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Med/Surg Nursing Diagnosis Risk for septic shock R/T multiple, concurrent infectious processes.

Long Term Goal

Pt. will not experience septic shock.

Outcome Criteria
1. Pt. VS will remain: BP
within 20 mmHg of
baseline, HR 60-100, RR
12-20, body temperature
96.8 99.0F qshift.

2. Pt. will remain COA x3


qshift.

Interventions
1. Assess VS and oxygen
saturation q4hrs.

2. Assess LOC q1hr.

Rationale

Evaluation

1. It is important to assess and establish the pts baseline vitals to


recognize changes indicative of worsening and/or new
infection. An elevation in overall body temperature is indicative
of systemic infection. This pt. presented without fever in the
E.R. in severe sepsis, but has spiked fevers throughout her
hospitalization, including a fever of 102F on 03/19. During
early septic shock (high output shock), which is more
treatable, there is an increase in CO reflected by tachycardia
and normal or elevated BP. As this phase is accompanied by
inflammation, pain may also contribute to increased HR and BP
via activation of the SNS. As septic shock continues beyond
the first phase, blood vessels dilate, causing hypovolemia and
subsequent hypotension a telltale sign of severe sepsis.
Typically, sepsis causes a systolic BP <90mmHg. Septic shock
also leads to changes in oxygenation, as the vessels dilate and
peripheral structures are no longer adequately perfused. SpO2
should be maintained at 92% or greater. This pt.s VS should
be monitored at least q4hrs, as she has a history of sepsis,
which predisposes her to future sepsis events, as well as
multiple active infectious processes including VRE and MSSA
infections of her L perirectal pressure ulcer, a systemic yeast
infection, and pneumonia.

1. Partially met pt.


spiked fever of
102F on 03/19 with
BP of 118/64 and
Ap. rate 84 bpm
and SpO2 of 95%
on RA; she denied
pain, but also
presented with
chills and
intermittent moans;
will continue to
monitor

2. At her basline, this pt. is sleepy but rouses easily to verbal


stimuli and is COAx3. A decrease in LOC related to decreased
cerebral perfusion may be the first sign of compensatory
response in the pt. to a septic state. Early signs of cerebral
hypoxia include restlessness and anxiety. Whereas, in later
stages the pt. may present with confusion and lethargy.

2. Met; pt. remained


COA x3 to
baseline
throughout shift

Changes in LOC may manifest before changes in VS or


alterations in lab values.

3. Pt.s wound will not


increase in size, have
malodorous drainage, or
increased slough or
eschar qshift.

3. Assess wound at least


once qshift and after
each stooling.

3. This pt. was admitted with a L gluteal abscess, with significant


malodorous discharge and obvious signs of dermal necrosis.
Two days prior to being admitted for this hospital stay she was
prescribed an antibiotic regimen for treatment of the abscess.
On arrival to the ED, she was diagnosed with severe sepsis
and subdermal pockets of air in the tissues surrounding the
abscess suggested extensive tissue damage and necrotic
infection. This prompted an extensive surgical I&D. Surgical
cultures of the wound identified active VRE and MSSA infection
in the wound. The result of her surgical I&D is a Stage IV
wound extending from her L gluteus immediately proximal to
the gluteal fold to her L medial thigh. She experienced fullthickness tissue loss, has a small area of necrotic tissue in the
center of the wound, and slough present throughout the wound
bed. Though surgeons were able to identify that the wound
extended to her L ischial tuberosity, no bone was exposed. As
her wound is a Stage IV wound without approximated wound
edges, it will be left open to heal by secondary intention as it
fills in with new granulation tissue and scar tissue.
Additionally, the wound is immediately proximal to the anus and
this pt. is incontinent of stool. The combination of these factors
places the patient at increased risk of worsening and/or new
wound infection. Currently, her extensive wound is her greatest,
least-stable risk factor for sepsis and possible septic shock.
The wound should be regularly assessed, fecal contamination
cleansed from the area, and characteristics of the wound itself
documented. Documentation should include the type of tissue
in the wound base; depth and size of the wound; amount and
location of granulation tissue, necrotic eschar, and slough; as
well as wound exudate characteristics, such as color,
consistency, and odor. The presence of excessive and/or
malodorous exudate indicates infection. Periwound skin
assessment should also be included, as the presence of
increased warmth, maceration, edema, or pain in the area
surrounding the wound may indicate wound deterioration rather
than healing.

