Kapiolani Community College

Practical Nursing Program

Nursing Care Plan
Student Name:
Clinical Week #: 10/10/11- 10/14/11
Date Submitted: 10/11/11
Omar Perez-Sandoval
Nursing Diagnosis #1 (3 parts) Infection related to urinary tract as evidenced by emergency admission due to hypotension and signs and symptoms of sepsis.
Definition: Sepsis if often caused by bacteremia of gram negative bacilli or gram positive cocci that invade the body systematically via the blood. Initially it causes an immune inflammatory
response by the body to fight bacterial endotoxins. If the infection continues, sepsis becomes more severe and leads to decreased oxygen and tissue perfusion. The bodies exaggerated inflammatory
response leads to hypotension due to massive vasodilation, maldistribution of blood volume, and myocardial depression in an attempt to fight off the bacterial infection.
#1 Short term OutcomeLess than 1 week.
Client will be free of infection
as evidenced by Vital signs,
negative cultures, normal
white blood cell count,
absence of chills, and normal
level of consciousness by
10/14/11

Interventions
(one assessment, one teaching, plus a minimum of 2
others for each Dx)

Rationale
As provided in the care plan book

#1 Monitor heart rate and blood pressure

#1 Refractory hypotension despite optimal fluid

therapy is a good indication for diagnosing septic
shock.

#1

#2 Assess skin turgor, color, temperature, and

peripheral pulses.

#2 In early septic shock, warm, dry, flushed skin

and bounding pulses are evident as vasodilation
occurs. As shock continues, cool, clammy, cyanosis
with decreased peripheral pulse occurs.

#2

#3 Use pulse oximetry to assess oxygen saturation.

#3 Useful tool in assessing changes in oxygenation.

Saturation should be kept at 90% minimal.

#3

#4 Monitor white blood cell count

#4 Provides data on progression of sepsis and

response to treatment.

#4

#5 Obtain culture and sensitivity samples as ordered

#6 Assess urine output
#2 Long Term Outcome
Greater than 1 wk
Client will be placed in
long term care after
systemic infection is
treated and patient is stable
to be discharged.

#5 Culture and sensitivity test will determine the

most effective antibiotic against the invading
organism.
#6 The renal system compensates for low blood
pressure by retaining water. Oliguria is a classic sign
of inadequate renal profusion.

Evaluation
Describe effectiveness of interventions.
Use Subjective & objective statements
Address Goals as met , partially met, not met

#5
#6
Short-term goal:
Long-term goal

Nursing Diagnosis #2 (3 parts)

Definition:

#1 Short term Outcome-

Interventions

Rationale

Evaluation

Less than 1 wk

(one assessment, one teaching, plus a minimum of 2

others for each Dx)

As provided in the care plan book

Describe effectiveness of interventions

Use Subjective & objective statements
Address Goals as met , partially met, not met

#1

#1

#1

#2

#2

#2

#3

#3

#3

#2 Long Term OutcomeGreater than 1 wk

#4

#4

#4

#5

#5

#5

#6

#6

#6
Short-term goal:
Long-term goal