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Signs & Symptoms Inadequate Secondary Defenses (e.g.

decreased Hgb, leukopenia)

Nursing Diagnosis Risk for Infection

Hemorrhage (Heme-positive Urine and Stool)

Fluid Volume Deficit

Patient is Becoming More Confused

Risk for Acute Confusion Ineffective Tissue Perfusion

GI Pain, Abnormal ABG, BP Changes in Extremities,

Nursing Intervention 1. Assess causative/contributing factors 2. Note s/s of sepsis (e.g. fever, chills, altered level of consciousness) 3. Stress proper handwashing by all caregivers 4. Maintain sterility in all invasive procedures 1. Assess causative/precipitating factors 2. Since patient is 48 y/o, determine higher risk because of decreased compensatory mechanisms 3. Evaluate degree of fluid volume deficit (note low BP, severe hypotension) 4. Review lab data 5. Stop blood loss thru drug administration and prepare for surgical intervention 1. Assess causative/contributing factors 2. Reduce/correct existing risk factors (e.g. give medications as needed (for pain)) 3. Maintain calm environment to prevent overstimulation 1. Determine factors related to situation (e.g. thrombus formation) 2. Note presence of conditions that can affect systems (e.g. sepsis) 3. Identify changes related to systemic alterations in circulation (e.g. altered mentation, VS changes) 4. Evaluate for signs of infection especially if immune system is compromised 5. Note signs of pulmonary emboli (e.g. sudden onset of respiratory distress, hypoxia) 6. Note degree of impairment (duration, frequency, recurrence , precipitating and aggravating factors)