Subjective: DX:: Case: Systemic Infection
Subjective: DX:: Case: Systemic Infection
Subjective: DX:: Case: Systemic Infection
Objective: Shock is a life-threatening STO: Dx: Cardiac output becomes severely depressed STO: (Goal Met)
condition that occurs when Monitored blood pressure (BP), due to major alterations in contractility,
CASE: SYSTEMIC INFECTION
Malaise the body is not getting Within 2 hours of effective especially noting progressive preload, and/or afterload, thus producing Within 30 mins of
Hyperthermia enough blood flow. This can nursing interventions, the hypotension and widening pulse profound hypotension. effective nursing
Inc. Heart rate lead to damage to multiple patient will be able to: pressure. interventions, the patient:
Systemic organs. Septic shock is a life- Respirations become shallow as respiratory
infection threatening condition that a. Understand plan of care insufficiency develops, creating the risk of a. Understood plan of care.
Decreased happens when your blood for compliance. Assessed respiratory rate, depth, and acute respiratory failure.
urinary output pressure drops to a quality. Note onset of severe dyspnea. LTO: (Goal Met)
dangerously low level after Changes in mentation reflect alterations in
Nursing Diagnosis: LTO: Assessed for changes in sensorium cerebral perfusion, hypoxemia, and/or Within 48 hours of
an infection.
(confusion, lethargy, personality acidosis. effective nursing
Risk for Shock related to Source: Within 48 hours of effective changes, stupor, delirium, and coma). interventions, the patient:
systemic infection nursing interventions, the
https://www.nhsinform.scot/i patient will be able to: Progressive deterioration requires more a. Manifested free of
Tx: aggressive therapy including hemodynamic complications such as
llnesses-and- Prepared for transfer to critical care
conditions/blood-and- a. Display adequate monitoring and vasoactive drug infusions. irreversible brain or
perfusion as evidenced by setting, as indicated. neurologic damage.
lymph/septic-shock
stable vital signs. To increase blood volume and cardiac
Given fluids to maintain blood pressure output. a. Display adequate
or cardiac output. perfusion as evidenced by
Manage current problem that may result to stable vital signs, palpable
Administered medications, as ordered complications if left untreated. peripheral pulses, skin
(ex. Corticosteroids, inotropic agents).
warm and dry, usual level
Information helps reduce anxiety. Anxious of mentation, and
Edx: clients unable to understand anything more
Explained all procedures as appropriate, individually appropriate
than simple, clear, brief instructions. urinary output.
keeping explanations basic.