About
Circulatory shock characterized by major systemic infection of the whole body.
Assess
( Early) Temperature, decreased urine output, confusion, elevated white blood cell count, tachycardia, warm flushed skin, agitation, ( late) severe hypotension, cool mottled skin, tachypnea, tachycardia.
Complications
Blood clots, multi-organ dysfunction syndrome, cardiac or respiratory arrest, death
Diagnosis
- Fluid volume deficit related to infectious process.
- Impaired tissue perfusion related to infectious process.
- Risk for injury.
- Risk for infection related to invading organism
- Activity intolerance related to fatigue, weakness, infection.
Goals
- The client will have a temperature within normal range.
- The client will have adequate urine output ( at least 30 cc's and hour).
- The client will remain free from injury.
- The client will maintain fluid balance.
Interventions
- Assess and monitor vitals, WBC count, blood cultures, pulse-oximetry.
- Monitor strict intake and output and daily weights.
- Administer antibiotics as indicated.
- Administer fluids as ordered.
- Encourage increased fluid intake.
- Implement safety precautions to prevent injury.
- Administer prophylactic heparin or low molecular weight heparin to prevent DVT.
- Monitor liver enzymes, BUN, Creatinine, and peaks/ troughs of antibiotics to prevent drug toxicity.
- Remove any invasive tubes ( catheters, central lines, PICC's) that may be source of infection.
- Reposition every two hours.
- Perform passive range of motion for the client immobilized.
- Encourage rest and energy conservation during acute illness.
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