PLANNING/IMPLEMENTATION/EVALUATION Pt. Room: 2A (Include a RUBRIC for each)

Transcription

1 PLANNING/IMPLEMENTATION/EVALUATION Pt. Room: 2A (Include a RUBRIC for each) Nursing Diagnosis Risk for decreased cardiac output r/t altered stroke volume secondary to sepsis. Long Term Goal Pt. will maintain adequate cardiac output. Outcome Criteria Interventions Rationale Evaluation 1. Pt. s oral temperature will be degrees Fahrenheit by day 1, as assessed Q4hr. Support 1 action with EBP documented on the NPG 1. Monitor oral temperature Q4hr. 1. Infection causes an inflammatory response and an elevation in temperature. The patient s initial rise in temperature was a sign of the acute infection in the abdominal incision. In sepsis, the temperature can rise initially then drop below normal limits due to the body s inability to continue to fight the infection. As of now the pt. s temperature has remained WNL, meaning the antibiotics are fighting the infection or her immune system is slowly worsening unable to fight it. M= met; P= partially met; U = unmet What did you do about any PM or U 1.P The pt. had a elevated temperature post-operatively due to an infection in the abdominal incision but with continuous antibiotic therapy her Temperature has remained WNL. 2. Pt. s heart rate will remain BPM by day 1, as assessed Q4hr. 2. Monitor heart rate Q4hr. 2. The pt. s HR has remained WNL and not become tachycardic. An altered stroke volume from fluids shifting from the vascular to the interstitial spaces would cause an increased HR to compensate for the decreased amount of blood pumped with each beat. 2. M.

2 3. Pt. s respiration rate will remain between breaths/min, easy and nonlabored by day 1, as assessed Q4hr. 3. Assess Respiration rate and rhythm Q4hr. 3. The pt. s respiration rate has remained WNL. Increased respirations are a direct effect of the body trying to compensate in times of stress, fever, or hypoxia. A fluid shift causing hypovolemia will decrease stroke volume and decrease oxygen carrying capabilities causing hypoxia and increased respiration rate. 3. M 4. Pt. s BP will be remain > 100/60 by day 1, as assessed Q4hr. 4. Assess BP Q4hr 4. Pt. s BP has remained >100/60. History of hypertension and on antihypertensive the pt. s BP is normally 130/72-110/64. The pt. is a high risk for sepsis after post-op complications of an abdominal incision dehiscence and a contained anastomosis leak. A sign of septic shock is a downward trend of the pt. s BP resulting from a shift of fluid from the vascular to interstitial spaces causing hypovolemia, decreased stroke volume and a decreased cardiac output. 4. M 5. Pt. s lung sounds will remain clear by day 1, as assessed Q4hr. 5. Assess lung sounds Q4hr. 5. Sepsis causes the fluid to shift from the vascular to the interstitial spaces causing decreased stroke volume. Crackles indicate pulmonary complications and possible onset of cardiac decompensation. The pt. had adventitious lungs sounds post-op but cleared with treatment. 5. P The pt. s lung sounds are now clear but diminished. Previous CXR show left lower lobe infiltrate but with use of incentive spirometer, TCDB, and Albuterol neb QID it has improved.

3 6. Pt. will remain alert and oriented x 3, able to follow simple commands, and answer questions appropriately by day 1, as assessed with every interaction. 6. Assess mentation with every interaction. 6. Septic shock can cause a change in neurologic status. Decreased blood volume in the vascular spaces causes a decrease in cerebral blood flow causing confusion, agitation, and a change in mentation from baseline. MP remained alert and oriented with no mentation changes from baseline. 6. M 7. Pt. will maintain a urine output of atleast 100cc/hr by day 1, assessed every void. 7. Assess urine output every void. 7. A decreased urine output can be indicative of septic shock. A decreased stroke volume and inadequate blood supply in the vascular system will decrease perfusion to vital organs including the kidneys. Decreased perfusion to the kidneys will decrease urine output. Monitoring the pt. s output every time she voids will indicate if the kidneys are perfusing adequately. Pt. s output has been greater that her intake meaning proper kidney perfusion. 7. M 8. Pt. s pedal pulses will remain 1+ at baseline by day 1, as assessed Q4hr. 8. Assess pedal pulses Qshift. 8. Pt. s pedal pulses remained 1+ with no changes from baseline. Diminished pulses can indicate a change in vascular fluid status causing thread, faint pedal pulses. Not a complete obvious sign of sepsis but looking at the pt. as a whole and all their clinical symptoms its another sign of fluid shift and decreased blood flow in the vascular system. 8. M

