Planning/Implementation/Evaluation

Samantha LaCLair
Med/Surg Nursing Diagnosis: Ineffective peripheral tissue perfusion R/T systemic inflammatory response AEB hypotension,
MAP of 50, Decreased LOC during admit.
Long-Term Goal: Pt will have adequate tissue perfusion
Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1.Pts will trend

towards baseline
of BP100-110/7080
P 60-100
R 12-20 even &
easy
T 98.6-99F
O2 sat 95-100%
RA
As assesses Q 4
hrs

1. Independent Assess V/S

Q 4 hrs & O2 sat

2. Pts I&O will

trend towards +/200ml of each
other Q 4hrs

2. Independent Monitor
I&O Q 4hrs

Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. My pt was admitted with Septic shock from the

introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. The heart works harder, to try to
perfuse the tissues. Pts may compensate by using
shallow fast respirations which may increase heart
rate, because the heart is trying to compensate for the
need for more O2. Your body needs adequate O2 to
function properly. O2 sat < 90% indicates hypoxemia,
and poor perfusion. Temperature is a good indicator of
infection and how well the medications given to treat
the infection are working. Monitoring V/S can indicate a
change from baseline and allow the MD and Nursing
staff to collaborate on a plan of care if the V/S indicate
worsening conditions.
2. My pt was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. Pt outcome
partially met: Pt had
BP 96/61
P 80
R 16 even & easy
T 98.06
O2-97% RA
Plan is ongoing V/S
were partially met
because pt had a low
BP of 89/44 and is still
trending slightly below
her baseline.

2. Pt outcome
partially met:
I- 480ml
O- 700ml

3.Pt will drink

2500-3000ml
fluid Q 24 hrs

3. Independent Encourage
2500-3000ml of fluid Q
24hrs

4. Pts CBC will

trend towards
the range of
WBC 4.1-11.0
Hgb 12-16
Hct 36-47
Platelets 150-450
Neutrophils 3575 Q shift.

4. Dependent Monitor CBC

Q Day

brain, kidneys, liver, and intestines because of the

systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Monitoring I &O will ensure that
there is adequate perfusion to the kidneys. When there
is adequate perfusion to the Kidneys the pt will have an
output of at least 30ml/hr and remain with +/- 200ml of
I:O.
3. My pt was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Maintaining fluid volume status is
pertinent in maintaining adequate tissue perfusion.
Sufficient fluid volume maintains adequate BP so that
the vital organs are perfused.
4. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. By monitoring the pts. CBC you
are able to track the progress of their infection through
the trending of their WBCs and neutrophils. When
elevated these are two indicators that the body is still

X1 unmeasured void
Plan is ongoingpartially met pt did not
have a nuns cap in her
room in the am. Had
x1 void unmeasured.

3. Pt outcome Partially
met: I-480ml from
0800 to 1230
Plan is ongoing.

4.Pt outcome
partially met:
WBC 6.6
Hgb 1.6 (L)
Hct 11.6 (L)
Platelets 163
Neutrophils 78 (H)
Pts WBCs were WNL.
Plan is ongoing.

5. Pt
procalcitonin will
trend towards
<0.10 Q day

5. Dependent Monitor
Procalcitonin Q day

6. Pt MAP will
trend towards
70-90 Q 4hrs.

6. Independent Monitor
pts. MAP Q 4 hrs

7. Pt cap refill will

remain <3 sec as

7. Independent Monitor
cap refill Q shift

fighting infection and if they continue to rise you are

able to note expected worsening conditions and
provide interventions. Hemoglobin carries O2 in the
blood, lower than normal limits alone are an indicator
that the bodys tissues are not being perfused
adequately.
5. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Procalcitonin above 9.99 is an
indication of an important systemic inflammatory
response almost exclusively due to severe bacterial or
septic shock. Peripheral tissue perfusion will continued
to be impaired with ongoing inflammation in the
vessels.
6. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. A MAP greater than or equal to 70
mm Hg is imperative to maintain perfusion pressure
and adequate flow at the arteriolar level. At pressures
below this number, auto regulation can be
dysfunctional in many tissue beds.
7. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV

5. Pt outcome not
met:
Procalcitonin 12.60 (H)
Normal range is <0.10
Plan is ongoing

6.Pt outcome not

met:
Pt MAP was 72.6 @
1200
During the night it was
59
Plan is ongoing

7. Pt outcome met :
Pt cap refill remained

assessed Q shift

8. Pt will
maintain 2+
peripheral pulses
as assessed Q
shift

8. Independent Monitor
peripheral pulses Q shift

9.Pt will remain

A&OX3 as
assessed at
baseline q 4 hrs

9.Independent Monitor pt.

LOC Q 4hrs

drugs. Septic shock can cause impaired perfusion

affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Cap refill > 3secs indicates that
the blood is not being adequately perfused to the
tissues. This test measures how well the vascular
system works to perfuse hands and feet, and the parts
of your body that are farthest from the heart indicating
whether are not pt has adequate perfusion.
8. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Peripheral pulses are usually weak
in times of shock because of the loss of circulating
blood volume. Weak thready pulses are an indicator
that the tissue in the peripheries is being poorly
perfused because of the poor amt. of blood being
circulated. Normal peripheral pulses should be 2+.
9. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to

<3 sec as assessed Q

shift
Plan is ongoing.

8.Pt outcome met:

Pt had 2+ peripheral
pulses as assessed Q
shift
Plan is ongoing.

