Question

22 yrs old Appendectomy currently recoving room nurse noticed vitals signs not going well .Heart rate increase BP decrease breathing rapid .urine ouput is 15ml .she dianosed sepsis.

Potential Nursing Diagnosis (3 minimum)

Risk Factors (3 minimum)

Signs & Symptoms/Expected Findings (6 minimum)

Laboratory Tests (3 minimum)

Diagnostic Procedures (2 minimum)

Client Education (3 minimum)

Treatments: (3 minimum)

Potential complications: (3 minimum)

APA reference (MUST be in APA format)

Answer 1

1) Potential nursing diagnosis:

a) fever

b) low blood pressure

c) tachychardia( increased heart rate)

d) low urine output

e) tachypnea(rapid breathing)

2)Risk factores:

a)African American race

b)morbid obesity,

c)acute renal failure or dialysis

,d)disseminated malignancy,

e)open appendectomy

3)Sign and symptoms:

a) hypotension

b) fever

c) tachycardia

d) warm body

e) low urine output

f)skin rash/mottled skin

g) tachypnea

h) confusion/ delirium

4)laboratory test:

a) bateremia in blood.

b) CBC

c) LFT/RFT

d) urine analysis

e) wound culture

f) imaging test (ct scan/ MRI for tracing infection.

5) diagnostics procedure:

a) hypothermia

b) shallow breathing

c) flush/ warm skin

d) wound culture

e) CBC

f) test for bacteremia

6) client education:

a) patient must be educated to be able to identify the recurrent episodes of sepsis

b)The patient and the family should be taught about assessments needed to identify the complications that may occur after discharge.

c)teach the patient and the family about treatment modalities such as emergency administration of medications, IV therapy, parenteral or enteral nutrition, skin care, exercise, and ambulation.

7) treatment:

a) antibiotic treatment

b) vasopressor administeration

c) iv fluid administration

d) oxygen support

8) complications:

a) SIRS

b) multiple organ failure

c)clot formation

d) reduced oxygen supply to vital organs