 95-96% RA.
RR 12-20 easy, Temp 36-
worsens, the heart beats rapidly, breathing becomes rapid, O2 sat decreases, and *On-going
37.0 oral, O2 sat >95% blood pressure drops. As it stands, her V/S were stable and not indictive of sepsis.
RA, as assessed q4h. (http://www.merckmanuals.com/home/infections/bacteremia,-sepsis,-and-septic-
shock/sepsis,-severe-sepsis,-and-septic-shock) (Class notes)

Outcome 2 Intervention 2
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI Met: Pt remained
pneumonia d/t being immunocompromised, as well as, many other types of A&Ox3. Pupil
infections. She is a high risk for becoming septic. Sepsis is a serious bodywide
response to bacteremia or another infection. Usually, sepsis results from certain
3mm & PERRL.
bacterial infections, often acquired in a hospital. Having certain conditions, such as Maintained
Patient’s LOC will not Assess patient’s Crohns, a weakened immune system, increases the risk. As blood pressure voluntary muscle
decrease from baseline, neurologic status decreases, and small clots form, it can lead to harmful complications. Blood flow control, with
as assessed q2h. q2h. decreases to vital organs (such as the kidneys, lungs, heart, and brain). As sepsis
equally strong
worsens, people become confused and less alert. Monitoring the onset of decrease
in LOC allows for earlier intervention. This patient remained alert, oriented, and handgrips. *On-
responded to verbal stimuli appropriately. going
(http://www.merckmanuals.com/home/infections/bacteremia,-sepsis,-and-septic-
shock/sepsis,-severe-sepsis,-and-septic-shock) (Class notes)
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Outcome 3 Intervention 3 Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI
pneumonia d/t being immunocompromised, as well as, many other types of

Met: WBC
Patient's WBC will remain remained
between 4.0-6.0.

Patient's WBC will remain
within 4.1-11, as assessed Monitor WBC, qd.
qd.
pneumonia d/t being immunocompromised, as well as, many other types of
infections. She is a high risk for becoming septic. Sepsis is a serious bodywide
response to bacteremia or another infection. Usually, sepsis results from certain
bacterial infections, often acquired in a hospital. Having certain conditions, such as
Crohns, a weakened immune system, increases the risk. White blood cells Met: WBC
(leukocytes) are an important part of the body’s defense against infectious
remained
organisms and foreign substances. To defend the body adequately, a sufficient
number of white blood cells must receive a message that an infectious organism or between 4.0-6.0.
foreign substance has invaded the body, get to where they are needed, and then kill *On-going.
and digest the harmful organism or substance. However, in patients that are
immunocompromised they may not have enough WBC to fight the infection.
Monitoring WBC allows us to put the patient on neuropenic precautions if necessary.
Or if their WBC are elevated, it can tell us they have an infection. In sepsis, a
patient can have a abnormally high, or low, WBC count. This patient was admitted
to the hospital with a WBC count of 6.0, by day 2 her WBC count was 4.0. If
continuing to decrease, she could be at high risk for infection.
NCP continued…
Outcome Criteria Nursing Actions Scientific Rationale Evaluation
Outcome 4 Intervention 4

Patient's EWS will remain Monitor EWS score,
<2, as assessed q4h.
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI
pneumonia d/t being immunocompromised, as well as, many other types of
infections. She is a high risk for becoming septic. Utilizing the Early Warning Score, Partially met:
allows us to monitor patients overall illness, and risk for decompensation. The EWS Pt's EWS score
score takes into account, the patient's; respiratoy rate, O2 sat, temperature, systolic ranged from 0-2.
q4h. BP, pulse, and level of response. This patient's highest score was a 2, when her O2
*On-going.
sat was 95% (1 point), and HR 93bpm (1 point). A score of 5 or more is statistically
linked to increased likelihood of death or admission to the ICU.
(http://www.ihi.org/resources/Pages/ImprovementStories/EarlyWarningSystemsScore
cardsThatSaveLives.aspx)

Outcome 5 Intervention 5

Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a Met: Pt's intake
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI Day #1 450ml,
pneumonia d/t being immunocompromised, as well as, many other types of Output 225ml.
Patient’s intake and Strict intake and infections. She is a high risk for becoming septic. In sepsis blood flow decreases to
output ratio will tread to output vital organs (such as the kidneys, lungs, heart, and brain), causing them to begin to Intake Day #2
within 200-300ml of each measurements, shut down. The kidneys excrete little or no urine, and metabolic waste products 480ml, Output
other, prior to discharge. q4h. (such as urea nitrogen) accumulate in the blood. This patient had adequate intake- 500ml. *On-
to-output ratio (within 225ml of eachother day 1, and within 20ml of eachother day going
2), both days after ambulation. (Class notes) (Lewis)