3. Partially met;
dressing changed
per order at 1500
and 2000 after
stooling; the L
gluteal aspect of
pts wound did not
increase in extent,
nor develop any
measurable
malodorous
discharge; pt.
denied pain on
palpation of
periwound area,
which remained
free of erythema
and edema;
however the L
medial thigh
aspect of the pts
wound showed
increased graygreen slough, and
periwound skin
around the medial
thigh aspect of the
wound was
reddened and
warm to touch

4. Partially met; pt.

4. Pt.s wound will show


continued signs of healing,
including decreased
slough in wound bed,
increased granulation
tissue, decreased eschar,
and decreased wound
size.

5. Pt.s skin will remain pink,


warm, and dry with brisk
capillary refill (<3seconds)
at least 1+ PP in all
extremities.

4. Implement measures to
promote wound healing
qshift.

5. Assess skin turgor,


color, temperature,
capillary refill, and PP
q2hrs.

4. Her ordered dressing wet-to-dry Kerlix, loosely packed, and


secured via ABD pads and paper tape is intended to support
tissue development and provide mechanical debridement when
removed. Due to its proximity to the anus, there is a significant
risk posed for fecal contamination of the wound. Thus, it is
critically important in reducing the risk of sepsis and septic
shock that the dressing be changed at least once per shift and
after each stooling in this incontinent patient. Mechanical
debridement of slough and necrosis with frequent dressing
changes promotes healing and the development of new tissue
as well. Additionally, the RN should work to promote adequate
nutritional intake of at least 1,500 kcal/day. Specifically, normal
wound healing depends on the availability of protein, vitamins C
and A, and trace minerals. Protein is especially important for
tissue repair and growth. The RN should promote and teach
the importance of the consistent intake of a well-balanced to
prevent the breakdown of proteins as a source of energy.
However, it is important that this pts carbohydrate intake be
carefully monitored due to her chronically uncontrolled DM type
2 and subsequent impaired ability to metabolize carbs. She is
on a consistent carb diet, and the RN plays a critical role in
monitoring adherence to said diet to promote wound healing,
maintain stable blood glucose levels and prevent further
complications. The nurse should also ensure adequate
peripheral tissue perfusion in caring for this patient, as oxygen
fuels the cellular functions necessary for the healing process to
take place. She has a prn order for 2-6 LPM of O2 to keep her
O2 sats >92%. This patient likely has compromised peripheral
vasculature due to continued insult resulting from chronically
labile blood glucose levels, so assessment of adequate
peripheral perfusion should be frequent.
5. In early septic shock, warm, dry, flushed skin and bounding
pulses are evident as a result of initial vasodilation (aka warm
shock). As the shock state progresses, skin becomes cool,
clammy and cyanotic with weakened, rapid peripheral pulses
as the cardiovascular system attempts to maintain perfusion in
a state of widespread vasodilation. In a shock state,
weakened, and possibly even absent, peripheral pulses are
accompanied by capillary refill time greater than 3 seconds due

did not show any


increase in eschar,
and beefy red
granulation tissue
was present in the
wound bed; no
measurable
drainage was
noted; however,
the medial thigh
aspect of her
wound showed
increased slough

5. Partially met; pt
maintained skin
turgor, brisk
capillary refill and
palpable (1+) PP
throughout shift;
presented with
increased pallor
and diaphoresis
with fever of 102F;

to decreased perfusion. Skin assessment also offers


information regarding hydration status. Compromised
regulatory mechanisms in a shock state may result in fluid and
sodium retention at the kidneys. Loss of interstitial fluid as it
shifts to the intravascular space to compensate for widespread
vasodilation causes loss of skin turgor. As sepsis continues to
a late, less treatable stage, toxins cause leakage of fluid into
tissues and cause swelling. On assessment, this pt.s skin was
non-tenting, warm and pale. However, she rapidly became
diaphoretic with fever, which was interpreted as a potential
indicator of sepsis, and should be identified as such throughout
the duration of her hospitalization.

6. Pt.s lungs will be free of


adventitious LS on
auscultation qshift.

7. Pt. will maintain urinary


output of at least 30mL/hr
qshift.

6. Assess LS q4hrs.

7. Assess urinary output


q4hrs.

6. The lungs are a likely site of infection, especially in this mostly


sedentary pt. Her most recent CXR on 03/17 showed bibasilar
patchy infiltrates and a small, right pleural effusion indicative of
pneumonia. Her pneumonia, along with other concurrent
infections including a systemic yeast infection and wound
infection, place her at higher risk of going into septic shock.
Auscultation of worsening adventitious LS indicates increased
accumulation of exudate and cellular debris r/t pneumonia.
This may necessitate a change or addition to the current
antibiotic regimen to prevent progression of untreated infection
to a state of septic shock. Additionally, widespread vasodilation
in later stage septic shock leads to increased pulmonary
capillary permeability and increased intra-alveolar edema,
auscultated as moist crackles. Pts who experience septic
shock may have difficulty clearing their airways. In this pts
case, this may cause a negative spiral of consequences,
worsening her pneumonia.

