Sepsis Care Plan

In this video, we are walking through a sepsis care plan. I know that care plans can be a little difficult to create in nursing school and especially to ace, but it is totally possible. You absolutely can get an A on your nursing school care plans, and I'm going to show you how in this video. Let's do it. So the key thing that your nursing instructor is looking for when you are creating your nursing school care plans is that they want to know that you actually understand what is going on with your patient and that you can provide safe and effective care for your patients. That is absolutely what they want to see. And how you do that is by writing a fabulous nursing school care plan. So in this video, I'm going to walk you through how to do that using sepsis as an example. So we'll walk through a sepsis care plan step by step so you can see how the process works. It's going to be super fun. And I am using the study guide actually from our nursing SOS membership community. So if you're a nursing SS member, don't worry about writing any of this down. It's all inside the membership community for you in the study guide for sepsis. Now, the first part of your care plan is the nursing diagnosis. Now, there's a few parts to the nursing diagnosis. The first part is the actual diagnosis part. That is the NANDA approved nursing diagnosis. Now, you do not make these up. These are actually standardized, which makes it so easy for you because all you have to do is choose from a list of them. Pretty cool. So nothing really to worry about there. All you have to do is select from a list. And if you need help with that, I walk you through how to do that in this video. Now, the second part is the related two factor and that is the pathophysiology of what is actually happening with your patient. So for our example of sepsis, you're going to dive into the pathophysiology for why it is happening. Why did you select your NANDA approved nursing diagnosis that you did? Why did you select that nursing diagnosis? And it comes back to the pathophysiology. Now here is where you really can impress your nursing instructor. You want to dive deep into the patho and make sure, like show your nursing instructor that you understand what is actually happening with your patient. That's a great way to do it, is to actually communicate what is actually happening with that patho. Now, the third part of this nursing diagnosis is the as evidenced by these are like the signs and symptoms that you would See that your patient displayed and why you chose that particular NANDA nursing diagnosis. So as evidenced by just think about the signs and symptoms. So for our example of sepsis, think of through the signs and symptoms of sepsis that you saw for your patient. Now we're going to walk through an example and like I said, we're going to walk through the diagnosis, we're going to walk through the assessment, we're going to walk through the nursing interventions and the evaluation for your care plan. So let's do just that. So for sepsis, some NANDA nursing diagnoses that you might want to use are risk for shock, risk for impaired gas exchange or risk for infection. Those would all be really, really good ones to use for a patient with sepsis, if your patient did have those risk force, it could always depend on your individual patient situation. But those are really good ones to give you a starting point. So now the next part is the patho. We're going to dive into the pathophysiology. So the pathophysiology of sepsis, basically the white blood cells are creating an immune response, inflammatory response in the body, and this decreases blood flow to the organs, right? So the organs are getting less and less blood flow. This could really cause a lot of issues in the body because if those organs are not functioning properly, it's bad news, right? So the patient's immune response is activated here. During sepsis, because there's a pathogen in the body, their immune system is triggered, the white blood cells are triggered, and that is now causing that pretty much systemic immune response through the body, which then decreases blood flow to other organs. So some common signs and symptoms that you would see for sepsis are a temperature above 38 degrees Celsius, heart rate over 90 beats per minute, 100 beats per minute, respiratory rate over 20 breaths per minute, a decrease in blood pressure, that is key. Okay? With sepsis, a Paco 2 of less than 38 and a white blood cell count of greater than 12,000. And of course, mental status changes, like we said that decreased blood flow, decreased perfusion to the organs, mental status changes, it all makes sense, right? So those are some really common signs and symptoms that you might see in a patient with seps. Those are all things that you could put in the as evidenced by section. Now, I want you to notice this here, these signs and symptoms that we just listed. You can use a lot of these for your patient goals section on your nursing care plan. Now, the patient goals section, this is where you are actually writing goals that your patient will want to achieve. Okay. They're very different than the nursing interventions you're going to do. The nursing interventions are what you will do as the nurse, but the patient goals are what we want the