92440 Nursing Care Plan for Sepsis Management Assignment Sample

Subject Code : 92440
University : University of Technology Sydney Gradesaviours is not sponsored or endorsed by this college or university.
Subject Name : Nursing

Complex Nursing Care Medical Surgical

Plan of Care
Patient or Nursing Oriented Problem or Patient Need	Patient Assessment Data	Optimal Patient Outcome or Goal
Patient problem/issues/need - which is related to Patient problems/issues/needs can be actual present and occurring now Or potential when the patient is considered to be ‘at risk of’.	As evidenced by (or how do we know this problem exists) Objective patient data Subjective patient data Lab and other test results	What do we (patient and nurse) want to achieve: Specific, measurable, attainable, realistic and time orientated (SMART goals)
1. Pain present ate the surgical site	The pain rating of the patient is 5 out of 10 on pain scale	To reduce the intensity of the pain
2. Presence of sepsis	Objective data- Presence of breathless as reported by the patient. Subjective data- Cold peripheries, increased respiration arte, increased heart rate. Pain and swelling at the incision site. Lab results- Low WBC count in blood counts.	Vital monitoring, monitoring of blood count, maintenance of oxygen supply, pain management and reduce swelling and maintain body temperature.
3. Risk of developing deep vein thrombosis	Objective data- Presence of breathless as reported by the patient. Subjective data- Reduced mobility in the patient, no precautions taken such as anti-thrombin medication or use of pressure stockings.	Reduce the underlying risk of development of DVT in the patient.
4. Issue of persistent dehydration in the patient	Objective data- Presence of breathless and shivering as reported by the patient. Subjective data- Reduced blood pressure reading	Stabilizing the blood pressure readings in the patient and reducing the underlying risk of dehydration.

Patient Information for Nursing Care Plan

The case study is of a-year-old male that was brought to the emergency department with a complaint of shivering, nausea and sever pain at the incision surgical site. Patient was initially diagnosed with grade one osteoarthritis in his left knee that had hampered his range of motion and mobility. It was also causing a lot of pain and discomfort to the patient. Patient was advised osteotomy, which he underwent 5 days ago. He had no post-operative episode of complication and was discharged after two days of his surgery. Patient was discharged with an advice of non-weight bearing ambulation and some NSAID’s to manage his pain and swelling. He was advised to ambulate with crutches along with brace support during movement. On admission to the emergency department his wound appeared to be red and shiny and it had presence of small area of dehiscence along with pus accumulation. Patient reported a feeling of breathlessness and thus, was provided with oxygen therapy to maintain and help with the same. Patient had personal history of asthma since childhood. He had no unknown allergies as well. Two of the main complications that were identified in the given case scenario included presence of post-operative sepsis and risk of developing deep vein thrombosis. Thus report will help in evaluating the important points that can be considered to be collected for recognizing the signs and symptoms in patients. This will help in identifying for the best possible intervention for the patient, in order to manage his current clinical status.

Sepsis

Sepsis is usually a life threatening condition that is caused due to bacterial infection. It occurs as a response to attack on the body by microorganisms that are causative agents for infection (Rudd, 2019). Post-operative sepsis development is very commonly observed in various individuals. It can be presented in clinical terms with patient having pain and infection present at the surgical site. Pus is also a common indicator of presence of sepsis in the wound. The body releases certain chemicals in the blood stream to fight against the ongoing infection. Infection is the main underlying reason for development of sepsis in the patient (Lakomkin, 2017). As blood flows to all vital organs, upon manifestation, the infection can hamper the normal functioning of these vital organs largely. If this sepsis goes untreated, it can lead to development of clots in the extremities, can affect the normal bodily functions and can also lead to death due to multiple organ failure in adverse cases.

Early stages of sepsis is required to be identified in order to save the body from deadly response of infection. It is also essential to monitor for scar tissues in post-surgical cases, as there are higher chances of contamination of infection in surgical site, due to hospital acquired infections. The signs of scar colour, skin integrity, and fluid accumulation and so on has to be identified for this purpose. The patient in the case study has pain around the surgical site and his skin appears to be red and shiny. He also has low skin integrity present along with swelling. All of these signs are a direct indicator of presence of infection /in the knee of the patient. Pain scare of 7/10 also reflects on presence of an active and acute infection that might have developed post-surgery in the patient. Patient is also having an increased amount of WBC, which is also a direct indication of presence of infection in the body.

