DIPLOMA OF NURSING

FACULTY OF MEDICINE AND HEALTH SCIENCES

UNIVERSITY MALAYSIA SABAH

Matric Number : DN15110007

Year/Semester : YEAR 3/SEMESTER 2(BATCH 7; Sept 2015)

Case Diagnosis : SEPSIS SECONDARY TO PERFORATED APPENDICITIS

Clinical Posting : MN32213 (Critical Care & Emergency Nursing Posting)

Ward/Hospital : GENERAL INTENSIVE CARE UNIT (GICU), QEH 2

Clinical Supervisor : MS.CHUNG SU CHIN

Examiner : MS.SUKHBEER KAUR

pg. 1
 DIPLOMA OF NURSING

FACULTY OF MEDICINE AND HEALTH SCIENCES

UNIVERSITY MALAYSIA SABAH

CONFIRMATION OF THE VALIDITY CASE STUDY

a) Registration Number: 102773

b) Name: Janainah@Fatimah Binti Sapri

c) Sex / Age: Female, 58 years old

d) NRIC: 591222-12-****

e) Address: Kampung Kerukan, Kuala Penyu

f) Ward: General Intensive Care Unit (GICU)

g) Hospital: QEH 2

h) Date of admission: 3/5/2018

i) Date & Time discharge: Client is not yet discharge during case study is taken

j) Final diagnosis: Sepsis secondary to perforated appendicitis complicated with acute

kidney injury

Hereby I confirmed the details/ content of case study are taken from

Verify by Clinical Instructor (In-charge of the ward),

Signature

Name & Chop

Date /Time

pg. 2
A. INTRODUCTION

My case study is about 58 years old MS.J (591222-12-XXXX) who admitted on 3/5/2018 at
4.09pm.MS.J’s case is a referral case from Hospital Kuala Penyu.Before admitted at
GICU,MS.J was admitted first at emergency department QEH2(2/5/2018) arrived by KKM
ambulance and was taken care at RED ZONE. Upon arrival at emergency department QEH2,
patient was already intubated and sedated with IV Noradrenaline for support of her low
blood pressure (post intubation patient’s BP start to drop). Before patient referred to QEH2,
patient was admitted at Hospital Kuala Penyu since 29/4/2018 came to HKP with AGE
symptoms and also on and off cough. Started on fluid replacement therapy for 2 days
(30/4/2018-1/5/2018) then suddenly patient change condition by having several episode of
temperature spike and tachypneic after admitted for 48 hours in the ward. Started on IV
Ceftazidime with IVD 1 pint normal saline running for 24 hours. Patient then intubated at
11.55am with ETT size 7cm anchored at 19cm.Pre medication given Fentanyl 100mcg,
Midazolam 5mg and Scoline 100mg.Post intubation sedated with IV Midamorphine running
for 2cc per hour. Reason for intubation is due to respiratory distress. Patient was manage at
ETD QEH2 with IV Cefepime 2g TDS, IVD 5 pints normal saline for 24 hour and was planned
to refer surgical team and for CT abdomen. Patient intubated with ventilator SIMV/VC
mode,FIO2 0.6,RATE 12,TV 350,PEEP 6 and I:E RATIO 1:2:0.Patient’s GCS level is
E1VTM1(2T/15) with pupil bilateral pinpoint (patient sedated and ventilated).Patient direct
admission from ETD QEH2 on 3/5/2018 at 1.15am. For patient’s past history, the history
was taken from her sister staying at Likas.Patient is taken care by her nieces in Kuala
Penyu.She is not married yet and single with underlying disease of Diabetes Mellitus and
Hypertension under HKP follow up. Patient chief complaints are generalised abdominal pain
for 1 week, several episode of diarrhoea with loose stool but no vomiting. At ETD QEH2,
patient presented with abdominal distended and tense. Bedside scan done and was found
free fluid in the abdomen. Ultrasound abdomen was done and was found that patient is
having ascites.

pg. 3
CASE DIAGNOSIS

Septic shock is caused by a release of vasoactive substances. Current theories suggest there
is a cascade of interactions between immune cells that happens rapidly and leads to
microcirculatory alterations. Septic shock is the most common cause of mortality in intensive
care units. Even with the best treatment, mortality ranges from 15% in clients with sepsis to
40% to 60% in clients with septic shock

ETIOLOGY AND RISK FACTORS

Sepsis is the presence of infection and activation of the inflammatory cascade. Systemic
inflammatory response syndrome (SIRS) is a term used to define the clinical condition and it
is considered present if abnormalities exist in two of the following four clinical parameters
such as body temperature, heart rate, respiratory rate and peripheral leukocyte count.
Sepsis is defined as the presence of SIRS in the setting of infection. Septic shock is defined
as sepsis with persistent hypotension despite fluid resuscitation and resulting tissue
hypoperfusion