4 9. Pt. s WBC will be between 5,000-10,000 by day 4 of antibiotic therapy, assessed when CBC levels drawn. 9. Administer Zosyn 3.375gm IV Q6hr per MD order. 9. Zosyn is an extended spectrum penicillin antibiotic. It binds the the bacterial cell wall causing cell death. The antibiotic was prescribed to MP due to a post-op complication causing her abdominal incision to dehisce and open up needing a wound vac. It s also prophylactically treating the contained leak at the anastomosis site, which could lead to peritonitis. Zosyn is helping kill the microorganisms, which could lead to septic shock. Pt. s WBC s elevated after surgery and slowly returned to normal limits after continued antibiotic therapy. The antibiotics are either, fighting her infection and controlling the sepsis risks or she s slowing losing WBC s and losing the fight against the infection. Based on her current mentation, BP, and adequate urine output, as of now she shows signs of fighting the infection. 9. M 10. Pt. s temperature will remain <100.5 degrees Fahrenheit orally by day 1, as assessed Q4hr. 10. Collaborate with MD to have blood cultures drawn as soon as possible. 10. Pt. s temperature never elevated over MP highest was prior to antibiotic therapy and there were no blood cultures ordered by MD. Blood cultures would be able to tell if the microorganism has now entered the blood stream from the localized infected site. Lab results indicating an elevated bacterial level can be treated immediately before the sepsis can cause havoc on the vascular system. 10. M

5 11. Pt. s will remain NPO except meds, monitored Qshift cc/hr and 42cc/hr via PICC line per MD order. 11. The MD put the patient on TPN and intralipids and NPO except medications. The contained leak at the anastomosis site increases the pt. s risk for peritonitis. The pt. not eating for drinking allows the bowel time to rest and decreases further risk of infection in the peritoneal cavity. The TPN is nutrition that bypassing the stomach providing the body with vitamins, salts, amino acids, glucose, and lipids. The continuous fluids also help maintain adequate vascular perfusion and increased stroke volume. 11. M 12.. Pt. s WBC will be between 5,000-10,000 by day 4 of antibiotic therapy, assessed when CBC levels drawn. 12. Monitor WBC s with every lab draw per MD order. 12. Pt. s WBC 16.9 and neutrophils 88 on 2/7/11 prior to antibiotic therapy. Neutrophil count up ready to fight the infection. By day 4 the WBC s were 8.6 and neutrophils WNL. WBc s dropping to normal limits can mean two things, her body is fighting the infection or the WBC s are trying to ward off the infection and losing. Based on her lab values, vitals, wound site, and mentation she is clinically showing she s fighting the infection. (EBN: WBC and Neutrophil count are better diagnostic tests for adults, Nursing Dx Handbook) 12. M 13. Pt. s BUN/Creat will be BUN 7-21 and Creat by day 4, as assessed every lab draw. 13. Monitor BUN/Creat lab values with every draw per MD order. 13. Pt. has chronic kindey disease and her BUN and Creat. levels correlate with it. But they are her baseline and can be assessed daily for a significant jump in trends. An 13. U Pt. s BUN 31-44, Creat BUN/Creat correlate with pt. s chronic kidney disease. Labs monitored daily by MD.

6 elevation above her baseline can indicate shock and decreased renal perfusion. Elevated levels above the baseline can indicate dehydration and decreased intravascular fluids. 14. Pt. s PICC line will be without phlebitis or infiltration by day 1, assessed Qshift. 14. Assess PICC line Qshift. 14. Assessing for phlebitis or infiltration every shift will decrease the risk of an infection from her peripherally inserted central catheter. She already has an infection and the PICC line is another portal of entry for microorganisms to enter central circulation and cause a septic infection. 14. M 15. Pt will verbalize 2 s/sx of infection after teaching Qday. 15. Teach s/sx of infection Qday 15. Teaching MP about her abdominal wound and anastomosis leak will educate her about her increased risks for the leaking content to sit in her belly and cause peritonitis which can lead to sepsis. Teaching her to notity the nurse or MD immediately if her abdomen becomes hard, rigid, steady pain, N & V, bloating, fever, or chills can promote acute interventions to treat it immediately and decrease the risks of sepsis and decreased cardiac output. 15. M

7 16. Pt. will verbalize why she needs to remain NPO when she states, I just want to eat. 16. Teach and remind pt. why she needs to remain NPO Qday. 16. Teaching MP that her bowels need to rest after the trauma from surgery to heal properly and limit gastric content to leak into her peritoneal cavity limits her risks of further infections and can help prevent sepsis. Her lack of knowledge and seriousness of her condition can be detrimental to her health. She needs continued reinforcement and education. 16. P.M. Pt. randomly states, I want to go home and I want to eat. I verbalized to pt. why her bowls need time to rest after surgery and limited content in her belly to decrease risks of infection from contained leak. She only nods with understanding. Continued teaching needed.

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