Presence of high level of WBC indicates that the body is actively trying to fight with an ongoing infection (Rashid, 2016).Patient can also be observed to report for breathlessness. This can be brought about due to a sudden change in the circulatory system of the body. This is usually observed in cases of sepsis. In sepsis the patient is also found to have a low systolic blood pressure, as observed in our case study. This can also be attributed to the circulatory deficit in the body, brought about by sepsis (De, 2017). The patient is also having a compensatory rise in heart rate. Al of these vital signs in the patient are an indicator of him being potentially subjected to risk of developing infection, leading to sepsis.

There are multiple nursing interventions that can be carried out in this scenario, to not only cure the patient but to attain better healthcare outcomes. The presence of pain and swelling are an indicator of active infection. Low blood pressure is a direct repercussion of poor blood supply to the body organs. Nurses can play a vital role in identifying these adverse signs and symptoms and can plan a holistic intervention program for the patient. In order to provide the patient with acute care, the patient needs to monitored for his vitals and maintained on high doses of antibiotics to clear out the infection. This has to be maintained for the first six hours post-administration (Londono, 2018). Along with clinical signs the patient needs to be monitored for cognitive as well as psychological impairments as well. This is important from the point of view of treating the patient through a holistic care approach and thus, assisting in improving the overall clinical status at large.

The first step that is required to assist in the same include, optimising the fluid-volume in the body. This is useful for proper functioning of the various body parts as well as will help in keeping the blood pressure optimal. Fluid management in patients with sepsis has been proven to be helpful method of treatment. Administration of antibiotics can also be done through the means of fluid therapy (Silverside, 2017). This is also found to reduce the mortality rate in the patient and encouraging more intake of fluid and antibiotic through simpler methods of administration. High calorie intake is also imperative in these cases to maintain for the response for the immune system. It will help largely in boosting the immunity of the person and thus, faster recovery rate can be observed in such individuals. The IV dose of the particular antibiotic should only be prescribed after assessing for the underlying causative pathogen in the body (Rhodes, 2017). This will also be helpful in reducing the fatality that can be caused by wrong dose administration to the patient. Patients should also be encouraged to continue with the dose till all of the symptoms doses off. Blood work-up should be followed on regular basis in order to keep a close vigil on the dose monitoring and its side-effects as well. An incomplete dose administration will subject the patient at a risk of further developing the same infection and with greater gravity as well.

Maintaining a high oxygen supply will also help in reducing the stress of the patient. Patient can also be provided with warm blankets to keep the extremities warm and ensure blood warming (Shin, 2016). This will reduce the adverse effects on the patient. The room temperature can also be attained at an optimal level where the patient will not be having any sensation of his extremities being cold. Unsettled body temperature is also a common sign observed in the cases of sepsis. Therefore, it becomes important to monitor for body temperature as well. There is an ongoing inflammatory response in the body of the patient. The patient is also vulnerable to catch infection by another pathogen as well. It is important to keep a continuous check on WBC counts in the body. Any fluctuation in the same should be noted and acted upon as anticipated, to lower the impact of infection spread in the patient’s body. Nutritional status is also imperative to be maintained as it will help the body in combating against the infection and will also help in promoting speedy recovery in the patient (Service, 2016). The wound care management is also crucial in this scenario as infection can further precipitate through the site of infection. While managing wound aseptic procedures should be followed and proper hand hygiene as well to break the chain of infection spread. Patient and his family can also be educated regarding wound care post-discharge from hospital setting (Sibaja, 2017).

Deep Vein Thrombosis

If not managed properly the deep vein thrombosis can also be a life threatening condition. The clot that if formed in the deep veins of legs, can dislodge with the blood circulation and can get disposed in major artery of heart or brain, leading to stroke in patients. It is one of most commonly observed complication in post-surgical cases. These clots usually develop in lower leg or inner thigh. As patient is having knee surgery, he is having a reduced blood flow in his lower leg. Therefore, he can be observed to be more predisposed to the risk of DVT formation in the operated leg. This also tags along with an increased potential for underlying risk factors due to the same (Ramakrishnan, 2017).

The primary intervention that can be used in this case scenario is management of the thrombosis with compression bandages. The patient can be encouraged to ambulate along with the same and it will help in increasing blood circulation in the lower limb and thus, early resolution of the thrombus. The patient can also be managed with the medical treatment of anti-clotting medications such as heparin (Butt, 2017). This will help in further prevention of clot formation in the lower extremity. Early mobilization will also help in scar healing of the patient and same can be assistive in reducing the pain by the help of promotion of blood circulation in the lower limb. Foot elevation in the level of heart will also help in back pumping of the blood and will help in prevention of DVT. Regular motion of the foot can be maintained during foot elevation so as to help with the enhancement of blood circulation. This will also be beneficial in reducing swelling in the lower limb and will help in faster recovery of the patient. By mobilizing the patient the wound will be healed in a faster manner and the same can be helped with promotion of scare tissue healing in the patient (Rhodes, 2017). As the patient is being managed by anti-coagulant therapy, he should be taught to note any abnormal signs of changes in skin colour or bleeding to be reported, so that the medications can be discontinued in a timely manner.

