Christina Rafano walks through a complete sepsis care plan using the five-stage nursing process: assessment, diagnosis, planning, implementation, and evaluation. She shows how to document vital signs and urine output, select a NANDA diagnosis, set SMART goals, and choose evidence-based interventions like fluid management and vasopressors tied to the underlying pathophysiology.
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Hello. Hello, friend. My name is Christina Rafano from nursingschoolofsuccess.com and today in this video we are going to walk through an example nursing care plan, and more specifically, this is going to be a sepsis care plan. Now, if you haven't watched the nursing care plan template video that we've got for you, you will definitely want to check that out first because I'll be building off of that video here today in this video. And of course, if you want more care plan exam, you do not want to miss out on the care plan database that I've actually got for you inside of the nursing SOS membership community. I will pop a link to that down below in the description for you to check out if you think that would be helpful for you. Now let's get into the sepsis care plan. Alrighty, so the nursing care plan is divided up into five main parts. You've got assessment, dental diagnosis, planning, implementation and evaluation. That's the nursing process. And I've actually got a free nursing care plan template for you to follow along with for this video. There's a link down below in the description for you to download that if you think that would be helpful. And there's also some free sample care plans that I threw in there as well for you. So definitely, you will definitely want to check it out. So to start, you will go to clinical, you'll assess your patient. So while you're assessing them, you're documenting as you go, writing down the subjective and objective data that you collect and making sure that you assess everything that you need to assess that you've got to know. I've got a whole other video on subjective and objective data for you if you want to deep dive into that. I'll put a link to that as well in the description if you want to check that one out. Now, this subjective and objective data will go in the first column of your nursing care plan template. And you can even get all fancy, separate the two if you want into subjective data and objective data components. So those just go there in the first column of your nursing care plan. So let's say for sepsis as an example, our patient has a pulse rate of 110 beats per minute, respiratory rate of 24 breaths per minute, a blood pressure of 90 over 50 and a temperature of 102 degrees Fahrenheit, a urine output of 25 milliliters per hour, diminished peripheral pulses, and the patient states that they're feeling kind of cold and weak. Okay, so none of that is good. Right. So we want to help our patient. And all of that assessment data will go here in the first column, the assessment column. And then once you've done your assessment and you've collected your subjective data and your objective data, you will look through your care plan book to find a proper NANDA nursing diagnosis that fits your patient and their situation. Now, my favorite care plan book is the Nursing Diagnosis Handbook by Ackley and Ladwick. It's amazing, fun, it's going to change your life. You should not live without it in nursing school. It basically writes your care plans for for you. So if you want to check that book out, I will put an affiliate link down below in the description of this video. And if you decide to purchase that book through my link, I will receive a small commission for that. Just a little disclaimer here. So thank you so much for that. I really appreciate it. Of course, you know that I'll never recommend anything to you that I don't 1000% love. So I do love that book and I hope you find it helpful. So this nursing diagnosis should be something of priority for them, something that you really want to fix with your nursing interventions. So in this second column here, you will write down your NANDA nursing diagnosis that you think fits your patient the best. Now, for example, here we're going to make up a nursing diagnosis of impaired perfusion. Now, this is not a real nursing diagnosis, but those do change. So you need to make sure that you have an up to date nursing care plan book with the current standardized nursing diagnoses listed. So for this video, we are just going to use a made up one of impaired perfusion just as an example. But you can look in your care plan handbook and see if you can find one that's closest to impaired perfusion if you'd like. There should be several in there that relate to decreased perfusion. So why did I choose impaired perfusion to focus on here? Well, that blood pressure is low, but mostly it's because of the urine output. Urine output should be at least 30ml per hour if the kidneys are healthy and they're functioning properly. But right now with this patient, they're having some trouble, which tells me that they might not be getting as much blood as they need those kidneys. Which means impaired organ perfusion. Right. And this is a priority nursing diagnosis for sepsis. Keeping the organs perfused is high on that list of priorities. So if you are curious, that's why. So now that we have our nursing diagnosis, we need to figure out the Related two factor. So our nursing diagnosis is impaired perfusion. And what is causing this? Well, we could