Outcome 6 Intervention 6

Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
Patient's SBO will recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO. She Unmet: Patient
improve, or remain initially presented to the ER with abd pain, and upon performing a CT scan, it did not have a
Repeat CT scan, confirmed she has an in-complete SBO. If her symptoms worsen; more abd pain, repeat CT scan
unchanged from previous
STAT. absent BS, fever, chills, and nausea/vomiting, could be indictative of a complete
completed.
scan, as assessed after CT SBO. This could be extremely dangerous and result in peritonitis. This patient only
scan. reported 4-5/10 abd discomfort/pressure. (Class notes)
NCP continued… Partially met:
After ambulating
Outcome Criteria Nursing Actions Scientific Rationale Evaluation
the patient to
Outcome 7 Intervention 7 the commode for
the second time
on Day 2, she
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t had a bowel
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a movement.
recent cholecystectomy. She is at risk for a bowel perforation, and peritonitis. Signs
Patient's abdomen will and symptoms of a complete bowel obstruction would cause her abd to be tender, Upon re-
trend to; girth <82.5cm, painful, bloated/distended, with absent bowel sounds. A careful assessment of her inspection of her
Assess abdomen, abdomen is essential in preventing a perforation, and subsequent infection. After abd, it was
soft, non-distended, non-
q4h. ambulating the patient to the commode for the second time on Day 2, she had a
slightly less
tender, and BSx4, prior to bowel movement. Upon re-inspection of her abd, it was slightly less firm/distended,
discharge. and BSx4 were less faint. Her abdomen at this time measured 81.75cm. Pt firm/distended,
reported feeling less discomfort and pressure. (Class notes) and BSx4 were
more less faint.
Pt reported
feeling less
Outcome 8 Intervention 8 discomfort and
pressure. *On-
going
Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO. She is a Paritally met:
high risk for becoming septic. The skin may become cool and pale and mottled or Patient's skin
Patient's skin will trend to,
blue because blood flow is reduced. Reduced blood flow may cause tissue,
normal for ethnicity, including tissue in vital organs (such as the intestine), to die, resulting in gangrene. was; pale, cool
Assess skin q4h. and dry. *On-
warm, & dry, prior to The patient already is suseptible to this process, as she recently had gangrenous
discharge. cholecystitis. My assessment of this patient found her skin to be pale, cool, and dry. going.
(http://www.merckmanuals.com/home/infections/bacteremia,-sepsis,-and-septic-
shock/sepsis,-severe-sepsis,-and-septic-shock) (Class notes)

Outcome 9 Intervention 9 Patially met:

Patient did not
receive an
Patient is a 68 year old female diagnosised with a small bowel antibiotic. She
obstruction d/t Crohns. She has a PMH of anemia, HTN, thyroid was free from all
Patient will be free from disease, urinary retention, and a recent cholecystectomy. She is at s/s of systemic
s/s of systemic infection; risk for a bowel perforation d/t the SBO. The patient is infection, except
Obtain order for immunocompromised and has a WBC count of 4.0, she is a high for loose stool.
fever, tachycardia,
antibiotic, STAT. risk for becoming septic. Having a antibiotic prophylatically on However, pt
tachypnea, N/V &
diarrhea. board could help prevent an infection from developing. She did not states the stool
display s/s of systemic infection. (Class notes) appears to be
normal in
character for her.
*On-going
NCP Continued…
Outcome Criteria Nursing Actions Scientific Rationale Evaluation
Outcome 10 Intervention 10

Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI
pneumonia d/t being immunocompromised, as well as, many other types of
infections. She is a high risk for becoming septic. She is also severely malnurished Unmet: Patient's
with a BMI of 16.9. Malnutrition can be a consequence of energy deficit (protein-
Patient's albumin will be 3.4- energy malnutrition - PEM) or a micronutrient deficiency. This direct relationship albumin was 1.7.
Monitor albumin, qd. *On-going.
5, as assessed qd. between malnutrition and death is mainly due to the resulting immunodeficiency
and, consequently, greater susceptibility to infectious agents. Monitoring albumin is
a good indicator of nutritional status. A low albumin also puts her at risk for fluid to
move to interstitial space, causing edema. Patient did have edema to her right
dorsal aspect of her foot, non-pitting. (Class notes)

