A client who had surgery two days ago has developed a systemic bloodstream infection and has entered a state of septic shock. Their vital signs are as follows: HR 108 bpm, RR 30/min, BP 90/50 mmHg, O2 84% on room air, T 101.8 F. Which of the following nursing diagnoses would be most appropriate for this client? Select all that apply.
a. Ineffective breathing pattern
b. Ineffective tissue perfusion
c. Alteration in urinary elimination
d. Pain
e. Fluid volume deficit
a. Ineffective breathing pattern
b. Ineffective tissue perfusion
e. Fluid volume deficit
rationale: "Fluid volume deficit", "Ineffective tissue perfusion" and "Ineffective breathing pattern" are correct. Septicemia is a serious complication that results from an infection source to which the person's immune system cannot adequately respond. Once the infection is in the bloodstream, septic shock can occur. A client with septicemia is at risk of fluid volume deficit, ineffective tissue perfusion, and ineffective breathing patterns, and must be treated with hemodynamic resuscitation (IV fluids), antibiotic therapy to treat the source of infection, and respiratory management (supplemental oxygen).
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