Douglas Sheffield

Planning/Implementing/Evaluation (See Grading Rubric for NCP Criteria)

Med/Surg Nursing Diagnosis R/f shock: sepsis r/t positive blood culture for klebsiella pneumoniae
Long Term Goal

Pt will be free of septic shock

Outcome Criteria

Priority Interventions

One outcome criteria for each

intervention. Number each one.

Label each intervention as:

Answers why, how, what your interventions will Evaluate the patient outcome
Assess/Monitor/Independent
help solve, prevent or lessen the stated problemNOT the intervention
Dependent/Teaching/Collaborationspecific to this patient.

1. Pt will have HR 60-100, BP

125/60-140/90, RR 12-20, O2
sats >95% RA, and Temp 97.2-98.6
q 4 hr

2. Pt LS will be clear q 4 hr

1.

Assess v/s q 4 hr

2. Assess LS q 4 hr

Rationale

Evaluation

1.Pt presented to ED with

BP 140/56 that dropped to 97/47, HR 120, RR 22,
O2 sats 87% RA, and temp of 101.6F. Pt was
diagnosed with sepsis, acute respiratory failure,
acute UTI, aspiration pneumonitis, increased CK
level, low BP but not hypotension, lactic acidemia,
septic encephalopathy, and macrocytosis. Sepis
leads to systemic inflammatory response
syndrome which causes fluids to shift from the
intravascular space into the interstitial spaces
causing hypovolemia. When fluid volume is
decreased, BP decreases due to the lack
of hydrostatic pressure that is exerted on the
arterial wall. The HR increases to maintain
adequate cardiac output. RR increases due to the
increased demand for oxygen and the O2 sats
decrease due to the lack of oxygen availability
to the body tissues. The pt is stable now and has
v/s that meet the outcome criteria. I will expect
this to remain as so because the pt has been
bolused with fluids to replace what was lost due to
third spacing. Pt was also given oxygen, aztreonam,
ceftriaxone, levofloxacin, and methylprednisolone.
Assessment of v/s allows for early identification of a
returning infection and early intervention to improve pt
outcomes.

1. Met Pt HR is 74, BP 138/88,

RR 20, O2 sats 95%, temp 97.8F

2.Pt presents to ED with BP 97/47, HR 120, RR 22, O2

sats 87%, and temp 101.6F. Pt was diagnosed with sepsis
probably due to a pulmonary infection and UTI, and
aspiration pneumonitis. The lungs are usually sterile.

2.Met pt LS were clear on

auscultation

Douglas Sheffield
The introduction of foreign microbes initiates the
inflammatory cascade. There is increased blood flow and
increased vascular permeability. Neutrophils flood the
lungs to phagocytize the organisms. Neutrophils, the
infectious organism, and blood from surrounding vessels
fill the alveoli. Mucous production also increases. This
would cause crackles to be noted from air moving
through fluid as well as diminished LS in the bases from
obstructed air flow. Assessment of LS would allow for
early identification of a deviation from baseline which
will be established with the initial assessment. Due to
the pt having a history of dysphagia and being diagnosed
with aspiration pneumonitis, the pt is at risk for her
pulmonary infection to reoccur. Early assessment would
allow for early initiation of antibiotic therapy to decrease
the bacterial load and prevent the pt from progressing to
sepsis.
3.Pt will have trend of WBC 500010000 and neutrophils 37-80 after
ciprofloxacin therapy.

3.Monitor CBC with deferential qday

3.Pt presents to with WBC of 16.6, bands 1, and

neutrophils 93. WBC are active in the immune system to
clear foreign material and microbes from the body.
Neutrophils are elevated in acute bacterial infection. .
Arterial vasodilation occurs due to ATP-sensitive
potassium channels in vascular smooth muscle which is
directly activated in lactic acidosis. WBC and neutrophils
increase due to the initiation of the inflammatory
response. The vasodilation causes decreased perfusion to
tissues including the brain causing hypoxia. This may
lead to the pt presenting with acute confusion. Bands are
immature neutrophils that are present with sepsis.
An increase in bands is called a shift to the left and
indicate the need for immediate intervention. When
neutrophils and WBC decrease below normal limits
is indicative of severe sepsis and require immediate
intervention. The pts presentation and labs should be
correlated to determine what is happening to determine
the cause of the sepsis. I expect the pts WBC and
neutrophils to continue to trend down until they are
within 5000-10000 and neutrophils due to her
ciprofloxacin use. Early identification of a worsening
infection allows for early intervention and improved pt
outcomes.

3.met WBC was 16.4 on 11/20

and 15.1 on 11/22 ,
neutrophils 93 on 11/20 and 85 on
11/21