9. Pt outcome met:
Pt remained A&OX3 as
assessed Q 4hrs
Plan is ongoing.

10. Pt will be
without
unilateral edema
to extremities,
sudden onset of
chest pain,
dyspnea,
anxiety, and +
homans sign Q
day

10. Dependent Administer

Lovenox Per MD order

11. Pt will trend

towards WBC 510,000 Q day.

11. Dependent
Administer IV Vancomycin
in 0.45% sodium chloride
Per MD order

maintain perfusion to vital organs leading to

compensated shock. Decreased LOC is an indicator
that the brain is not receiving adequate tissue
perfusion. Especially during hypoxic events pts may
become dizzy, confused, and lethargic. My pt. at
baseline is A&Ox3 so a change in her LOC could
indicate worsening conditions from decreased tissue
perfusion.
10. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. The widespread inflammation can
cause the blood to clot and further impair tissue
perfusion. Lovenox is used to keep the blood thin and
prevent clotting, it is a low molecular weight heparin in
the antithrombotic pharm class. Lovenox potentiates
the inhibitory effect of antithrombin on factor Xa and
thrombin, resulting in prevention of thrombus
formation.
11. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Treating the infection will increase
peripheral tissue perfusion by eliminating the

10. Pt outcome met:

Pt was without
unilateral edema to
extremities, sudden
onset of chest pain,
dyspnea, anxiety, and
+ homans sign Q day.
Plan is ongoing.

11. Pt outcome met:

Pt WBCs 6.6
Plan is ongoing.

12. Pt will trend

towards
Na 136-145
Cl 100-108
K+ 3.6-5.2

12. Dependent
Administer IV 0.45% NaCl

inflammatory process caused by the growth of bacteria

in the blood. Vancomycin is an anti-infective used in
the treatment of potentially life-threatening infections
when less toxic anti-infectives are contraindicated. It is
particularly useful in staphylococcal infections,
including septicemia. Vancomycin binds to bacterial
cell wall, resulting in cell death, which would ultimately
improver her overall condition.
12. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. 0.45 Sodium chloride IV solution
is used to correct fluid and electrolyte imbalances that
occur during septic shock. 0.45% ("half-normal saline")
solution is most commonly used for hydration.
Replenishing fluids is pertinent in maintaining
adequate tissue perfusion especially during shock
when refractory hypotension occurs. Fluids are pushed
to try to increase BP to maintain perfusion. 0.45% NaCl
is a hypotonic solution that is used to push fluid into
the cells. Compared with intracellular fluid, hypotonic
solutions have a lower concentration, of solutes
(electrolytes) The infusion of hypotonic crystalloid
solutions lowers the serum osmolality within the
vascular space, causing fluid to shift from the
intravascular space to both the intracellular and
interstitial spaces. Pt had a 5 liter bolus of 0.9% NaCl in
ER to maintain vascular blood volume. 0.45% NaCl will
pull fluid out of vascular space and back into the cells
and interstitial space to correct fluid and electrolyte

12.Pt outcome
partially met:
Na 142
Cl 98
K+ 3.4
Labs were slightly
below normal limits.
Plan is ongoing

13.Pt will trend

towards normal
sinus rhythm
without ST
depression/eleva
tion Q shift

13. Dependent Monitor

Telemetry Q shift

14. Pts. troponin

will trend
towards the
normal range of
0.0-0.10

14. Dependent Monitor

Troponin levels Q shift

balance.
13. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. During periods of inadequate
tissue perfusion the heart compensates increasing the
HR to try to perfuse the body adequately. Monitoring
telemetry can indicate whether the heart is receiving
enough oxygenated blood. An increase in heart rate or
sinus tachycardia would indicate the heart is working
harder to perfuse the tissue, and would be cause for
interventions. Telemetry can show indications of
demand ischemia to the heart through a depressed ST
wave, or even an NSTEMI that could be cause from a
clot formed from the inflammation in the vessels r/t the
systemic inflammation.
14. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. During septic shock pts can have
an increased troponin either related to an MI caused
from a thrombus formed from inflammation, or demand
ischemia related to inadequate perfusion to the heart.
Monitoring troponin can help determine how well the

13.Pt outcome met:

Pt remained in Normal
sinus rhythm without
ST
elevation/depression Q
shift
Plan is ongoing.

14. Pt outcome
Partially met:
Troponin 0.13
Pt troponin trending
back down from 32 on
10/2 to 0.13 on 10/3
Troponin lad drawn for
10/4 after we left floor
Plan is ongoing.

15. Pt will
verbalize 3
important S/S to
report about
ineffective
peripheral tissue
perfusion Q day.

15. Independent Teach

important S/S of ineffective
peripheral tissue perfusion
to report Q shift

heart is being perfused with O2.

15. My pt. was admitted with Septic shock from the
introduction of bacteria into her body from the use of IV
drugs. Septic shock can cause impaired perfusion
affecting every part of the body, including the heart,
brain, kidneys, liver, and intestines because of the
systemic inflammatory response that occurs when the
body responds to the toxins given off by the bacteria.
The bodys compensatory mechanisms are initiated to
maintain perfusion to vital organs leading to
compensated shock. Teaching a pt important s/s of
ineffective peripheral tissue perfusion can initiate a
response sooner if nursing staff fails to recognize them,
or they have a sudden onset. Important things to teach
pts would be a sudden onset of dizziness, anxiety, or
chest pain, numbness and tingling in extremities, N/V,
and abd pain. These could indicate life threatening
conditions which should be addressed immediately.

15. Pt outcome met:

Pt verbalized 3
important s/s to report
indicating ineffective
tissue perfusion
1. Sudden onset of
dizziness
2. Chest pain
3. Numbness
tingling
Plan is ongoing.