About
End stage or by-product of shock causing organ failure and, potentially, death.
Assess
Respiratory distress, need for mechanical ventilation, ( renal) elevated BUN, creatinine, ( cardiac) decreased blood pressure, inadequate tissue perfusion ( liver) Elevated liver enzymes, ( Hematologic) impaired immune response, increased bleeding, blood clotting, ( neuro) coma, unresponsiveness
Complications
Organ damage and failure, death
Diagnosis
- Impaired tissue perfusion related to decreased cardiac output.
- Risk for injury; skin integrity, immobility
- Decreased cardiac output related to decreased stroke volume.
- Ineffective family coping related to crisis of loved one.
- Ineffective gas exchange related to respiratory compromise.
Goals
- The client will remain free from injury.
- The client will have no evidence of tissue breakdown.
- The client will maintain adequate blood pressure.
- The client will have a pulse ox above 90%.
- The family will be able to identify support persons and coping mechanisms.
Interventions
- Assess and monitor vitals, telemetry, pulse-oximetry, CBC, Bun, creatinine, liver enzymes, clotting factors, electrolytes.
- Implement safety precautions to prevent injury.
- Reposition patient every two hours.
- Perform passive range of motion for the client immobilized.
- Administer oxygen or prepare for mechanical ventilation as indicated.
- Monitor strict intake and output and daily weights.
- Administer fluids, medications as indicated.
- Encourage family to verbalize concerns, fears and encourage support programs.
- Teach family about plan of care and involve with medical decision making.
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