NCP #1: Impaired gas exchange related to interference with oxygen delivery and utilization in the tissues (endotoxin-

induced damage to the cells and capillaries)

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired gas Within 1 hour of Independent: After 1 hour of
N/A exchange related proper nursing - Encourage a - A relaxed and proper nursing
Objective: to interference intervention, the relaxed and restful intervention, the
-Pale and moist with oxygen patient will display restful environment patient display
skin delivery and ABGs and environment can help reduce ABGs and
-Radial pulse is utilization in the respiratory rate - Reposition the the body respiratory rate
rapid and thready tissues within normal patient metabolic within normal
-Crackles and (endotoxin- range, with the frequently requirement range, however
wheezes in all induced damage breath, sounds - Demonstrate - Facilitate crackles and
lung field to the cells and clear and instruct oxygenation wheezes are still
-Confusion capillaries) the patient on and proper audible in all lung
Vital signs are deep breathing circulation field.
taken as follows: and relaxation - To enhance
Temp: 38.4°C techniques lung expansion
RR: 32 cpm - Place in a - Elevating the
PR: 82 bpm position of head of bed
BP: 82/66 mmHg comfort with enhances lung
O2 stat: 90% the head of the expansion and
bed elevated reduce
to 30 to 40 respiratory
Dependent: effort
- Administer - Supplemental
supplemental oxygen is
oxygen as important for
necessary correction of
- Administer hypoxemia with
prescribed failing
medications respiratory
- Administer red effort or
blood cells progressing
(RBCs) as acidosis
indicated - May be
 - Administer required to
medications as improve
prescribed available
oxygen to treat
sepsis-induced
hypoperfusion
- To aid and
alleviate
symptoms

NCP #2: Decreased cardiac output related to the reduction in the venous volume secondary to alteration of heart rate,
 rhythm, and conduction
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Decreased cardiac Within 1-2 hours of Independent: After 1-2 hours of
N/A output related to proper nursing - Assess for - Indicates proper nursing
Objective: the reduction in the intervention, the chest pain imbalances intervention, the
-Pale and moist venous volume patient will - Monitor the between patient
skin secondary to demonstrate patient urine oxygen demonstrates
-Radial pulse is alteration of heart hemodynamic output and supply and hemodynamic
rapid and thready rate, rhythm, and stability as commence the demand stability as
-Crackles and conduction evidenced by blood patient on a - The body evidenced by:
wheezes in all lung pressure within fluid balance compensate BP= 100/80
field normal limit and chary s for the PR= 87
-Capillary refill is 3 cardiac output - Encourage a decreased
seconds relaxed and cardiac
-Urine output is restful output by
18ml environment reabsorbing
Vital signs are - Position the fluid from
taken as follows: patient in the renal
Temp: 38.4°C modified tubule back
RR: 32 cpm Trendelenburg into the
PR: 82 bpm - Demonstrate systemic
BP: 82/66 mmHg and instruct circulation to
O2 stat: 90% the patient on increase
deep breathing blood
and relaxation volume.
techniques - A relaxed
- Elevate lower and restful
extremities environment
above the level can help
of heart reduce the
Dependent: body
- Administer metabolic
supplemental requirement
oxygen as - This position
necessary increases
- Administer venous
parenteral return to the
fluids heart this
- Administer turn
medications as increases
prescribed strength of
- Provide cardiac
medical anti- contractility
shock trouser and
(MAST) as improves
ordered cardiac
- Provide output
mechanical - To increase
ventilation oxygen for
cardiac
consumption
- Facilitate
oxygenation
and proper
circulation
- A reduce
cardiac
output can
cause a
reduce
delivery of
oxygen in
the systemic
circulation.
- Parenteral
fluids
therapy
helps
maintain
tissue
 perfusion
and expand
circulating
volume
- To aid and
alleviate
symptoms
- To improves
venous
return and
increase
cardiac
workload
- For patient
with sepsis-
induced
respiratory
distress
syndrome

