Question

My patient is a 82 year old female with a diagnosis of Sepsis. She is confused and her baseline is orientated x3. She is extremely weak and fatigued. She has HTN and diabetes 2. We are waiting on blood and urine labs but she has classic symptoms of UTI. Relevant VS T. 101.8 (oral), HR 110, BP 102/50, RR 24, Pain: Dull ache, (R) flank, 5/10, elevated creatinine 1.5, lactate 3.2. Dr. has ordered IV NS 0.9% NS 1000 mL IV bolus, Acetaminophen 650 mg po, Ceftriaxone 1g IVPB…after blood/urine cultures obtained,  Morphine 2 mg IV push every 2 hours prn-pain.  

What are the top three nursing diagnosis (problem r/t a/e/b), three SMART goals for each diagnosis, interventions and rationales for this patient with sepsis?

Answer 1

Nursing diagnosis for sepsis.

1, Risk for infection relatd to compromised immune system functioning.

Goal: Client get free from infection.

Intervention	Rationale
Assess the source or orgin of infection	To get a baseline data about patient condition
Monitor the vital signs and blood test	To assess for presence of any infection
Use asceptic technique while performing procedures	To avoid the transmission of infection

2, Hyperthermia related to infectious process or increased metabolic rate.

Goal: Reduce the body temperature to normal.

Interventions	Rationales
Monitor the vital signs	To get a baseline data about patient condition
Administer antipyretics	To reduce the body temperature
Provide sponge bath to he patient	To reduce the body temperature

3, Risk for hock related to hypovolemia, reduction in blood flow.

Goal: Patient get free from shock

interventions	ratinale
Monitor herat rate, rhythm and BP	To get a baseline data about patient condition
Assess skin for changes in color, temperature, and moisture.	To monitor for any signs of shock
Monitor the urine output hourly	To check the fluid volume in the body