Diagnosis: To consider septic shock secondary to community acquired pneumonia; high risk, Hepatitis A infection.

Date: April 29, 2025

Nursing Care Plan

Assessment Nursing Diagnosis Pathophysiologic/ Desired Outcome Nursing Rationale Evaluation
Cues Schematic Diagram Intervention

After 8 hours of After 8 hours of

Excess Fluid Volume nursing care, the nursing care,
Predisposing Precipitating
Objective: related to patient is expected the patient was:
Factors Factors
compromised to:
Received Patient regulatory 75 years old Sepsis secondary to Independent: 1. Demonstrate a
asleep, but is mechanisms as (Advanced age) pneumonia 1. Demonstrate a a. Monitor and a. To assess reduction in
arousable to evidenced by pitting reduction/stabilizatio document the changes in the edema. The
speech. edema grade +2 on Low Albumin levels nof edema. patient’s edema for severity of edema patient still has
both feet and localized every hour. and the edema present
GCS: 8 (E4VTM4) edema on the right effectiveness of on both feet and
metacarpal. b. Elevate the interventions. right metacarpal
Integumentary: Pathophysiologic Changes: patient’s affected (no significant
- Temp = 36 legs and arm. b. To reduce the reduction
degrees Celsius Definition: accumulation of observed).
(afebrile) Excess fluid volume - fluid in the lower GOAL NOT
- Ongoing IVF #2 Increased isotonic c. Keep the extremities. MET.
PNSS 1L x 60 fluid retention. patient’s skin clean
cc/hr at Right arm. and dry c. To prevent skin
- Localized edema Reference: breakdown and
on the right infection in
metacarpal. NANDA book d. Monitor edematous areas.
- Pitting edema on peripheral edema
both feet (2+) Doenges, M., d. To evaluate the
- Swollen and Moorhouse, M., & extent of fluid
shiny feet. Murr, A. (2019). retention and the
Nurse’s Pocket Guide patient’s response
: Diagnoses, e. Reposition the to treatment.
Cardiovascular: Prioritized patient with
- BP = 150/90 Interventions and dependent edema e. To prevent
mmHg Rationales (15th ed.). frequently, as prolonged
- PR = 118 bpm F.A. Davis Company appropriate. pressure on
edematous areas
and fluid
Respiratory: accumulation.
- RR = 23 Dependent:
breaths/min 2. Maintain stable f. Administer due f. To promote 2. Maintain
- O2 Sat = 99% vital signs medications as precipitating stable vital signs.
ordered by the factors that Patient’s vital
GUT: physician contribute to fluid signs are as
-with Foley retention. follows: PR (90
(UDCACID 300
Catheter attached bpm), BP
mg/tab TID,
to a urine bag (90/70), O2 sat
Diloxanide 500
- 50 cc of urine (99%), Temp
per hour mg/tab TID, NAC (38.3 celsius),
600 mg/tab OD, and RR (20 bpm)
Laboratory: Rebamipide 1 tab indicating that
- Albumin: 1.90 TID via NGT) vital signs are
g/dl (low) not within normal
- BUN: 30 mg/dl Independent: g. To detect early value. GOAL
(high) g. Monitor vital signs of fluid NOT MET.
- SGOT: 254 u/l signs every hour. overload, allowing
(high) for timely
- SGPT: 105 u/l interventions to
(high) prevent further
complications.

Weakness: h. To promote
Reference: h. Ensure the blood volume and
-​ Widowed patient receive IV circulation through
Ignatavicius, D. D., & Workman, M. L. (2020). fluids as adequate
Strength: Medical-surgical nursing: Concepts for appropriate for her hydration.
-​ strong interprofessional collaborative care (10th condition
support ed.). Elsevier.
system. i. To support
-​ The family i. Administer overall stability of
is willing to prescribed OTF via vital signs through
admit the Nasogastric tube. proper nutrition
patient to support.
ICU to
receive
adequate Independent: j. To monitor for
treatment. 3. Maintain clear lung j. Assess any changes in 3. Maintain clear
fields respiratory status the patient’s lung fields
(rate, rhythm, respiratory evidenced by the
effort, and oxygen function. patient's
saturation) every respiratory
hour. function
k. To enhance maintained, with
k. Position the lung expansion stable respiratory
patient in a and ventilation by rates of 20 bpm,
semi-Fowler’s reducing pressure oxygen
position. (30 to 45 on the diaphragm. saturation levels
degrees) of 99%, and
oxygen support
l. To remove not needed at
l. Perform secretions that the end of the
suctioning of the can affect lung shift. GOAL
ET tube and function. MET.
mouth.