CASE: SYSTEMIC INFECTION

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: Hypothalamus controls body STO: Dx: STO: (Goal Met)

temperature. In response to Assessed client temperature degree and Beneficial as a baseline status for
Patient verbalized an infection, the Within 6 hours of effective pattern. comparing. Within 4 hours of effective
“Nagpudut tuy riknak ken hypothalamus resets the nursing interventions, the nursing interventions, the
malamlamin nak” body to a higher patient will be able to: Monitored environmental temperature. Room temperature and linens should be patient:
temperature. The patient is Limit or add bed linens, as indicated. altered to maintain near-normal body temp.
Objective: currently experiencing a. Maintain normal body a. Maintained normal body
systemic infection. The temperature. Checked client’s current medication temperature of 37.2 °C.
 Flushed skin therapies.
increase of patient’s body Determine drug interactions
 Skin is warm to b. Understand plan of care b. Understood plan of care.
temperature happens because
touch for compliance.
of the body’s immune LTO: (Goal Met)
 Temp. of 37.9 Tx:
response to an infection.
 General Provided tepid sponge baths.
weakness LTO: Tepid sponge baths may help reduce fever. Within 48 hours of
effective nursing
Within 48 hours of effective Provided cooling blanket, or Used to reduce fever. interventions, the patient:
Source: hypothermia therapy as indicated.
nursing interventions, the
Nursing Diagnosis: patient will be able to: a. Manifested free of
https://www.webmd. Administered antipyretics, as ordered
Reduces fever by its central action on the complications such as
com/first-aid/finger-infection (ex. Tylenol).
Hyperthermia related to a. Be free of complications hypothalamus. irreversible brain or
body’s immune response such as irreversible brain or neurologic damage.
Edx:
to infection neurologic damage.
Encouraged adequate fluid intake. b. Demonstrated actions
Help lower the body temperature.
b. Demonstrate actions that Educated the patient and family that may help the
may help the temperature members about the signs and symptoms For early detection of increase/decrease of temperature back to
back to normal range. of hyperthermia and help identify factors temperature and avoiding risks and normal range. Like tbs, use
related to the occurrence of fever. complications. of thermometer and
medication compliance.
Demonstrated pt. and SO on TSB and
medication compliance.
For continuance of care.

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Objective: Shock is a life-threatening STO: Dx: Cardiac output becomes severely depressed STO: (Goal Met)
condition that occurs when Monitored blood pressure (BP), due to major alterations in contractility,

 Malaise the body is not getting
 Hyperthermia enough blood flow. This can
 Inc. Heart rate lead to damage to multiple
 Systemic organs. Septic shock is a life-
infection threatening condition that
 Decreased happens when your blood
urinary output pressure drops to a
dangerously low level after
Nursing Diagnosis:
an infection.
Risk for Shock related to Source:
systemic infection
https://www.nhsinform.scot/i
llnesses-and-
conditions/blood-and-
lymph/septic-shock
Within 2 hours of effective
nursing interventions, the
patient will be able to:
a. Understand plan of care
for compliance.
LTO:
Within 48 hours of effective
nursing interventions, the
patient will be able to:
a. Display adequate
perfusion as evidenced by
stable vital signs.
CASE: SYSTEMIC INFECTION
especially noting progressive
hypotension and widening pulse
pressure.
Assessed respiratory rate, depth, and
quality. Note onset of severe dyspnea.
Assessed for changes in sensorium
(confusion, lethargy, personality
changes, stupor, delirium, and coma).
Tx:
Prepared for transfer to critical care
setting, as indicated.
Given fluids to maintain blood pressure
or cardiac output.
Administered medications, as ordered
(ex. Corticosteroids, inotropic agents).
Edx:
Explained all procedures as appropriate,
keeping explanations basic.
Encouraged the client to verbalized his
or her feelings.
Instructed to take medication therapies
on time as prescribed.
preload, and/or afterload, thus producing Within 30 mins of
profound hypotension. effective nursing
interventions, the patient:
Respirations become shallow as respiratory
insufficiency develops, creating the risk of a. Understood plan of care.
acute respiratory failure.
LTO: (Goal Met)
Changes in mentation reflect alterations in
cerebral perfusion, hypoxemia, and/or Within 48 hours of
acidosis. effective nursing
interventions, the patient:
Progressive deterioration requires more a. Manifested free of
aggressive therapy including hemodynamic complications such as
monitoring and vasoactive drug infusions. irreversible brain or
neurologic damage.
To increase blood volume and cardiac
output. a. Display adequate
perfusion as evidenced by
Manage current problem that may result to stable vital signs, palpable
complications if left untreated. peripheral pulses, skin
warm and dry, usual level
Information helps reduce anxiety. Anxious of mentation, and
clients unable to understand anything more
individually appropriate
than simple, clear, brief instructions. urinary output.
Talking about anxiety-producing situations
and anxious feelings can help the client
perceive the situation in a less threatening
manner.
For continuance of care and prevent
complications.