7. In septic shock, the pt. quickly becomes hypovolemic. In an


attempt to compensate for said hypovolemic state, the kidneys
retain water to restore normal intravascular volume. Oliguria is
also a sign of inadequate renal perfusion that results from
reduced cardiac output in a hypovolemic state. As septic shock
remains untreated, the kidneys fail, resulting in no urinary

acetaminophen
administered;
diaphoresis
ceased with return
to temp. of 99.2F,
pallor remained;
will continue to
monitor

6. Unmet; pts LS
diminished in
bilateral bases
(ant. and post);
expiratory
wheezes
auscultated
throughout
remaining lung
fields; encouraged
TCDB and IS x10
qhr while awake;
will continue to
monitor

7. Met pt.
maintained UO
>30mL during shift

output and the build-up of metabolic wastes. In the case of this


pt. who has an in-dwelling Foley catheter draining to gravity,
reduction in urinary output may also indicate a urinary tract
infection or catheter occlusion. Thus, decreased urinary output
should be promptly addressed as an early sign of septic shock
and/or evidence of an additional infectious process placing this
pt. at even higher risk for septic shock.
8. Pts WBC count will be
within 4,000 to
11,000/mm3 (4.0 11.0),
her Hgb will trend toward
12 16, and Hct will trend
toward 34.9 44.5%
during hospitalization.

9. Pts WBC count will be


within 4,000 to
11,000/mm3 (4.0 11.0)
and blood cultures will
remain negative for growth
after 24 hours during
hospitalization.

8. Monitor CBC daily.

9. Administer piperacillintazobactam 3.375g via


IVPB q6hrs and
linezolid 600mg IVPB
q12hrs daily.

8. WBCs increase in response to active infection. An increase in


WBCs may be interpreted as indication of the presence and
severity of infection. On admit, this pts WBC was >20. A
noted rise in WBC above 11.0 may indicate recurrent infection,
ineffective ABx regimen and/or a new infectious process, all of
which place the patient at higher risk of septic shock.
Additionally, her H & H were low. Decreased H & H should be
recognized and promptly treated to maintain adequate
perfusion in order to reduce her risk for septic shock. In
adequate perfusion, especially in this pt. with uncontrolled type
2 DM and subsequent peripheral neuropathies, could
eventually lead to tissue necrosis and further infection. Without
adequate perfusion to her stage IV, L perirectal to L medial
thigh ulcer, wound healing will be further delayed, prolonging
the opportunity for wound infection, and increasing the risk for
sepsis.

9. On admit, this pt. was diagnosed with a stage IV, L perirectal to


L medial thigh decubitus ulcer and underwent an extensive
surgical I & D to remove necrotic tissue and explore the extent
of infection. She was initially treated with broad spectrum
antibiotics IV Levaquin, IV Clinamycin. Surgical C&S of
wound drainage identified the causative infectious organisms,
including vancomycin resistant enterococci (VRE) and
methicillin susceptible staphylococcus aureus (MSSA). As
such, her ABx regimen was changed to replace Levaquin with
piperacillin-tazobactam (Zosyn) and clindamycin with linezolid
(Zyvox). Zosyn is an extended spectrum penicillin often
prescribed for skin and skin structure infections. Piperacillin
binds to bacterial cell wall membranes, causing bacterial cell

8. Partially met on
03/19 pts WBC:
9.7; Hgb: 8.0; Hct:
23.8; will continue
to monitor; will
transfuse 1U
PRBC per MD
order if Hgb
decreases to 7.

9. Met; on 03//19,
WBC: 9.7; blood
cultures for
growth after 24
hrs.

death; while tazobactam inhibits the bacterial enzyme betalactamase which can destroy penicillins. Linezolid is an
oxazolidinone specifically prescribed for complicated skin and
skin structure infections caused by MSSA and VRE. Linezolid
inhibits bacterial protein synthesis, thus halting replication of
bacteria and preventing progression of infection. The
bacteriocidal action of piperacilling-tazobactam is intended to
compliment the bacteriostatic action of linezolid, thus
eliminating the pt.s wound infection and decreasing her
likelihood of recurrent sepsis.

10. Pt.s body temperature will


remain >96.8F and
<101F qshift.

10. Administer
acetaminophen 650 mg
PO q6hrs for body
temperature >101F.

11. Pt.s blood glucose will


trend toward 70-110
mg/dL during
hospitalization.

