- Deficient Knowledge related to Poor health literacy and Unawareness of the severity of untreated infections as evidenced by Inaccurate statements about preventing UTIs and development of recurrent UTIs
- Hyperthermia Related to Dehydration and Urinary tract infection as evidenced by Skin warm to touch and Diaphoresis
- Impaired Gas Exchange related to Sepsis and Ventilation-perfusion mismatch as evidenced by Abnormal ABG levels and Bradypnea
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbalizes poor understanding -Seeks additional information Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition | Deficient Knowledge related to Poor health literacy and Unawareness of the severity of untreated infections as evidenced by Inaccurate statements about preventing UTIs and development of recurrent UTIs | Patient will explain the symptoms of a UTI and when to call their provider. Patient will demonstrate completion of their antibiotic regimen. | 1. Teach the patient about preventing UTIs. Preventing UTIs and bladder infections in the first place will reduce incidences of urosepsis. Instruct the patient on the following: Wipe front to back after using the bathroom (in females) Drink plenty of water to flush the urinary system Empty the bladder when you feel the urge to prevent urine stasis Wear loose-fitting cotton underwear and clothing 2. Educate the patient about signs that require medical attention. Fever, rapid heart rate, altered mental state, and dry mucous membranes can indicate a developing complication like septic shock. 3. Instruct always to complete a course of antibiotics. The nurse can teach the patient about antibiotic resistance, which results from overuse and incorrect use of antibiotics, making treatment of infections more difficult. Antibiotics should always be completed, even if symptoms go away. 4. Instruct on a healthy lifestyle. Maintaining good overall health through diet, physical activity, immunizations, handwashing, and managing chronic conditions will guard against sepsis and lead to better outcomes if sepsis occurs. | Patient explained the symptoms of a UTI and when to call their provider. Patient demonstrated completion of their antibiotic regimen. |
| Subjective data: Verbalizes Increased Body Temperature Objective data: -Flushed skin -Skin warm to touch -Diaphoresis -Restlessness -Tachypnea -Tachycardia -Stupor | Hyperthermia Related to Dehydration and Urinary tract infection as evidenced by Skin warm to touch and Diaphoresis | Patient will maintain a core body temperature within normal limits. Patient will not experience complications from hyperthermia. | 1. Administer antipyretics as indicated. Antipyretics can help regulate body temperature and lower it within normal parameters. 2. Provide a tepid sponge bath. A tepid sponge bath can help lower body temperature that is caused by urosepsis. 3. Institute cooling measures. Cooling measures like removing extra clothing and linen and maintaining a cool environment can help reduce body temperature. 4. Increase fluid intake if not contraindicated. Hyperthermia can cause rapid dehydration. Offer oral fluids if the client is alert. Cooled saline can also be administered IV to reduce the core temperature. 5. Monitor for seizure activity. Hyperthermia can result in fever-induced seizures. Monitor for symptoms like nystagmus, eye fluttering, and changes in mental status. | Patient maintained a core body temperature within normal limits. Patient not experienced complications from hyperthermia. |
| Subjective data: Dyspnea Diaphoresis (excessive sweating) Visual disturbances Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Abnormal arterial blood gas values or blood pH -Vital signs changes -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to Sepsis and Ventilation-perfusion mismatch as evidenced by Abnormal ABG levels and Bradypnea | Patient will demonstrate improved ventilation and adequate oxygenation with blood gas levels within normal range. Patient will remain free from any signs of respiratory distress. | 1. Continuously monitor the patient’s oxygen saturation. Continuous monitoring of the patient’s oxygen saturation can help determine worsening gas exchange in patients with urosepsis. An oxygen saturation measuring less than 88% indicates a significant oxygenation problem. 2. Administer supplemental oxygen as indicated. Supplemental oxygenation is essential in preventing hypoxemia in patients with impaired gas exchange. Oxygen therapy must be titrated accordingly to improve hypoxemia and promote an increase in oxygen saturation of at least 90%. 3. Monitor ABGs frequently. After administering oxygen, check ABG results every 30-60 minutes to monitor for acidosis. 4. Administer antibiotic therapy as indicated. Aggressive antibiotic therapy is essential in resolving urosepsis and reversing its systemic effects and symptoms. 5. Intervene if respiratory distress develops. If acute respiratory distress occurs, prevent deterioration to respiratory failure by alerting the emergency response system and preparing the patient for intubation. | Patient demonstrated improved ventilation and adequate oxygenation with blood gas levels within normal range. Patient remained free from any signs of respiratory distress. |