NURSING CARE PLAN

STUDENT_____Audrey Lewis___________PATIENT INITIALS_ M.D.____ROOM NUMBER__________ DATE__05/04/2012_________ BRIEF MEDICAL HISTORY _Pt. M.D. is a 40 yr. old female who was healthy until a recent hysterectomy she had performed while in Mexico visiting her family. Since the surgery she has felt fatigued, feverish, and had a cough. She was admitted to San Antonio through the E.R. for fever and N/V. She was diagnosed with sepsis and is being monitored in the ICU. Her blood pressure has been low at 110/54 being her highest and she is on a Levophed drip to maintain perfusion and prevent vascular collapse. NURSING DIAGNOSIS STATEMENT: Altered tissue perfusion: peripheral related to vasodilation in response to multi-organ infection AEB SOB with minimal exertion, pt stating I feel out of breath, I cant do anything, cold, cyanotic extremities, peripheral edema non-pitting +1, peripheral pulses weak and thread, HR 102, BP 110/54, RR 30, shallow breaths with diminished lung sounds, weakness with reduced grip strength of +1, RBC 3.88, HgB 10.9, Hct 33%. ASSESSMENT NURSING DIAGNOSIS PLANNING/OUTCOME (GOALS) IMPLEMENTATION (INTERVENTIONS) EVALUATION (If met or not within time frame)

-Subjective SOB with minimal exertion I feel so out of breath, I cant do anything

1. Altered tissue perfusion: peripheral

-Objective Cold, cyanotic extremities Peripheral edema nonpitting +1 Peripheral pulses weak and thready HR 102 BP 110/54 RR 30 Shallow breaths with diminished lung sounds Weakness AEB reduced grip strength of +1 RBC: 3.88, HgB: 10.9, HcT: 33 Cap refill <3sec

1. Long-Term: (needs to be measureable) Client will verbalize knowledge of their treatment regimen, including medications, their actions and possible side effects by 04/30/2012 at 17:00.

2. Short-Term: (needs to be measureable) Client will demonstrate adequate tissue perfusion AEB SBP >100, pulse and respiratory rate within normal parameters for client; strong peripheral pulses, warm, pink extremities and ability to tolerate activity without dyspnea, by 04/30/2012 at 14:00.

1. Intervention: Assess current level of knowledge r/t treatment regimen, exercise and medications. (Lippincott & Williams, 2008) -Rationale: Understanding the patients level of knowledge and their ability to understand will allow teaching to be tailored to their individual needs and knowledge deficits. 2. Intervention: Teach client the treatment regimen, exercise goals and plan, and medication regimen along with actions and side effects. (Lippincott & Williams, 2008)

1. Goal 1 met. Pt. and parents were very receptive to teaching and had no barriers to teaching. Pt. was assessed and level of knowledge was determined. Her teaching was administered at a level that she could understand. She was able to verbalize the purpose, side-effects, and regimen of medications. 2. Goal 2 was not met. Pt. continued to deteriorate. While BP was maintained at >100 SBP her extremities showed worsening signs of inadequate perfusion. Cap refill went from <3sec to <5sec. Fingertips became even more cyanotic.

NURSING CARE PLAN

-Rationale: In order to increase patient compliance and satisfaction it is imperative to teach patients the purpose of each of their medications and to remind them of the importance of ongoing monitoring. 1. Intervention: Administer vasoconstrictors as ordered and titrate if necessary. (McClough, 2002) -Rationale: Vasoconstrictors help to maintain adequate blood flow. 2. Intervention: Administer IV fluids as ordered. (McClough, 2002) -Rationale: IV fluids help to maintain adequate blood volume in order to prevent hypovolemia and further complications.