Sepsis: Caused by decreased tissue perfusion as a result of a severe infection.
• Deficient fluid volume related to vomiting, diarrhea, high fever, and shift of intravascular volume to interstitial spaces,
• Ineffective breathing pattern related to rapid respirations and progression of septic shock,
• Ineffective tissue perfusion related to progression of septic shock with decreased cardiac output, hypotension, and massive vasodilatation,
• Anxiety related to feelings that illness is worsening and is potentially life threatening, and the transfer to the critical care unit
• Maintain adequate circulating blood volume.
• Regain and maintain blood gas parameters within normal limits.
• Regain and maintain stable hemodynamic levels.
• Verbalize increased ability to cope with stressors.
PLANNING AND IMPLEMENTATION:
Monitor neurologic status, including mental status and level of consciousness.
Monitor cardiovascular status, including arterial blood pressure; rate, rhythm, and quality of pulses; central venous pressure; pulmonary artery pressure; and cardiac output.
Monitor color and character of skin.
Monitor results of arterial blood gases, blood counts, clotting times, and platelet counts.
Monitor respiratory status, including respiratory rate, rhythm, and breath sounds.
Monitor body temperature every 2 hours.
Monitor urinary output hourly, reporting any output of less than 30 mL per hour.
Explain procedures and provide comfort measures (oral care, skin care, turning, positioning).
EVALUATION Despite intensive nursing and medical care, the patient’s condition remains critical. The interventions are continued. Critical Thinking in the Nursing Process:
1. Vasopressors may be used in the treatment of septic shock.
2. Explain the rationale for their use.
3. Monitoring patient arterial blood gases.