Page 437 - Critical Care Nursing Demystified

422 CRITICAL CARE NURSING DeMYSTIFIED

Identify the causative organism and remove any potential infection source
(IVs, debridement of wound).
Institute the ABCs of assessment and care.
Support cardiovascular functioning with fluids, medication, and hemody-
namic monitoring.
Give oxygen.
Combat infection by administering antibiotics after body fluid cultures.
Dialysis to decrease high electrolytes like potassium and phosphorus and to
replace kidney functioning.

6 Nursing Diagnoses for Septic Shock Expected Outcomes
Tissue perfusion, alteration in The patient will be normothermic
(peripheral) due to invasion by foreign The cultures will be negative
organisms
The BP, CO, and SVR will be normal
Urinary output will be >30 mL/hr
Hyperthermia due to release of The patient will be normothermic
endotoxins from pathogenic cell walls

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Assess the patient’s VS for recovery from shock indicated by baseline tem-
perature, pulse, respirations, and return of BP above 100 systolic.
Prepare to insert a pulmonary artery pressure to more accurately measure
preload, afterload, contractility, cardiac output, and system vascular resistance.
Monitor the patient’s peripheral perfusion by assessing urinary output greater
than 30 mL/hr, skin color normal tone, all peripheral pulses intact.
Culture all possible infectious sources (blood, urine, wounds, etc.) before
starting antibiotics to determine the causative organism.
Remove and reinsert all invasive lines to eliminate the possible causative organism.
Monitor the patient for bleeding, which can be caused by coagulopathy.
Administer antibiotics to eliminate causative organism.
Institute mechanical ventilation in patient who becomes severely hypoxic.
Start continuous renal replacement therapy, which can be used to combat
effects of metabolic acidosis and electrolyte imbalances.
Administer IV fluids, albumin, and blood products to increase intravascular
volume.
Administer Levophed to vasoconstrict blood vessels elevating the BP.