Patient is a 68 year old female diagnosised with a small bowel obstruction d/t
Outcome 11 Intervention 11 Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary retention, and a
recent cholecystectomy. She is at risk for a bowel perforation d/t the SBO, and HAI
pneumonia d/t being immunocompromised, as well as, many other types of
infections. She is a high risk for becoming septic. She is also severely malnurished
with a BMI of 16.9. Malnutrition can be a consequence of energy deficit (protein-
energy malnutrition - PEM) or a micronutrient deficiency. This direct relationship
between malnutrition and death is mainly due to the resulting immunodeficiency Unable to assess:
and, consequently, greater susceptibility to infectious agents. Monitoring albumin is
Administer TPN a good indicator of nutritional status. TPN requires water (30 to 40 mL/kg/day),
Patient's albumin
Patient's albumin will be 3.4- was 1.7 at start of
60ml/hr, per MD energy (30 to 45 kcal/kg/day, depending on energy expenditure), amino acids (1.0
5, as assessed qd. TPN. *On-going.
order. to 2.0 g/kg/day, depending on the degree of catabolism), essential fatty acids,
vitamins, and minerals. TPN supplies all daily nutritional requirements. This patient
has been recommended for surgery to resolve her SBO, however, she has been
deamed not nutritionally stable for surgery. Without adequate protein, she is at risk
for infection and impaired wound healing after surgery. The surgons have reported
they want her to have 7-10 days of TPN prior to considering surgical involvement.
(http://www.merckmanuals.com/professional/nutritional-disorders/nutritional-
support/total-parenteral-nutrition-tpn) (Lewis)
Outcome 12 Intervention 12

Patient is a 68 year old female diagnosised with a small bowel

Met: Patient is
obstruction d/t Crohns. She has a PMH of anemia, HTN, thyroid
recommended to
disease, urinary retention, and a recent cholecystectomy. She is at
have a SBO
Patient will not have a risk for a bowel perforation d/t the SBO, and risk for becoming
Obtain a surgery resection when
bowel perforation, while septic. It needs to be determined, when and if they can surgically
consult, STAT. nutritionally
admitted at the hosptial. repair her small bowell to resolve the obstruction. Should she
stable. *On-
perforate her bowel, she will be rushed to emergent surgery
going.
regardless of her nutritional status. (Class notes)
NCP Continued…
Outcome Criteria Nursing Actions Scientific Rationale Evaluation
Outcome 13 Intervention 13
Patially met:
Patient was free
Patient is a 68 year old female diagnosised with a small bowel
from all s/s of
obstruction d/t Crohns. She has a PMH of anemia, HTN, thyroid
systemic
disease, urinary retention, and a recent cholecystectomy. She is at
Patient will be free from infection, except
Monitor and risk for a bowel perforation d/t the SBO, and HAI pneumonia d/t
s/s of systemic infection; for loose stool.
restrict visitor being immunocompromised, as well as, many other types of
fever, tachycardia, However, pt
access, as infections. She is a high risk for becoming septic. Limiting visitors
tachypnea, N/V & states the stool
appropriate, qd. reduces her risk for developing an infection d/t being
diarrhea. appears to be
immunocompromised. This patient did not have any visitors this
normal in
shift. (Class notes)
character for her.
*On-going
Patient is a 68 year old female diagnosised with a small bowel obstruction
Outcome 14 Intervention 14 d/t Crohns. She has a PMH of anemia, HTN, thyroid disease, urinary
retention, and a recent cholecystectomy. She is at risk for a bowel
perforation d/t the SBO, and HAI pneumonia d/t being
immunocompromised, as well as, many other types of infections. She is a
high risk for becoming septic. In sepsis blood flow decreases to vital
organs (such as the kidneys, lungs, heart, and brain), causing them to
begin to shut down. Mean Arterial Pressure is defined as the average Met: Patient's
Monitor the pressure in a patients arteries during one cardiac cycle. It can be used to MAP remained
Patient's MAP will remain
patient's mean calculate the overall blood flow and thus delivery of nutrients to the between 83-92.
between 70-90, as
arterial pressure, various organs. The blood pressure value that should be targeted during *On-going
assessed qd.
q4h. the management of septic shock is an important clinical issue. The mean
arterial pressure (MAP) is one of the first variables that is monitored in
these patients. Prolonged hypotension, defined as a MAP of less than 60
to 65 mm Hg, is associated with poor outcome. This patient's MAP
remained between 83-92.
(https://www.nursingcenter.com/ncblog/december-2011/calculating-the-
Outcome 15 Intervention 15 map) (Class notes)
Patient is a 68 year old female diagnosised with a small bowel Patially met:
obstruction d/t Crohns. She has a PMH of anemia, HTN, thyroid Patient was free
disease, urinary retention, and a recent cholecystectomy. She is at from all s/s of
risk for a bowel perforation d/t the SBO, and HAI pneumonia d/t systemic
Patient will be free from being immunocompromised, as well as, many other types of infection, except
s/s of systemic infection; infections. She is a high risk for becoming septic. Washing your for loose stool.
Perform proper hands properly is one of the most important things you can do to However, pt
fever, tachycardia,
hand hygiene, aat. help prevent and control the spread of many illnesses. Good hand states the stool
tachypnea, N/V &
diarrhea, att. hygiene will reduce the risk of things like flu, food poisoning and appears to be
healthcare associated infections being passed from person to normal in
person. (https://www.nidirect.gov.uk/articles/hand-hygiene) (Class character for her.
notes) *On-going

Evaluation On-going.
Evaluation On-going.