patient patient to accomplish. So you're going to write them as the patient will. So all of your patient goals for your care plan, you're going to start it with that phrase, the patient will. Okay, so let's go back to those signs and symptoms and I want you to think about possibly using these signs and symptoms for your patient goals because they're great goals to have. So let's go through some of these. The patient will have a temperature of less than 38 degrees Celsius. That's a pretty good goal, Right. Or the patient's heart rate will be less than 100 beats per minute or less than 90 beats per minute. The patient's respiratory rate will be less than 18 breaths per minute. Right. The patient's blood pressure will be stable. Right. So all of those would be fantastic goals for your patient with a diagnosis of sepsis. Now, a key thing to note here is that your nursing instructor or your school might require you to write more smart patient goals, which would require you to put a deadline to it. So you could say the patient will have a temperature below 30 degrees Celsius by discharge. So you would just put a deadline to it, like by discharge or by, oh, 700 on this day, you know, tomorrow, or what have you, you know, they could require a deadline on it. So just be mindful of that. You might want to check with your instructor, check with your school to see if that's a requirement for you. Now, the next column of your care plan are nursing interventions. And this is what you will do as the nurse or the nursing student in order to help your patient meet their patient goals. So we used a lot of these signs and symptoms from our, as evidenced by column, our signs and symptoms column for our care plan in that nursing diagnosis. And so in order to achieve those, there's a lot of nursing interventions that we could do to help our patient reach those goals and reduce those signs and symptoms. Right. So some really good nursing interventions you could do are fluid resuscitation, you know, providing adequate fluids to your patient to make sure that their organs are being perfused, that their heart is pumping adequately, that they're getting enough blood flow Right. During sepsis, and then frequent vital sign monitoring. You have to make sure that their vitals are stable. Right. Frequent head to toe assessments and assessing their perfusion, assessing their, assessing their Vital signs, assessing their respiratory status and their cardiac status, tracking their intake and output. Okay. And then medication management. Antibiotics for sure. Drawing blood cultures before you give antibiotics, giving vasopressors oxygen as needed. All of these are really, really great nursing interventions that you can do for sepsis. Now, a key thing to note with this column for your nursing care plan, the nursing interventions column, is that you will write them as the nurse will. So the nurse will assess vital signs every two hours, every hour, depending on the status of your patient. The nurse will provide fluid resuscitation based on facility protocol. The nurse will. You see what I'm saying? So in the patient goals column, it starts with the patient will. But in the nursing interventions column, it starts with the nurse will. So it's a really key thing to remember because you don't want to get those confused when you write your nursing care plan. Remember we're trying to impress your instructor and you absolutely can do that. Now, the last column for your nursing care plan is evaluation. So this is basically just another reassessment you're going to see did your patient meet their goal or not? And if they did, fantastic. You're not going to change anything in the care plan because they already met that goal. If they didn't meet that goal, then you will write out what would you change in your nursing care plan in order to help them meet that goal in the future. So if they didn't meet that goal of whatever you set, like if they didn't have a temperature below 30 degrees Celsius, if they didn't have their blood pressure being stable, what happened? You would write that out in the evaluation column of your care plan. Why didn't they meet that goal? And what you would do differently as the nurse in order to help your patient progress and follow that care plan and meet their goal. So I hope that gave you some great ideas to use for your sepsis care plan in nursing school. Let me know in the comments if this was helpful for you. Write Love in the comments below if you loved it. Of course, we used to do that in our older videos and I want to bring it back. So write love in the comments below if this was helpful for you. Like I said, if you're a nursing SS member, be sure to check out the study guide because I pulled a lot of the information that I talked about in this video from the study guide inside the membership community. And if you want more care plan examples, I actually have a ton of free ones that I want to send to you. So I'll put the link down below in the description for you to snag those free care plans. And be sure to check out this video here on how to write an amazing nursing diagnosis so that you do not lose points on your care plan and go become the nurse that God created only you to be. And I'll see you over there in that next video, my friend. Take care. Bye bye.