NCP #3: Altered body temperature related to the direct effect of circulating endotoxins on the hypothalamus, altering
temperature regulation
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Altered body Within 2 hours of Independent: After 2 hours of
N/A temperature proper nursing - Monitor - Room proper nursing
Objective: related to the direct intervention, the environmental temperature intervention, the
-Pale and moist effect of circulating patient temperature. and linens patient
skin endotoxins on the temperature Limit or add should be temperature
-Flushed skin, hypothalamus, decreased from bed linens, as altered to decreased from
warm to touch altering 38.4 C to the indicated. maintain near- 38.4 C to 37.0 C
-Radial pulse is temperature normal range - Provide tepid normal body
rapid and thready regulation (36.5-37.5) sponge baths. temperature.
-Crackles and Avoid use of - Tepid sponge
wheezes in all lung alcohol. baths may
field - Encourage a help reduce
-Capillary refill is 3 relaxed and fever. The use
seconds restful of alcohol may
-Urine output is environment cause chills,
18ml - Provide elevating
Vital signs are cooling temperature,
taken as follows: blanket, or and skin
Temp: 38.4°C hypothermia dehydration.
RR: 32 cpm therapy as - A relaxed and
PR: 82 bpm indicated. restful
BP: 82/66 mmHg - Demonstrate environment
O2 stat: 90% and instruct can help
the patient on reduce the
deep breathing body
Dependent: metabolic
- Administer requirement
medications as - Used to
prescribed reduce fever,
especially
when higher
than 104°F to
105°F
(39.9°C–
 40°C), and
when seizures
or brain
damage are
likely to occur.
- To provide
relaxation
technique
- Antipyretics
reduce fever
by its central
action on the
hypothalamus;
fever should
be controlled
in clients who
are
neutropenic or
splenic.

NCP #4: Deficient fluid volume related to capillary permeability with fluid leaks into the interstitial space (third spacing)
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Deficient fluid Within 3-4 hours of Independent: After 3-4 hours of
N/A volume related to proper nursing - Measure and - Decreasing proper nursing
Objective: capillary intervention, the record urinary urinary output intervention, the
-Pale and moist permeability with patient will output and with a high patient maintains
skin fluid leaks into the maintain adequate specific specific gravity adequate
-Radial pulse is interstitial space circulatory volume gravity. suggests circulatory volume
rapid and thready (third spacing) as evidenced by - Assess color relative hypovo as evidenced by
-Crackles and vital signs within and amount of lemia vital signs within
wheezes in all the client’s normal urine. Report associated client’s normal
lung field range, palpable urine output with range, palpable
-Confusion peripheral pulses less than 30 vasodilation. peripheral pulses
-Capillary refill is 3 of good quality, ml/hr for two - Normal urine of good quality,
seconds and individually (2) output is and individually
-Nausea appropriate urinary consecutive considered appropriate urinary
-Urine output is output. hours. normal, not output.
18ml - Encourage a less than
Vital signs are relaxed and 30ml/hour.
taken as follows: restful Concentrated
Temp: 38.4°C environment urine denotes
RR: 32 cpm - Provide a fluid deficit.
PR: 82 bpm comfortable - A relaxed and
BP: 82/66 mmHg environment restful
O2 stat: 90% by covering environment
the patient with can help
light sheets. reduce the
- Demonstrate body metabolic
and instruct requirement
the patient on - Drop situations
deep breathing where patients
and relaxation can experience
techniques overheating to
- Elevate lower prevent further
extremities fluid loss.
above the level - Fluid therapy is
 of heart most effective
Dependent: early during
- Administer IV severe sepsis
fluids, such as because as the
isotonic condition
crystalloids worsens, there
(D5W normal is greater
saline [NS], dysfunction at
lactated the cellular
ringer’s [LR] level.
and colloids - To aid and
(albumin, fresh alleviate
frozen symptoms
plasma), as - Blood
indicated. transfusions
- Administer may be
medications as required to
prescribed correct fluid
- Administer loss 
blood products
as prescribed.
 NCP #5: Deficient knowledge related to lack of exposure or recall information misinterpretation
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Deficient Within 5 hours of Independent: After 5 hours of
‘’Bakit nagkaroon knowledge related proper nursing - Review - Discussing the proper nursing
ako ng to lack of exposure intervention, the disease disease and intervention, the
complication or recall patient will process and clinical patient will
ganito?’’ information verbalize future expectations verbalize
Objective: misinterpretation understanding of expectations provides a understanding of
-Lack of source of the disease . knowledge disease process,
information process, prognosis, - Review base from prognosis, and
-Denial of condition and potential individual which client potential
-Confusion complications. risk factors, can make complications.
Vital signs are mode of informed
taken as follows: transmission choices.
Temp: 38.4°C , and portal - Awareness of
RR: 32 cpm of entry of means of
PR: 82 bpm infections. infection
BP: 82/66 mmHg - Discuss transmission
O2 stat: 90% need for a provides an
good opportunity to
nutritional plan for and
intake or institute
balanced preventive
diet. measures.
- Provide - Good nutrition
information is necessary
about drug for optimal
therapy, healing,
interactions, immune
side effects, system
and the enhancement,
importance and general
of well-being.
compliance - Sufficient and
with the appropriate
 treatment information
regimen. promotes
- Identify understanding
signs and and enhances
symptoms compliance
requiring with treatment
medical or prophylaxis,
evaluation: and reduces
persistent the risk of
high fever, recurrence
increased and
heart rate, complications
syncope, - Early
rashes of recognition of
unknown developing
origin, infection will
unexplained allow a timely
fatigue, intervention
anorexia, and reduces
increased the risk of life-
thirst, and threatening
changes in complications.
bladder - Prophylactic
function. vaccines and
- Stress the antibiotics
importance prevent the
of occurrence of
prophylactic infection,
immunizatio especially in
ns and high-risk
antibiotic groups such
therapy, as as those of
needed. extreme ages
or with chronic
illness and a
history of
infective heart
disease and
immunosuppre
ssion.
 CHARTING
Name: Mrs. B  
Age: 72 years old
Gender: Female

