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!
