Nursing 217

Planning/Implementation/Evaluation
Med/Surg Nursing Diagnosis: Risk for shock: Sepsis r/t inflammatory process
Long-Term Goal: Patient will not develop septic shock

Outcome Criteria Interventions Rationale Evaluation

1. Patients vitals will 1. Assess 1. Assessing vital signs frequently will give the nurse an implication of the patients current health status and to quickly 1. Met;
trend: T 96.8-100.4, P Assess VS q4h notice any change in patients condition. Early signs of sepsis include increased heart rate (>90 bpm), respiratory rate over Pts T 97.1-98.1, P 76-
60-100 and regular, R and PRN 20 breaths per minute, and changes in temperature (> 100.4F or under 96.8F). An increase in heart rate and respiratory 77, R 18, BP 108/64-
12-20, BP: systolic < rate occurs as the body attempts to compensate for a decrease in tissue perfusion As sepsis progresses to septic shock, 112/62, o2 sat 97-99%
140 or > 90 diastolic < acute vasodilation and increased capillary permeability can cause reduced vascular volume and decreased cardiac output, on 2L/min o2.
90 or > 50, O2 sat 95- which is reflected as hypotension. The pt is a 73 y/o male who was admitted with osteomyelitis and sepsis. It is important to Plan is ongoing
100% RA as assessed continue monitoring his vitals to make sure the sepsis has been resolved and doesnt progress to septic shock.
q4h and PRN
2. Pts wound cultures 2. Monitor 2. Pt is a 73 y/o male with DM 2, neuropathy, and CVA in the past. He was admitted with osteomyelitis and sepsis. He has a 2. Unmet;
will show decrease in Monitor wound necrotic pressure ulcer on his left foot that they are treating with antibiotics. There are many different antibiotics that treat Pts wound has not
bacterial growth within culture results as different strains of bacteria. It is important to culture the wound to verify what bacteria is growing within the wound bed. been cultured since
24hrs of antibiotic ordered Once that is determined the doctors can prescribe the best course of antibiotics to clear up the infection. Clearing up the admit date of 1-3-17.
therapy infection within the wound will aid in the healing process of the whole wound. Pressure ulcers take a while to close up, Plan is ongoing
especially with DM 2, so if there are risk factors for infection that can be resolved it is important to do so. Continual
monitoring of the wound cultures will help assess whether or not the wound infection has been cleared up with the course
of antibiotics that have been prescribed. Clearing up the infection will prevent this patient from going into septic shock.

3. Patients CRP will 3. Independent 3. The level of C-reactive protein (CRP), which can be measured in your blood, increases when there's inflammation in your 3. Unmet;
trend down toward Monitor C- body. The doctor may check your C-reactive protein level treatment for infections or for other medical conditions. Upon Only CRP drawn was
normal range of <5 Reactive protein admission this 73 y/o male patients CRP was >16. Normal range is <5. His CRP was triple what it shouldve been. This on admit and it was
within 24h of antibiotic results as indicates inflammation somewhere within the body. A test result showing a CRP level greater than 10 mg/L is a sign of >16.
intitiation ordered serious infection, trauma or chronic disease, which requires further testing to determine the cause. You cant go by CRP Plan is ongoing.
alone in diagnosing sepsis because an elevated CRP can indicate inflammation anywhere in the body. It is important to
perform other tests to confirm diagnosis of sepsis.

4. Pt glucose level will 4. Dependent 4. Pt is a 73 y/o male with DM 2/neuropathy who was admitted with osteomyelitis which led to sepsis. Elevated blood sugar 4. Unmet;
be between 70-110 Administer Insulin level stiffens the arteries and causes narrowing of the blood vessels. Narrowed blood vessels lead to decreased blood flow Pts glucose level
gm/dl upon assessment Aspart and oxygen to a wound. An elevated blood sugar level decreases the function of red blood cells that carry nutrients to the before dinner was 128
AC & HS 100unit/1mL SQ tissue. This lowers the efficiency of the white blood cells that fight infection. Without sufficient nutrients and oxygen, a and HS glucose 135.
AC &HS per wound heals slowly. Insulin aspart is an antidiabetic that works to bind to the insulin receptors on muscle and fat cells and Plan is ongoing
sliding scale per lower blood glucose by facilitating the cellular uptake of glucose and simultaneously inhibiting the output of glucose from
MD order the liver. Controlling glucose levels allows the patient to have better wound healing, avoid infections and ultimately sepsis.