Ahmed Ba Elaian
BSN
1. Define Sepsis?
Sepsis is the body's extreme response to an infection, potentially life-
threatening condition that occurs when the body's response to an infection
damages its own tissues. When the infection-fighting processes turn on
the body, they cause organs to function poorly and abnormally. Sepsis
happens when an infection you already have triggers a chain reaction
throughout your body. Infections that lead to sepsis most often start in the
lung, urinary tract, skin, or gastrointestinal tract.
2. Enumerate the signs and symptoms of Ryan following his
diagnosis and discuss the relevance of early detection of Sepsis
through these signs and symptoms?
Signs and symptoms:
Sore throat, tonsillitis symptoms, confusing, dehydrated, coma, also
tachycardia and heart arrest.
Diagnosis test:
Blood test: Blood samples are used to test for Evidence of infection
Other lab tests to identify the source of the infection might include samples
of: Urine test, Wound secretions, and Respiratory secretions.
Imaging tests:
X-ray. X-rays can identify infections in your lungs.
Ultrasound. This technology uses sound waves to produce real-time
images on a video monitor. Ultrasound may be particularly useful to
check for infections in your gallbladder and kidneys.
Computerized tomography (CT). This technology takes X-rays from a
variety of angles and combines them to depict cross-sectional slices of
your body's internal structures. Infections in your liver, pancreas or
other abdominal organs are easier to see on CT scans.
Magnetic resonance imaging (MRI). This technology uses radio
waves and a strong magnet to produce cross-sectional or 3D images of
the internal structures of your body. MRIs may be helpful in identifying
soft tissue or bone infections
The longer it takes to diagnose sepsis, the worse it gets for the
patient. As in case of Ryan, if he has been diagnosed quicker, if
there’s a more rapid test for sepsis, he could not reach the level of
sepsis that he reaches and done from the first time he came to GPs
surgery and stop him from getting septic shock. I think rapid or early
detection of sepsis would make huge difference to a lot of patients
NURSING CARE PLAN
1) Hyperthermia
Assessmen Diagnosis Planning Intervention Rational Evaluation
t
Subjective: Hyperthermi STG: After -Monitor the -Acute After
" I feel that a nursing client’s infectious nursing
my body is related to intervention temperature. disease intervention
hot" Dehydration , the patient - Adjust processes are , the patient
verbalized as evidenced will environmenta often state that
suggested by a
by the by Flushed experience l factors as he feel good
temperature
patient skin, warm no indicated. that’s 102°F and goals
to touch. associated Remove and higher. met as
Objective: Increased in complicatio excess - Adjusting evidence, T=
T= 39F body n clothing as room 37f
HR=120 temperature necessary. temperature HR= 85
RR=22 higher than LTG: the - Provide and linens RR=18
Warm skin the normal patient will tepid sponge can assist in Skin is
Tiredness range. demonstrat baths as maintaining a normal
Increased e necessary. near-normal
respiratory temperatur - Administer body
rate, e within antipyretics temperature.
tachycardia. normal as ordered. - Tepid
range and - Provide a sponge baths
be free of cooling can help
chills. blanket. lower fever.
- Antipyretics
acts on the
hypothalamu
s to lower the
body’s
temperature.
- Cooling
blankets can
reduce fever
when the
temperature
is above
104°F.
2) Risk For Deficient Fluid Volume
Assessmen Diagnosis Planning Intervention Rational Evaluation
t
Risk for After - Assess Tachycardia, After
Deficient nursing vital signs. hypotension, nursing
Fluid Volume intervention Measure and fever can intervention
related to , the patient and record signal the , Client has
Increase in will maintain urinary body’s maintain
vascular adequate output and response to adequate
compartment circulatory specific fluid loss circulatory
, massive volume as gravity. Decreasing volume as
vasodilation evidenced Note urinary evidenced
as evidence of by vital signs cumulative output with a by vital signs
dehydration. within intake and high specific within
client’s output gravity client’s
normal (I&O) suggests normal
range, imbalances. relative range,
palpable - Observe hypovolemia palpable
peripheral for associated peripheral
pulses of excessively with pulses of
good dry skin and vasodilation. good
quality, and mucous - This quality, and
individually membranes indicates individually
appropriate . excessive appropriate
urinary - Monitor fluid loss urinary
output. for because of output. and
peripheral severe skin is
edema in dehydration. normal
the legs, - Fluid
back, and moving from
scrotum. the vascular
- Check compartmen
peripheral t towards the
pulses. interstitial
- Administer space leads
IV fluids as to tissue
ordered. edema.
- Pulses that
are weak and
easily
obliterated
indicate
hypovolemia.
- Fluid
therapy in
the early
course of
sepsis is
more
effective. It’s
a
fundamental
sepsis
therapy
3) Risk For Shock
Assessmen Diagnosis Planning Interventio Rational Evaluation
t n
Risk For Shock After - Monitor the cardiac After
related to nursing the blood output nursing
Reduction of interventio pressure becomes interventio
arterial/venous n, the (BP), severely n, , the
blood flow: patient will Monitor depressed due patient has
selective display heart rate to major display
vasoconstrictio adequate and rhythm. alterations in adequate
n, vascular perfusion Maintain contractility, perfusion
occlusion– as stable body preload, as
intimal evidenced temperatur and/or evidenced
damage, by stable e, using afterload, thus by stable
.microemboli vital signs, adjunctive producing vital signs,
Relative or palpable aids as profound palpable
actual peripheral necessary. hypotension. peripheral
hypovolemia pulses, skin - Assess for Temperature pulses, skin
warm and changes in elevations warm and
dry, usual sensorium increase dry, usual
level of (confusion, metabolic, and level of
mentation, lethargy, oxygen mentation,
individually personality demands individually
appropriate changes, beyond appropriate
urinary stupor, cellular urinary
output, and delirium, resources, output, and
active and coma). hastening active
bowel - Monitor tissue bowel
sounds. for signs of ischemia, and sounds.
bleeding. cellular
- Administer destruction.
parenteral - Changes in
fluids to mentation
helps reflect
maintain alterations in
tissue cerebral
perfusion perfusion,
and expand hypoxemia,
circulating and/or
volume. acidosis.
-
Coagulopathie
s such as DIC
may occur,
related to
accelerated
clotting in the
microcirculatio
n reflecting
activation of
chemical
mediators,
vascular
insufficiency,
and cell
destruction
creating a life-
threatening
hemorrhagic
situation and
multiple
emboli.
