- Chills. - T: 36.0°C (96.

8°F), P:120 beats per minute

Huda Al-harthi - Productive cough. - BP 85/52 mm Hg
A 55-year-old female - Weakness/ lethargy - RR: 22 breaths per minute.
Assess
Sepsis shock due to - Tachycardic/ regular. - Pulse are rapid and thready.
infection - Altered mental status - Mucous membranes are dry.
- Crackles at lungs with a wheeze. - Cool extremities.
Nursing diagnosis
Nursing

1-Impaired Gas Exchange related to septic shock secondary to pneumonia as evidenced

by tachypnea, and altered mental status.
outcomes

improve oxygenation and ventilation, and mental status aeb:

- Oxygen saturation: >93%.
- Respiratory rate: 12-22/min
within 24
- Resolution of lung crackles and wheezing hours
- Improved mental status, as evidenced by increased alertness and
orientation to person, place, and time. Stabilizing vital signs and Preventing further complications
- BP (90-120 mm Hg)
Nursing interventions
- Pulse <100 bpm
- T: (36.5°C to 37.5°C or 97.7°F to 99.5°F)
Respiratory and
Hemodynamic Status
- Enhanced peripheral perfusion Capillary Refill < 2 seconds
Monitoring - Relief from chills and a subjective feeling of warmth

activity activity Nursing interventions

- Blood culture (two sets)

- Urinalysis with culture Respiratory and
- Chest X-ray/ CT scan Hemodynamic Status
Assess ABCs activity - CBC Monitoring
activity - CMP
- Arterial Blood Gases activity
- Lactate Levels activity
activity
activity

- Monitor Fluid Balance by Skin Perfusion Assessment

Measurement of Intake and activity - Skin Color
Output activity - Temperature
- Administer supplemental - Urine Output
Administer vasopressors - Capillary Refill.
oxygen by facemask - Detect Signs of Fluid Overload
(norepinephrine, or activity
- Place the patient in or Dehydration.
dopamine).
semi-Fowler activity
removal of the source of
infection, such as IV,
intra-arterial, or urinary ECG
drainage catheters to evaluate for cardiac
Large-bore intravenous
Administer antibiotics ischemia secondary to
catheter for fluid
intravenously: hypoperfusion or
resuscitation of crystalloid
Broad-spectrum antibiotics arrhythmias
solution (normal saline)
every 15 minutes for - Frequent Vital Signs
hypotension. Monitoring
- blood pressure
- oxygen saturation
- urine output
- mental status Deep vein thrombosis
- Monitor blood glucose levels prophylaxis:
-low-dose heparin
-compression stockings