SOAPIE #1

S:

N/A

O:

 Pale and moist skin

 Radial pulse is rapid and thready
 Crackles and wheezes in all lung field
 Confusion

Vital signs are taken as follows:

Temp: 38.4°C
RR: 32 cpm
PR: 82 bpm
BP: 82/66 mmHg
O2 stat: 90%

A:

Impaired gas exchange related to interference with oxygen delivery and utilization in the
tissues (endotoxin-induced damage to the cells and capillaries)

P:
Within 1 hour of proper nursing intervention, the patient will display ABGs and respiratory
rate within normal range, with the breath, sounds clear

I:
 Encouraged a relaxed and restful environment
 Repositioned the patient frequently
 Demonstrated and instruct the patient on deep breathing and relaxation techniques
 Placed in a position of comfort with the head of the bed elevated to 30 to 40
 Administered supplemental oxygen as necessary
 Administered prescribed medications
 Administered red blood cells (RBCs) as indicated
 Administered medications as prescribed

E:
After 1 hour of proper nursing intervention, the patient display ABGs and respiratory rate
within normal range, however crackles and wheezes are still audible in all lung field.
 CHARTING
Name: Mrs. B  
Age: 72 years old
Gender: Female

SOAPIE #2

S:

N/A

O:

 Pale and moist skin

 Radial pulse is rapid and thready
 Crackles and wheezes in all lung field
 Capillary refill is 3 seconds
 Urine output is 18ml

Vital signs are taken as follows:

Temp: 38.4°C
RR: 32 cpm
PR: 82 bpm
BP: 82/66 mmHg
O2 stat: 90%

A:
Decreased cardiac output related to the reduction in the venous volume secondary to
alteration of heart rate, rhythm, and conduction

P:
Within 1-2 hours of proper nursing intervention, the patient will demonstrate hemodynamic
stability as evidenced by blood pressure within normal limit and cardiac output

I:
 Assessed for chest pain
 Monitored the patient urine output and commence the patient on a fluid balance chart
 Encouraged a relaxed and restful environment
 Positioned the patient in modified Trendelenburg
 Demonstrated and instruct the patient on deep breathing and relaxation techniques
 Elevated lower extremities above the level of heart
 Administered supplemental oxygen as necessary
 Administered parenteral fluids
 Administered medications as prescribed
 Provided medical anti-shock trousers (MAST) as ordered
 Provided mechanical ventilation