11. Administer bolus


coverage (regular
insulin) per sliding scale
based on AccuChecks
ac and at H.S. daily.

10. Partially met pt


spiked fever of
10. Temperature rises in response to activation of the bodys
102F, which had
immune system, making the body a less favorable environment
decreased to
for pathogens. Chills often precede temperature spikes. On
99.2F after
03/19, this pt. presented with rapid onset chills and intermittent
administration of
whimpers without c/o pain. Her body temperature was promptly
acetaminophen
assessed at 102F. A spike in body temperature should be
interpreted as an important indicator of systemic infection.
However, elevated body temperature causes stress on the
cardiovascular system, as it causes increased metabolic rate.
As the body is already stressed during infection, fever should
be controlled to prevent further predisposition to septic shock.
Acetaminophen is an antipyretic that inhibits the synthesis of
prostaglandins, which serve as mediators of pain and fever
response in the CNS. Acetaminophen should be administered
to lower fever and prevent further complications.
11. Unmet; pts BG
readings remain in
11. This pt. has an extensive history of uncontrolled type 2 diabetes
140s 250s range;
mellitus (DM). On admit, in severe sepsis, her BG was 24.
insulin
She was unresponsive and required immediate treatment with
administered
D50W for resuscitation. She was also recently hospitalized for
according to sliding
DKA, and her family reports poor compliance with her DM
scale; will continue
management regimen. Though on Levemir and NovoLog at
to monitor
home, her BG is being managed in the hospital via Regular
insulin bolus coverage based on an MD-ordered sliding scale.
As diabetics are at risk of developing wounds and sores that
dont heal well, it is believe that her uncontrolled DM
contributed to the development of her extensive L perirectal to
L medial thigh stage IV pressure ulcer, wound infection, and

subsequent sepsis. Infections in diabetics can get severe


quickly and lead to the development of sepsis and eventual
septic shock. Thus, it is important that this pts BG be routinely
monitored in the hospital setting to prevent delayed wound
healing, prevent the development of additional wounds, and
lessen the likelihood of septic shock.
12. Pts wound will remain
free of fecal contamination
qshift.

13. Pt. will remain free of S/S


of central line infection,
including fever >101F,
chills, HR >100 bpm, or
erythema, edema,
warmth, and/or drainage
at the catheter insertion
site qshift.

12. Change wound


dressing per MD order
after each stooling.

13. Assess PICC insertion


site qshift.

12. This pt is incontinent of stool and has a L perirectal to L medial


thigh wound. Due to its close proximity to the anus, her wound
should be inspected and cleaned frequently and its dressing
changed with each stooling. On 03/17-03/18, the pt. presented
with diarrhea, necessitating 3+ dressing changes per shift. Per
MD order, the dressing applied to her wound is wet-to-dry
Kerlix, secured with abd pads and paper tape. Failure to
change the dressing on her perirectal ulcer could lead to
colonization of the wound by fecal bacterial (notably, E. coli),
causing increased infection and increased risk for sepsis and
eventual septic shock.
13. Infection prevention beings with minimizing possible sites for
bacterial entry into the body. As this pt. presently has several
active infections, her health care team should work to prevent
any hospital acquired infection in an effort to minimize her risk
for septic shock. She has a double-lumen PICC in her right
upper arm. A PICC is an invasive catheter that disrupts the skin
and interferes with the bodys first line of defense against
infection, but in this case is necessary for the administration of
her prescribed ABx regimen for her wound infection. IV
insertion sites should be viewed as portals of entry directly into
the bloodstream for infectious organisms. It is the responsibility
of the RN to minimize the risk of central line infection by
regularly inspecting the insertion site to ensure that the catheter
insertion site is free of signs of infection including erythema,
edema, and/or drainage. The RN should also ensure that the
insertion site is covered by an occlusive, transparent dressing.
In the event that the dressing is wet torn or loose, it should be
replaced utilizing sterile technique. When the dressing remains
intact, it should be changed no more than q7days.

12. Met dressing


changed at 1500
and 2000 after
BMs on shift;
wound remained
free of visible fecal
contamination

13. Met PICC


dressing remained
clean, dry, and
intact

14. Unmet
fluconazole one

14. Pt will be free of S/S of


vaginal yeast infection
such as white, creamy
vaginal discharge and
pruritis at the labia 24
hours after administration
of fluconazole.

15. Pt. will remain free of S/S


of UTI, including
suprapubic distention
and/or discomfort, pain in
the urethra, cloudy, dark,
bloody or malodorous
urine, fatigue, confusion,
chills, and fever qshift.

16. Pt. will verbalize at least


one method of infection
prevention at end of
teaching session.