Evaluation of Nursing Care Plan

The main goal of nursing evaluation is to make sure that the patient is assessed as well as managed in a holistic manner. Post noting for the WBC counts the antibiotic should be commenced immediately and fluid therapy should be maintained to support the medical management and prevent any side effects due to the same. Post these interventions the patient in the given case study will be at a lower risk of developing infection again. By managing the wound the patient can also be helped with mobilization and this will also help in better wound healing. Monitoring of the incision site is to be done till the scar tissues are completely healed and it is also important from the point of view of reducing the risk of infection spread in the patient. Blood pressure should also be maintained at a normotensive state and this will help in reducing the additional load on the vital organs of the body. Patient education will also be helpful in this scenario, as it will guide the patient on important dos’ and don’ts.

Conclusion on Sepsis Management

All of the clinical signs and symptoms of Christopher reflects on him being subjected to a risk of developing sepsis as well as deep vein thrombosis. Current interventions are maintenance of fluid therapy, antibiotic, patient education and wound care management. Nurses can work along with eth family of the patient to provide him with the care needed. Along with clinical signs and symptoms, it also crucial to monitor for the underlying cognitive as well as psychological impairments as well. This will help in reducing the adverse signs and will help in providing the patient with a holistic care plan as needed by him.

References for Sepsis Management

Butt, M. U., Buzsaki, L. A., Smyth, S. S., & Elayi, S. C. (2017). Deep vein thrombosis complicated by spontaneous iliopsoas hematoma in patient with septic shock. The American journal of case reports, 18, 11-48.

De Backer, D., & Dorman, T. (2017). Surviving sepsis guidelines: a continuous move toward better care of patients with sepsis. Jama, 317(8), 807-808.

Lakomkin, N., Sathiyakumar, V., Wick, B., Shen, M. S., Jahangir, A. A., Mir, H., ... & Sethi, M. K. (2017). Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients. Journal of Orthopaedics and Traumatology, 18(2), 151-158.

Londono, J., Nino, C., Archila, A., Valencia, M., Cardenas, D., Perdomo, M., ... & Ascuntar, J. (2018). Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis. Journal of Critical Care, 48, 191-197.

Ramakrishnan, N., & Detect-Dvt Investigators. (2017). Prophylaxis and incidence of symptomatic deep vein thrombosis in indian patients with sepsis: DETECT-deep vein thrombosis registry. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 21(11), 765.

Rashid, A. O., & Fakhralddin, S. S. (2016). Risk factors for fever and sepsis after percutaneous nephrolithotomy. Asian Journal of Urology, 3(2), 82-87.

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., ... & Rochwerg, B. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377.

Rudd, K. E., Hantrakun, V., Somayaji, R., Booraphun, S., Boonsri, C., Fitzpatrick, A. L., ... & West, T. E. (2019). Early management of sepsis in medical patients in rural Thailand: a single-center prospective observational study. Journal of Intensive Care, 7(1), 55-58.

Service, E., & Anwar, F. (2016). Nutritional management in critically ill trauma patients is challenging. Trauma, 18(3), 231-236.

Shin, T. G., Jo, I. J., Hwang, S. Y., Jeon, K., Suh, G. Y., Choe, E., ... & Sim, M. S. (2016). Comprehensive interpretation of central venous oxygen saturation and blood lactate levels during resuscitation of patients with severe sepsis and septic shock in the emergency department. Shock: Injury, Inflammation, and Sepsis: Laboratory and Clinical Approaches, 45(1), 4-9.

Sibaja, P., Sanchez, A., Villegas, G., Apestegui, A., & Mora, E. (2017). Management of the open abdomen using negative pressure wound therapy with instillation in severe abdominal sepsis: A review of 48 cases in Hospital Mexico, Costa Rica. International journal of surgery case reports, 30, 26-30.

Silversides, J. A., Major, E., Ferguson, A. J., Mann, E. E., McAuley, D. F., Marshall, J. C., ... & Fan, E. (2017). Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive care medicine, 43(2), 155-170.