E:
After 1-2 hours of proper nursing intervention, the patient demonstrates hemodynamic
stability as evidenced by:
BP= 100/80
PR= 87
 CHARTING
Name: Mrs. B  
Age: 72 years old
Gender: Female

SOAPIE #3

S:

N/A

O:
 Pale and moist skin
 Radial pulse is rapid and thready
 Crackles and wheezes in all lung field
 Confusion
 Capillary refill is 3 seconds
 Nausea
 Urine output is 18ml

Vital signs are taken as follows:

Temp: 38.4°C
RR: 32 cpm
PR: 82 bpm
BP: 82/66 mmHg
O2 stat: 90%

A:
Altered body temperature related to the direct effect of circulating endotoxins on the
hypothalamus, altering temperature regulation

P:
Within 2 hours of proper nursing intervention, the patient temperature decreased from 38.4 C
to the normal range (36.5-37.5)

I:
 Monitored environmental temperature. Limit or add bed linens, as indicated.
 Provided tepid sponge baths. Avoided the use of alcohol.
 Encouraged a relaxed and restful environment
 Provide cooling blanket or hypothermia therapy as indicated.
 Demonstrate and instruct the patient on deep breathing
 Administer medications as prescribed

E:
After 2 hours of proper nursing intervention, the patient temperature decreased from 38.4 C
to 37.0 C
 CHARTING
Name: Mrs. B  
Age: 72 years old
Gender: Female

SOAPIE #4

S:

N/A

O:
 Pale and moist skin
 Flushed skin, warm to touch
 Radial pulse is rapid and thready
 Crackles and wheezes in all lung field
 Capillary refill is 3 seconds
 Urine output is 18ml

Vital signs are taken as follows:

Temp: 38.4°C
RR: 32 cpm
PR: 82 bpm
BP: 82/66 mmHg
O2 stat: 90%

A:
Deficient fluid volume related to capillary permeability with fluid leaks into the interstitial
space (third spacing)

P:

Within 3-4 hours of proper nursing intervention, the patient will maintain adequate circulatory
volume as evidenced by vital signs within the client’s normal range, palpable peripheral
pulses of good quality, and individually appropriate urinary output.

I:
 Measured and recorded urinary output and specific gravity.
 Assessed color and amount of urine. Report urine output less than 30 ml/hr for two
(2) consecutive hours.
 Encouraged a relaxed and restful environment
 Provided a comfortable environment by covering the patient with light sheets.
 Demonstrated and instruct the patient on deep breathing and relaxation techniques
 Elevate lower extremities above the level of heart
 Administered IV fluids, such as isotonic crystalloids (D5W normal saline [NS],
lactated ringers [LR], and colloids (albumin, fresh frozen plasma), as indicated.
 Administered medications as prescribed
 Administered blood products as prescribed

E:
After 3-4 hours of proper nursing intervention, the patient maintains adequate circulatory
volume as evidenced by vital signs within client’s normal range, palpable peripheral pulses
of good quality, and individually appropriate urinary output.
 CHARTING
Name: Mrs. B  
Age: 72 years old
Gender: Female

SOAPIE #5

S:
‘’Bakit nagkaroon ako ng complication ganito?’’

O:
 Lack of source of information
 Denial of condition
 Confusion

Vital signs are taken as follows:

Temp: 38.4°C
RR: 32 cpm
PR: 82 bpm
BP: 82/66 mmHg
O2 stat: 90%

A:
Deficient knowledge related to lack of exposure or recall information misinterpretation

P:

Within 5 hours of proper nursing intervention, the patient will verbalize understanding of the
disease process, prognosis, and potential complications.

I:
 Reviewed disease process and future expectations.
 Reviewed individual risk factors, mode of transmission, and portal of entry of
infections.
 Discussed the need for a good nutritional intake or balanced diet.
 Provided information about drug therapy, interactions, side effects, and the
importance of compliance with the treatment regimen.
 Identified signs and symptoms requiring medical evaluation: persistent high fever,
increased heart rate, syncope, rashes of unknown origin, unexplained fatigue,
anorexia, increased thirst, and changes in bladder function.
 Stressed the importance of prophylactic immunizations and antibiotic therapy, as
needed

E:
After 5 hours of proper nursing intervention, the patient will verbalize understanding of
disease process, prognosis, and potential complications.