- Decreased Cardiac Output related to altered hemodynamic parameters and loss of vascular tone Hypovolemia as evidenced by tachycardia and Hypotension
- Ineffective thermoregulation related to dehydration and Inflammatory process as evidenced by Increased body temperature higher than normal range and Flushed skin, warm to touch
- Ineffective Protection related to Infectious process and Poor nutrition as evidenced by change in level of consciousness and Poor ability to handle stress
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbalizes inability to cope with the increased heart rate. -Cold, clammy skin Objective Data: -Central venous pressure < 8 mmHg -Mean arterial pressure < 65 mmHg -Cyanosis -Pallor -Prolonged capillary refill time -Hypotension -Oliguria -Alteration in the level of consciousness | Decreased Cardiac Output related to altered hemodynamic parameters and loss of vascular tone Hypovolemia as evidenced by tachycardia and Hypotension | Patient will manifest adequate cardiac output as evidenced by the following: Vital signs within normal limits: Blood pressure: 90/60 mmHg to 120/80 mmHg Pulse rate: 60 to 100 beats per minute Central venous pressure 8-12 mmHg Mean arterial pressure 65-90 mmHg Urine output: 0.5 to 1.5 cc/kg/hour Unremarkable cardiac findings: Adynamic precordium Absence of cardiac dysrhythmias Absence of murmurs | 1. Administer fluid resuscitation as prescribed. Adequate volume therapy remains essential in treating sepsis-induced tissue hypoperfusion and counteracting absolute and relative hypovolemia caused by vasodilatation, external fluid loss, and capillary leakage. Based on Frank-Starling law, increasing preload will increase stroke volume and cardiac output. But this must be done cautiously because cardiomyopathy will shift the Frank-Starling curve, and excessive fluid management can lead to complications. 2. Administer medications as prescribed. Antibiotics: Broad-spectrum antibiotics are the first choice and should be administered immediately after obtaining blood cultures. Vasopressors cause vasoconstriction to counteract the systemic arterial vasodilation caused by the pathogen to increase blood pressure and perfusion. 3. Anticipate the need for adjunctive therapies as indicated. Mechanical support is widely used in septic cardiomyopathy. Intra-aortic balloon pump (IABP), percutaneous ventricular assist devices, or extracorporeal membrane oxygenation (ECMO) may be indicated to support cardiac output when primary therapies fail. 4. Meet oxygen demands. Ensure adequate oxygenation to support cardiac function and perfusion via high-flow mask or ventilation as necessary. | Patient shown adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient returned to baseline activity level. Patient displayed adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient verbalized future self-care activities to improve cardiac health. |
| Subjective Data: -Verbalize the Increase in Body temperature Objective Data: -Tachypnea -Tachycardia -Confusion -Seizures -Pyrexia | Ineffective thermoregulation related to dehydration and Inflammatory process as evidenced by Increased body temperature higher than normal range and Flushed skin, warm to touch | Patient will maintain body temperature within normal limits. Underlying causes (infection) will be treated to prevent worsening hyperthermia. | 1. Provide a cool environment. Keep the room temperature cooler, remove extra linens, and remove heavy or restrictive clothing. 2. Apply a cooling blanket. A cooling blanket will reduce surface temperature. These should be monitored closely so as not to induce shivering, which will have an inverse effect. 3. Administer antipyretics. Administer acetaminophen or other antipyretics to reduce fever. 4. Provide cool rags or a tepid bath. Place cool rags around the groin or axillae which are areas of high blood flow, and provide tepid baths to increase heat loss by evaporation. | Patient maintained core body temperature within normal limits. Patient verbalized underlying factors that contribute to hyperthermia. Patient remained free of life-threatening complications such as brain damage or organ failure from hyperthermia. |
| Subjective Data: -Verbalize food choices to eat. Objective Data: -Change in level of consciousness -Insomnia -Immobility -Poor ability to handle stress -Open wound/pressure ulcer | Ineffective Protection related to Infectious process and Poor nutrition as evidenced by change in level of consciousness and Poor ability to handle stress | Patient will remain free from infection. Patient will verbalize food choices to meet nutrition needs. Patient will demonstrate measures to protect or increase immune system protection. | 1. Encourage rest. Sleep is vital to cellular repair and allows the release of growth hormone to heal the body. When sleep is disrupted or inadequate, growth hormone is suppressed. 2. Avoid invasive procedures as much as possible. Catheterization, injections, and rectal or vaginal procedures must be avoided or kept at a minimum. These procedures increase the risk of introducing harmful pathogens. If the patient must have an invasive line, clean using aseptic techniques. 3. Encourage high protein, nutrient-rich diets. Protein helps the body repair tissues and fight against infection. If the patient lacks an appetite, consider appetite stimulants or dietician consultation. 4. Educate the patient and family about infection control measures. Hand hygiene is the simplest way to prevent infection transmission. Instruct the patient and family/caregivers on proper handwashing techniques. | Patient remained free from infection. Patient verbalized food choices to meet nutrition needs. Patient demonstrated measures to protect or increase immune system protection. |