14. Administer fluconazole


(Diflucan) 150mg tab.
PO once.

15. Encourage increased


fluid intake qshift.

16. Teach pt. and family


members how to
decrease risk for
infection qshift.

14. This pt. is receiving a prescribed ABx regimen of intermittent IV


piperacillin-tazobactam and linezolid, a common S/E of which is
superinfection by C. albicans yeast. Her 03/18 urine micro.
results revealed moderate yeast in her urine, and urine culture
revealed >100,000 col/mm of C. albicans. On physical
assessment, she was noted to have white, creamy vaginal
discharge, indicative of a vaginal yeast infection. Her provider
diagnosed a superinfection by C. albicans based on these data,
and prescribed a one time dose of fluconazole to treat the yeast
infection. Fluconazole is an antifungal, which inhibits the
synthesis of fungal sterols, a necessary component of the
fungal cell membrane in Candida spp.
15. Due to the proximity of her L perirectal wound and fecal
incontinence, this pt. was provided with an in-dwelling Foley
catheter draining to gravity for bladder emptying. This places
her at increased risk for UTI. She also received fluconazole for
yeast infection and continues to receive aggressive antibiotic
therapy for her wound infection, all of which may impact kidney
function. In an effort to maintain adequate kidney function,
promote fluid balance, and prevent urinary stasis, she should
be encourage to increase her fluid intake to minimize the risk
for UTI, and thus, minimize her risk for sepsis and septic shock.

16. This pt. presented to the ER with severe sepsis and profound
hypoglycemia with a BG of 24. She also has a history of past
diabetes-related health crises and sepsis. She was a poor
historian on admit, but her family members reported poor med
compliance and lack of self-health management on her behalf.
It is the responsibility of the RN to provide instruction for
prevention of future infections and sepsis. In the hospital
setting, she should be instructed in proper incentive spirometry
use and the importance of thorough oral care to minimize her
risk for pneumonia. She should be encouraged to ambulate to
promote lunge expansion and prevent pooling of pulmonary
secretions. She and her family members should also be
instructed in proper handwashing technique. It is especially
important, since she is incontinent of stool and urine that she

time dose
administered at
1631, unable to
assess 24 hours
after
administration; pt.
still had white
vaginal discharge
at end of shift
(assessed at 2000)
15. Unmet pt.
consumed
1,210mL on 03/19;
will continue to
encourage fluids

16. Met pt.


verbalized
understanding of
IS purpose and
provided correct
return
demonstration;
performed 5x
immediately after
teaching

be instructed in proper pericare, including wiping front-to-back


and changing of urine-soaked undergarments and bedding.
She should be taught the importance of managing her type 2
DM via prescribed insulin regimen to prevent further
neurovascular compromise that places her at increased risk for
infection. She should be instructed in the S/S of pressure ulcers
and skin infection, including redness, erythema, non-blanching
areas of skin, skin color changes to black or green, and
drainage. By teaching both the patient and her family the S/S
of infection and infection prevention methods, the likelihood of
preventing future infections increases, thus preventing future
sepsis episodes.
17. Pt. will be treated and
monitored for sepsis per
ACH P & P if appropriate
criteria is met.

17. Initiate and maintain


17. This pt. was admitted to the ER with profound hypoglycemia
ACH Sepsis Pathway if
(BG=24) and an infected L perirectal to L medial thigh pressure
pt. exhibits two or more
ulcer with abscess. She was tachycardic and unresponsive
of the following:
with shallow respirations and elevated temperature. She was
RR < 10/min
diagnosed with severe sepsis, and the sepsis pathway was
RR > 25/min
initiated for her care. She received IV fluids, was transferred to
SpO2 < 95%
the unit, underwent extensive surgical l & D, and was placed on
SBP < 100mmHg
an aggressive ABx regimen. Per her treatment plan, though
HR < 50 bpm
her sepsis has improved, she is frequently reassessed for
HR > 110 bpm
sepsis. ACH protocol for sepsis intervention and treatment
Altered LOC/new onset
includes: oxygen therapy, blood, sputum, urine, and wound
confusion
cultures, large amounts of IV fluids. Because she has several
Temp. < 95.9F or > 100.3F
concurrent infections and has a history of sepsis, she is
predisposed to septic shock and future sepsis events. In the
event that her condition deteriorates this hospital stay, she will
again be treated (as soon as possible) via the sepsis pathway
to promote optimal outcomes.

17. Unmet pt. did not


exhibit more than
one stated criteria
for initiation of
sepsis pathway on
03/19; only fever of
102F, all other VS
within acceptable
limits per ACH
policy; will continue
to monitor