Septic Shock

  1. 0
    Hi, I'm kind of desperate for some help.

    I've got a 24 yo pt. who received a GSW to the abdomen with perforation of the mall intestine and the colon. He had intestinal resection and right side hemicolectomy. He's got metabolic acidosis, elevated WBC, BUN, creatinine and glucose. Continues to present elevated temperature, respirations and pulse, but low BP. He's intubated, and has gone into septic shock. I'm not sure about nursing diagnosis.

    Acute pain r/t trauma or maybe surgical procedure, but since the pt. can't verbalize it, I don't know what the manifestation is.

    Ineffective breathing pattern r/t abdominal trauma manifested by dependance on endotracheal tube

    Ineffective peripheral tissue perfusion r/t septic shock (can I use septic shock or should I put infectious process?) manifested by...

    Deficient fluid volume r/t infectious process secondary to sepsis manifested by decreased urinary output and elevated temperature

    Honestly, I'm not even 100% what the priority problem is here. PLEASE HELP!
  2. Get the Hottest Nursing Topics Straight to Your Inbox!

  3. 5,963 Visits
    Find Similar Topics
  4. 12 Comments so far...

  5. 0
    You'll find this easier if you think about your assessment data and not so much about the medical diagnoses or surgeries. I think that's why you're able to come up with a few possible nursing diagnoses but you're having trouble with the defining characteristics (the "manifested by" portion). Those defining characteristics come from a detailed patient assessment.

    Hypotension in shock isn't good, but there's a lot more to the story. What is the skin like? Pulses? Neuro? Any work of breathing?
  6. 1
    Welcome to AN! The largest online nursing community!

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    So tell me about your patient
    .......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient?
    Last edit by Esme12 on Nov 7, '12
    Wise Woman RN likes this.
  7. 1
    So looking at your scenario........what does this tell me about your patient.
    I've got a 24 yo pt. who received a GSW to the abdomen with perforation of the mall intestine and the colon. He had intestinal resection and right side hemicolectomy. He's got metabolic acidosis, elevated WBC, BUN, creatinine and glucose. Continues to present elevated temperature, respirations and pulse, but low BP. He's intubated, and has gone into septic shock. I'm not sure about nursing diagnosis.
    What is your assessment of the patient. What are their vital signs? What is their color, skin, lung sounds? Are they awake? Do they follow commands? Are they heavily sedated? What is the normal care of a post op patient? Do they have invasive lines? What are they? Tell me what he LOOKS like.

    Why are they in septic shock? What is this condition of his abdomen? Peritonitis? What is peritonitis? If he had perforation of the small bowel that means he has e-coli, gm negative, sepsis. What do you know about gm neg sepsis? What is sepsis?

    Give me more information on your patient so we can go tothe next step.
    Wise Woman RN likes this.
  8. 0
    That's why I'm so lost. They didn't give me any information about skin, patient condition, I don't know if he's sedated or how he's responding to the treatment. He was confused and agitated when he arrived, but it says nothing of his mental state later on. His last set of vitals were:

    T: 39.3
    P: 118
    BP: 88/58
    R: 20
    SpO2: 90%

    Quote from superana
    Hi, I'm kind of desperate for some help.

    I've got a 24 yo pt. who received a GSW to the abdomen with perforation of the mall intestine and the colon. He had intestinal resection and right side hemicolectomy. He's got metabolic acidosis, elevated WBC, BUN, creatinine and glucose. Continues to present elevated temperature, respirations and pulse, but low BP. He's intubated, and has gone into septic shock. I'm not sure about nursing diagnosis.

    Acute pain r/t trauma or maybe surgical procedure, but since the pt. can't verbalize it, I don't know what the manifestation is.

    Ineffective breathing pattern r/t abdominal trauma manifested by dependance on endotracheal tube

    Ineffective peripheral tissue perfusion r/t septic shock (can I use septic shock or should I put infectious process?) manifested by...

    Deficient fluid volume r/t infectious process secondary to sepsis manifested by decreased urinary output and elevated temperature

    Honestly, I'm not even 100% what the priority problem is here. PLEASE HELP!
  9. 0
    Is this a real patient?
  10. 0
    Oh, I forgot to mention that he does have subclavian central line and pneumonia because they found some infiltrates in his lungs on the CRX. I feel like they gave a lot of information on the medical condition, but not enough to properly complete the nursing assessment.
  11. 0
    No. At least I don't think so. It's a "hypothetical clinical situation."
  12. 0
    Well actually they did.....the problem is to know how to find it. How do you know they are acidotic?
  13. 0
    They gave ABGs results.

    pH: 7.31
    PO2: 75 mmHg
    PCO2: 31 mmHg
    HCO3: 18 mEq/L


Top