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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, Icant do anything, cold, cyanotic extremities, peripheral edema non-pitting +1, peripheral pulses weak and thread, HR 102, BP 110/54, RR 30, shallow breathswith 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 minimalexertion

I feel so out of breath, Icant do anything

-Objective

Cold, cyanotic extremities Peripheral edema non-

pitting +1

Peripheral pulses weakand thready

HR 102 BP 110/54 RR 30 Shallow breaths with

diminished lung sounds

Weakness AEB reducedgrip strength of +1

RBC: 3.88, HgB: 10.9,HcT: 33

Cap refill 100, pulse

and respiratory rate

within normal parametersfor client; strong

peripheral pulses, warm,

pink extremities andability to tolerate activity

without dyspnea, by

04/30/2012 at 14:00.

1. Intervention:

Assess current level ofknowledge r/t treatment

regimen, exercise and

medications. (Lippincott

& Williams, 2008)

-Rationale:

Understanding thepatients level ofknowledge and their

ability to understand will

allow teaching to be

tailored to theirindividual needs and

knowledge deficits.

2. Intervention:

Teach client the treatmentregimen, 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 toteaching and had no barriers

to teaching. Pt. was assessed

and level of knowledge wasdetermined. 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 extremitiesshowed worsening signs of

inadequate perfusion. Cap

refill went from

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NURSING CARE PLAN

-Rationale:

In order to increasepatient compliance and

satisfaction it isimperative to teach

patients the purpose ofeach of their medications

and to remind them of the

importance of ongoing

monitoring.

1. Intervention:

Administervasoconstrictors as

ordered and titrate ifnecessary. (McClough,

2002)-Rationale:

Vasoconstrictors help tomaintain adequate bloodflow.

2. Intervention:

Administer IV fluids asordered. (McClough,

2002)

-Rationale:

IV fluids help to maintainadequate blood volume inorder to prevent

hypovolemia and further

complications.