Urinary Tract Infection Leading to Sepsis Care Plan

Purpose: 1. The student will collect pertinent data on one the assigned I-Human cases and the student will create and formulate two (2) care plans. 2. The student will utilize the “Nursing Process” model to develop a Plan of Care that identifies the problem and customizes care to meet the person’s needs. 1.ASSESSMENT Subjective Data Objective Data Patient states “urine dark/foul odor, she has a history of incontinence, had a cystoscopy a week ago in urologist office, pinching when voiding, decreased in urine output,” had symptoms “for a few days, I think, I mean it came on subtly, didn’t think anything at first.” Pt states history of incontinence Patient Chief Complaints: Acute onset of confusion, low-grade fever Assessments/Observations T=99.8 BP=98/60 R=24 and deep PP= 90 Distended bladder Skin warm dry flushed Lungs clear no consolidation 2. NURSING DIAGNOSIS 1. Risk for Shock 2. low bp, increase respirations, acute onset of confusion, fever R/T UTI- Sepsis. Diagnostics/Procedures/Surgery Cystoscopy- Urologist office Urinalysis Blood Culture Urine Culture and Sensitivity Procalcitonin CBC BMP 3.PLANNING SHORT Term Goal (STG) LONG Term Goal (LTG) The patient will display perfusion The patient will display as evidence by vital signs and adequate perfusion as evidence urinary output during shift. by appropriate vital signs, usual level of mentation and urinary output. 4. IMPLEMENTATION Independent Interventions 1. The nurse will maintain bedrest and assist with care activities. 2. The nurse will monitor trends in blood pressure (BP), especially noting progressive hypotension and widening pulse pressure. 3. The nurse will assess respiratory rate, depth, and quality. Note onset of severe dyspnea. 4. The nurse will record hourly urinary output and specific gravity. Dependent Interventions 1. Monitor laboratory studies, such as ABGs and lactate levels. 2. The nurse will provide supplemental oxygen by RATIONALE Independent Interventions 5. EVALUATION Independent Interventions 1. Preventing overexertion decreases myocardial workload and oxygen consumption, thus maximizing effectiveness of tissue perfusion (Doenges, Moorhouse, Murr, 2010, p 692). 2.Hypotension develops as circulating microorganisms stimulate release and activation of chemical and hormonal substances. These endotoxins initially cause peripheral vasodilation, decreased systemic vascular resistance, and relative hypovolemia. As shock progresses, cardiac output becomes severely depressed due to major alterations in contractility, preload, and/or afterload, thus producing profound hypotension (Doenges, Moorhouse, Murr, 2010, p 692). 3. Increased respirations occur in response to direct effects of endotoxins on the respiratory center in the brain, as well as developing hypoxia, stress, and fever. Respirations become shallow as respiratory insufficiency develops, creating risk of acute respiratory failure. (Doenges, Moorhouse, Murr, 2010, p 693). 4 Decreasing urinary output with high specific gravity indicates diminished renal perfusion related to fluid shifts and selective vasoconstriction occurs, shunting blood to vital organs, reducing peripheral blood flow, and creating cool, clammy, pale and dusky skin. (Doenges, Moorhouse, Murr, 2010, p 693). Dependent Interventions 1. Circulatory collapse reduces tissue perfusion. Inadequate renal perfusion alters filtration, 1. in progress 2. Pt BP stabled during shift 3. Pt has deep breath and respirations are stabilized 4. Pt urinary output and specific gravity has increased. Dependent Interventions 1. in progress 2. in progress appropriate route. reabsorption, and secretion of various substances resulting in fluid and electrolyte imbalances. ABGs and serum lactate levels indicte acid-base balance and anaerobic metabolism. Respiratory or metabolic acidosis indicates weakened compensatory mechanisms. Lactic acid accumulation is due to inadequate oxygenation and thus accumulation of anaerobic by productrs or lactate (Doenges, Moorhouse, Murr, 2010, p 694). 2. Supplemental oxygen improves cellular oxygenation (Doenges, Moorhouse, Murr, 2010, p 694). SUMMARY Short Term Goal (STG) Pt is still hospitalized Long Term Goal (LTG) Pt is still hospitalized.