Septic Shock

EricJRN, MSN, RN · Nov 7, 2012

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?

Esme12, ASN, BSN, RN · Nov 7, 2012

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

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
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?

Esme12, ASN, BSN, RN · Nov 7, 2012

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.

superana · Nov 7, 2012

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%

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!

Esme12, ASN, BSN, RN · Nov 7, 2012

Is this a real patient?

superana · Nov 7, 2012

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.

superana · Nov 7, 2012

No. At least I don't think so. It's a "hypothetical clinical situation."

Esme12, ASN, BSN, RN · Nov 7, 2012

Well actually they did.....the problem is to know how to find it. How do you know they are acidotic?

superana · Nov 7, 2012

They gave ABGs results.

pH: 7.31

PO2: 75 mmHg

PCO2: 31 mmHg

HCO3: 18 mEq/L

Esme12, ASN, BSN, RN · Nov 7, 2012

No. At least I don't think so. It's a "hypothetical clinical situation."

Grrrrrrrrr this drives me nuts. I believe that this is why student have such difficulty with nursing diagnosis and care plans because it is all about the patients assessment.

Ok......first. What is shock? Welcome to Critical Care Medicine Tutorials What is sepsis? Infections and Intensive Care

What does it do to the body?http://www.ccmtutorials.com/infection/sepsis/page2.htm

The patient is initially injured in some way - this may be, for example, infection, trauma or inflammation.
The result of this injury is activation of host defense mechanisms, including release of inflammatory cytokines, particularly interleukin-6 and tumor necrosis factor alpha.
The physiologic manifestations of this process include tachypnea, tachycardia, leucocytosis and pyrexia, and we call this the systemic inflammatory response. The body is, in effect, responding to the source of inflammation and making physiologic compensation for the systemic upset.
If the patient is unable to adequately compensate, and suffers acute organ failure, then he /she requires critical care interventions - usually mechanical ventilation, often with cardiovascular support.
The patient has undergone a "first hit". He/she is now vulnerable to further injury.
At this point one of three things may happen: 1) the injury and inflammatory and or inflammatory response may persist (26). 3) The patient may develop a second (or third or fourth) injury, such as nosocomial pneumonia, ventilator induced lung injury or bacterial translocation from the gut, which stokes up the inflammatory response.
Persistent inflammation leads to widespread endothelial dysfunction, and ischemic tissue injury (due to hypotension, intravascular thrombosis, tissue edema, abnormal oxygen extraction etc).
The result of this is sequential organ damage - multi organ dysfunction. Examples of this are an increase in the alveolar to arterial oxygen gradient, a reduced ejection fraction, agitation or coma, a reduction in creatinine clearance, and increase in serum bilirubin, a decrease in platelets and clotting factors etc.
As the disease process progresses, multi-organ dysfunction becomes multi-organ failure. This is characterized by the requirement for external interventions to maintain homeostasis - mechanical ventilation, inotropes and vasopressors, renal replacement therapy, continuing blood product transfusions etc.
The patient becomes severely catabolic, physiologic reserve deteriorates and neuroendocrine exhaustion occurs. The latter is characterized by the inability of the patient to mount an appropriate endocrine response to ongoing stress and inflammation.
The majority of patients who develop multi organ failure succumb, due to inability to wean external interventions (usually mechanical ventilation and vasopressors).
Death is inevitably as a result of withdrawal of this support.

Systemic inflammatory response syndrome (SIRS)

http://www.stagesofshock.com/SIRS/index.html#

is a general inflammatory response to various causes. It is considered to be due to cytokines ("cytokine storm")

SIRS can be diagnosed when two or more of the following are present

(1) Heart rate > 90 beats per minute

(2) Body temperature 38°C

(3) Hyperventilation (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg

(4) White blood cell count 12000 cells/mm3, or the presence of greater than 10% immature neutrophils. SIRS + proof of infection = sepsi

Care of the Patient with Sepsis

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442679.cw/index.html

http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25166/6442619.cw/index.html

Esme12, ASN, BSN, RN · Nov 7, 2012

They gave ABGs results.
pH: 7.31
PO2: 75 mmHg
PCO2: 31 mmHg
HCO3: 18 mEq/L

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

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.

OK now what does your patient need by looking at this scenario. Your patient is febrile (hyperthermia), hypoxic(impaired gas exchange), acidotic, and hypotensive. Knowing what we know about sepsis and the patients high fluid requirements from leaky capillary beds....could the hypotension be caused by deficient fluid volume. Does this patient have impaired gas exchange from the pneumonia? Is the patient at risk for ineffective airway clearance R/T mechanical ventilation? Is this patients acidosis metabolic from lactic acid and multi-system failure? From the multi-liumen is the patient at risk for injury related to impaired catheter function? Does this patient have acute pain from the surgery?

Do you have a Nursing diagnosis book? Look there for the taxonomy.