Nursing diagnosis of SEPSIS

  1. Hi All,
    I have my first careplan due and my patients dianosis was sepsis. The books I have have little to no information on sepsis. I reall need help with nursin interventions for the nursing diagnosis ofsocial interaction impaired and impaired comfort! Any suggestions I would greatly appreciate!!!!
    My pt had chronic dementia and was non verbal

    Thank you
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    About pinkfan

    Joined: Apr '10; Posts: 29; Likes: 2


  3. by   kimmie4476
    I'm confused, you have a patient with sepsis and you are using impaired social interaction and impaired comfort as your nursing diagnosis? You might want to pick a higher priority nursing dx.
    Look up sepsis and learn what it is, then find your nursing diagnosis. I personally think these are inappropriate for a potentially life threatening condition. just my
  4. by   pinkfan
    yes I choose those because we have to have a total of 10 nursing diagnosis with 10 interventions each and those are the last 2 I need help with!
    Any help is appreciated
  5. by   kimmie4476
    oic, that's better what interventions do you already have for these dx?
  6. by   pinkfan
    I changed social interaction impaired to impaired verbal communication r/t psychological barriers which would be my pt's depression and for my interventions I put: allow body contact such as touching to show you care and your presence, limit the number of people in the room at bedside so you don't overwhelm the pt and do not push communication.

    I worked on the impaired comfort and got ten!

    My priority nursing dx is: infection r/t microorganism invasion into the body. Do you think this is a good one? I looked in my nurses pocket guide Ed 12 and they only have risk for infection not just infection by itself. Is this still nanda approved?

    Thank you!
  7. by   DolceVita
    Infection is not a nursing diagnosis according to NANDA's most recent publication.

    Do you have any assessment data?
    What are their vital signs? With sepsis you could have everything from depressed temp. to elevated temp. Oxygenation? BP (usually low BP is a symptom of sepsis)?

    You get my point. You are assessing the patient as a whole. So a medical diagnosis in itself can point you in the right direction for what complications you need to monitor, but you, the nurse, still need to assess. You know the patient is depressed so I bet you know much more.

    Their impaired VERBAL communication will be r/t the alteration of the CNS then you need to add the defining characteristics: aphasia perhaps? None the less it is unlikely that the impaired verbal communication is going to be in your top few NDs.

    If you are looking for priority NDs then you should always consider ABCs -- you should always consider these anyway. If you post some of your assessment data we could probably help you more.

    As for looking up conditions Google "family practice notebook", Mayo Clinic or Cleveland Clinic. Still your nursing textbook often have the NDs for conditions listed.
    Last edit by DolceVita on Apr 11, '10
  8. by   DolceVita
    ooooooooh I just got that you are on your last 2. Not enough coffee this morning. Still more data needed. What are your first 8 for this patient?
  9. by   kimmie4476
    I don't know if infection is NANDA approved,it's not in my older book but in by nursing dx book, under sepsis it lists Deficient fluid volume RT vasodilation of peripheral vessels, leaking capillaries
    Imbalanced nutrition less than body requirements RT anorexia, generalized weakness
    ineffective tissue perfusion RT decreased systemic vascular resistance

    and under septic shock is deficient fluid volume RT abnormal loss of fluid through capillaries, pooling of blood in peripheral circulation
    ineffective protection RT inadequately functioning immune system

    Don't know if they pertain to your pt, but some interventions I have in my book are
    Use presence. Spend time with the pt, allow time for responses and make the call light readily available

    Listen carefully. Validate verbal and nonverbal expressions

    Use simple communication, speak in a well modulated voice, smile and show concern for the pt.

    recognize behavioral cues for pain

    assess whether a person is averse to touch

    maintain eye contact at the pt. level
  10. by   kimmie4476
    oops, think I just did your homework for you...been a long 12 hour shift
  11. by   pinkfan
    Here's my assessment data! Bp: 108/64, temp: 96.7 pulse: 70 resp: 14

    decreased cardiac output, impaired skin integrity, social interaction impaired, chronic confusion, risk for injury, risk for dehydration, imbalanced nutrition, ineffective protection

    my priority nursing dx was infection rt microorganism in the body but I have to change infection to something nanda improved!
    Any thoughts on what that could be?
  12. by   pinkfan
    Thanks for all the help!!! I greatly appreciate it!!! I'm a first semester nursing student and am overwhelmed with this full lenght careplan! It's a whole new way of thinking!

    My pt was 89 yrs old had hx of kidney disease, chronic dementia, diabetes. Pt was nonverbal and during my whole shift we were waiting on the speech therapist to come in and perform a swallowing test which did not happen by the end of my shift. I feel stressed but I greatly appreciate all the wonderful help!!!
  13. by   kimmie4476
    take note of the temperature, I didn't see hypothermia in your list
  14. by   kimmie4476
    your priority dx can be determined by Maslow's needs. List all of them and find out which one is highest according to Maslow and you should be fine.