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    Septic Shock

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    Yuvi Rociandel LUARDO
    The nursing care plan addresses a patient experiencing septic shock and ineffective breathing. Short term goals include stabilizing the respiratory rate to an effective pattern within 4 hours. Long term goals are to establish a normal breathing pattern within 12 hours as shown by normalized vital signs and blood gases. Interventions include monitoring vitals, assessing breathing sounds and cognition, administering oxygen, keeping the patient calm, and medicating for pain relief.

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    Septic Shock

    Uploaded by

    Yuvi Rociandel LUARDO
    23 views3 pages
    The nursing care plan addresses a patient experiencing septic shock and ineffective breathing. Short term goals include stabilizing the respiratory rate to an effective pattern within 4 hours. Long term goals are to establish a normal breathing pattern within 12 hours as shown by normalized vital signs and blood gases. Interventions include monitoring vitals, assessing breathing sounds and cognition, administering oxygen, keeping the patient calm, and medicating for pain relief.

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    The nursing care plan addresses a patient experiencing septic shock and ineffective breathing. Short term goals include stabilizing the respiratory rate to an effective pattern within 4 hours. Long term goals are to establish a normal breathing pattern within 12 hours as shown by normalized vital signs and blood gases. Interventions include monitoring vitals, assessing breathing sounds and cognition, administering oxygen, keeping the patient calm, and medicating for pain relief.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    23 views3 pages

    Septic Shock

    Uploaded by

    Yuvi Rociandel LUARDO
    The nursing care plan addresses a patient experiencing septic shock and ineffective breathing. Short term goals include stabilizing the respiratory rate to an effective pattern within 4 hours. Long term goals are to establish a normal breathing pattern within 12 hours as shown by normalized vital signs and blood gases. Interventions include monitoring vitals, assessing breathing sounds and cognition, administering oxygen, keeping the patient calm, and medicating for pain relief.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    NURSING CARE PLAN

    Oncologic Emergency: Septic Shock

    Nursing Diagnosis: Ineffective breathing pattern related to rapid respirations and progression of septic shock

    Expected Outcomes:

    Short term:

    ● After 4 hours of providing nursing care, the patient will be able to establish an effective respiratory pattern as manifested by stabilizing
    respiratory rate.

    Long term:
    ● After 12 hours of providing nursing care, the patient will be able to establish a normal, effective respiratory pattern as evidenced by the absence
    of cyanosis and other s/sx of hypoxia, with arterial blood gases (ABG's) within the client's normal or acceptable range.

    Signs and Symptoms:


    ● Fever and shaking chills
    ● reduced mental alertness, sometimes with confusion
    ● nausea and vomiting
    ● diarrhea
    ● increased heart rate, greater than 90 bpm
    ● increased respiratory rate

    Interventions Rationale Evaluation

    1. Establish rapport 1. Establishing rapport promotes patient Short Term:


    cooperation and creates a close and harmonious
    relationship with the client. 1. After 4 hours of providing nursing care,
    the patient was able to establish an
    2. Monitor vital signs and laboratory results. 2. To provide baseline data. Tachypnea, effective respiratory pattern as
    tachycardia, elevated blood pressure and manifested by stabilizing the respiratory
    increasing hypoxemia and hypercapnia are rate of 16 bpm.
    signs of compromised respiratory status.
    Long Term

    3. Respiratory rate and rhythm changes are 2. After 12 hours of providing nursing care,
    3. Assess respiratory rate and depth by listening to lung early warning signs of impending respiratory the patient was able to establish a
    sounds. difficulties. normal, effective respiratory pattern as
    evidenced by the absence of cyanosis and
    other s/sx of hypoxia, with arterial blood
    4. Affects ability to manage own airway and gases (ABG's) within the client's normal
    4. Assess the client's cognition and awareness. cooperate with interventions such as controlling or acceptable range.
    breathing

    5. Rate may be faster than usual. Depth may be


    5. Note rate and depth of respiration, counting for 1 full difficult to evaluate but is usually described as
    minute, if the rate is irregular. shallow, normal, or deep.

    7. Client may report a range of symptoms (e.g.,


    7. Note client's reports and perceptions of breathing ease.
    air hunger, shortness of breath with speaking,
    activity, or at rest) and demonstrate a wide
    range of signs (e.g., tachypnea, gasping,
    wheezing, coughing).

    8. Observe characteristics of breathing patterns. 8. May see the use of accessory muscles for
    breathing, nasal flaring, or pursed-lip breathing.
    9. Note the color of skin and mucous membranes.
    9. If pallor, duskiness, and/or cyanosis are
    present, supplemental oxygen and/or other
    10. Elevate the head of the bed and/or have the client sit up interventions may be required.
    in a chair as appropriate
    10. To promote physiological and
    11. Use pulse oximetry to monitor O2 saturation and pulse psychological ease of maximal inspiration.
    rate.
    11. To verify maintenance/improvement in O2
    12. Administer oxygen at the lowest concentration indicated saturation.
    and prescribed respiratory medications.
    12. For management of respiratory distress.
    13. Maintain a calm attitude while dealing with the client
    and significant other (s).
    13. To limit the level of anxiety.
    14. Medicate with analgesics, as appropriate.
    14. To promote deeper respirations.

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