choose a lot of things, but for this care plan, let's just say that it's due to vasodilation secondary to sepsis. So vasodilation means that the blood vessels are dilating, right? So the blood just can't get to the organs as well as it should. Now, I did throw in there that secondary two component. You don't have to do that if you don't want to, but it does kind of help clarify exactly what's going on. That secondary two part should be disease or disorder related. That's causing whatever you wrote about in that related to part of your nursing diagnosis statement. So I hope that clarifies that I just threw it in there for fun. And finally, the last part of the nursing diagnosis is the as evidenced by part or the aeb. So here you list your assessment evidence that supports why you chose your nursing diagnosis. So here we could really rewrite all of the assessment things we originally wrote because they all really have something to do with perfusion. But for simplicity, we're gonna stick to the four main ones that we'll talk about here. The blood pressure, the urine output, the peripheral pulses, and the patient feeling pretty weak. So that gives us our whole nursing diagnosis statement. Impaired perfusion related to vasodilation, that's the cause secondary to sepsis. That's the medical diagnosis, as evidenced by a blood pressure of 90 over urine output of 25 milliliters per hour, diminished peripheral pulses, and the patient states she feels weak. So now that you've got your nursing diagnosis statement written, let's move on to the next column in the sepsis care planning. So here's where you will write your patient goals. And you'll need to make sure that these goals are smart goals and that they are written as what the patient will do. They're patient centric. And if you need a refresher on how to write smart patient goals, you'll definitely want to check out the how to write care planes video that I've got for you. So we'll start our patient goal with the patient will, and then we'll write what we want them to achieve or to help them improve. So for this sepsis care plan example, we'll say that our goal is the patient will have a blood pressure above 100 millimeters mercury by 1700 tomorrow. This goal follows the smart framework because it's specific, it's measurable, it's achievable, it's relevant and it's time bound and it's also patient centric because we have written it as what the patient will do. And now let's create some nursing interventions to solve the underlying problem, the vasodilation and the sepsis. So, so for this example sepsis care plan, we could write some nursing interventions such as the nurse will draw labs and take blood cultures. The nurse will assess the patient's vital signs frequently. This would be per facility policy. And the nurse will give fluids as prescribed. The nurse will give vasopressors, oxygen and other medications as prescribed. So all of these nursing interventions that I just listed and really help to solve the underlying problem, that vasodilation and the sepsis. It's important that when you do, when you write your nursing interventions, you're not just trying to put a band aid over the signs and symptoms just to cover it up. We want to fix the underlying condition. Right? So all of these nursing interventions help to solve that underlying problem of sepsis and vasodilation and in turn they help the patient reach that goal of having a blood pressure above 100 millimeters mercury. And for most nursing schools, they will want you to find an evidence based rationale for each nursing intervention that you use. So I recommend that you go through your textbook and find where they talk about the disorder or about the intervention that you chose for your care plan and figure out why that nursing intervention is important for your patient. And finally, you'll need to evaluate your patient's progress. Did they meet their goal or not? If they did meet their goal, you will need to start a new goal for them, set a new goal and do this whole process over again with a brand new goal. If they didn't meet their goal, write down what changes need to be made in their care plan in order for them to get there to meet their goal. So with this example sepsis care plan, if our patient didn't meet their goal of having a blood pressure above 100 millimeters mercury, we would write what we could change in the care plan to make that happen. Things like consult with the healthcare team to choose the best course of action, continue to assess and monitor the patient, recommend an increase in fluids to the healthcare team, things like that. So if the goal was not met, make sure that you give some recommendations to help them meet that goal and to change their care plan up so that they can do that. And that is your sample sepsis care plan. I really hope this helped to clarify this whole process for you. And if you need more sample care plans, you will definitely want to jump into the Nursing SOS Membership community where we've got a ton of them in there for you. And of course, if you liked this video, please write love in the comments below to let me know. I can't wait to chat with you and make sure you subscribe and hit that little bell icon to never miss a future video. Thank you so much for watching friend, and for being here and supporting everything we do here on the Nursing School Show. Now go become the nurse that God created only you to be and I'll see you right back here next time on the Nursing School Show. Take care of.
