Hello, i need some help. I have this case study i need assistance with. Here is the scenario:
"Mrs. Perry has been admitted to the ward via the emergency department (ED) with a historyof severe abdominal pain due to pancreatitis. Mrs Perry informed staff in the ED that she drinks a couple of cases of beer each weekâ€, stating her last drink was the early hours ofthe morning prior to her attending the ED. While doing rounds in the evening you notice thatMrs. Perry has tremors, is very anxious and restless. She has vomited approximately 250mLof bile type fluid. Her skin is cold and clammy to touch and she looks very pale. HR 121/minBP 90/42mmHg, RR 28/min, SpO2 92% on air, Temp.39.8C"
As the nurse caring for Mrs Perry assess and plan her care
Now looking at her observations, it looks like she has sepsis, I need to find one main problem, although she has pancreatitis, sepsis is a main problem so would the nursing diagnosis be: Deficient fluid volume related to vomiting secondary to sepsis as evidenced by decreased BP, High temperature and respiration rate.