PATHOPHYSIOLOGY

Sepsis begins with the unchecked growth of organisms at a tissue site. About 50% of clients
with septic shock have bacteraemia with gram negative rods and gram positive organisms
being the most common agents

CLINICAL MANISFESTATIONS

A person with severe sepsis develops the hypotension, coagulation disorders and
multisystem organ dysfunction of septic shock due in part to a dysregulated expression of
the body’s mediators of inflammation. Sepsis is diagnosed when two or more of these
manifestations are present:

 Temperature greater than 38 degree celcius or less than 36 degree celcius

 Heart rate greater than 90 beats per minute
 Respiratory rate greater than 20 breaths per minute or a paco2 in arterial blood
gases less than 35mmhg
 WBCs count greater than 12000 cells/ml or less than 4000 cells/ml

In the early stages of septic shock the body experiences massive vasodilation. Warm, dry,
flushed skin is apparent during this hyperdynamic stage of septic shock. The compensatory
increase in cardiac output and resultant increased perfusion of the skin. During the later
stages when compensatory mechanisms fail the release of myocardial depressant factor and
result in decreased venous return, decreased perfusion called the hypodynamic stage result.
At this point the skin becomes pale, cold, clammy and mottled and body temperature
decreases

pg. 4
pg. 5
B. Health History

1. Biographic data

Name : MS.J

Sex / age : Female/58 years old

Date of birth : 22th of December 1959

NRIC : 591222-12-XXXX

Citizenship : Malaysian

Race : Bisaya

Religion : Muslim

Marital status : Single

Occupation : None

Address : Kampung Kerukan Kuala Penyu

Contact number : 019XXXXXXX

2. Source of reference

& information : Client’s sister, nieces and case note

3. Chief complaints : Abdominal pain for 1 week

particularly at right iliac fossa, several

episodes of diarrhoea with loose stool,

cough on and off, abdominal

distended and tense

pg. 6
4. Past health history

a) Family Health History (family tree)

FATHER MOTHER

83 y/o 79 y/o

SISTER

SISTER BROTHER PATIENT BROTHER SISTER

61 y/o 59 y/o 58 y/o 55 y/o 49 y/o

INDICATORS: FOR MALE, FOR FEMALE

pg. 7
b) Past Medical History : Diabetes Mellitus, Hypertension

c) Past Surgical History : NIL

d) Number of Hospitalisation : First hospitalisation

5. Psychiatric problem

Onset : client has no psychiatric problem

Number of relapse : client has no psychiatric problem

Type of treatment (hospital/traditional) : client has no psychiatric problem

6. Allergy

Food : NIL

Medication : NIL

Others : NIL

7. Psychosocial History (post extubation)

Mental status :-client is conscious and but not fully alert

around her surrounding.no abnormalities

was found

Behaviour :-client just lying on her bed, no active

movement made, client obey simple

command

pg. 8
Communication/interaction :-most of the time client just sleep and

wake up when someone call her, client

just say simple words and cannot be

interviewed because she still very weak.

she just use hand gestures and facial

expression to describe what she wants to tell

Reaction towards the

disease & treatment :-client very cooperative in every procedure

that is done to her

Client’s expectation towards

doctors & nurses :-client cannot be interviewed

because she still very weak to communicate

Home environment / facilities :-client live in a clean and conducive

area. Client’s house is complete with

electricity, water and near to grocery

store. All basic facilities are save

to use (describe by client’s niece)

-client live with her two nieces

pg. 9
C. Medications

 TAB PERINDOPRIL 2MG OD

Indications: hypertension, congestive heart failure, stable coronary artery disease

Contraindication: angioedema induced by other ACE inhibitors, hypersensitivity to this ACE

inhibitors, pregnancy, lactation

Dose: 2mg od

Route: tablet

Side effects: GI disorders, dizziness, headaches, mood or sleep disorders, cramps, localised
skin rashes, dry cough, angioneurotic oedema

 TAB PRAZOSIN 2MG TDS

Indications: hypertension

Contraindication: hypersensitivity to prazosin products

Dose: 2mg tds

Route: tablet

Side effects: dizziness, orthostatic hypotension, oedema, palpitations, urinary incontinence,

dyspnoea, headache, lack of energy, nausea

 IV MGSO4 10mmol OD

Indications: treatment and prophylaxis of acute hypomagnesaemia, prevention and

treatment of life threatening seizures in the treatment of toxaemias of pregnancy (pre
eclampsia and eclampsia)

Contraindication: heart block, severe renal impairment, myocardial damage, pregnant

woman prior to delivery

Dose: 10mmol od

Route: intravenous

Side effects: hypermagnesaemia characterised by nausea, vomiting, flushing, thirst,

hypotension, drowsiness, confusion, slurred speech, double vision, bradycardia, muscle
weakness

pg. 10
  TAB SIMVASTATIN 20MG ON

Indications: hypercholesterolemia and coronary heart disease intolerant or not responsive to

other forms of therapy

Contraindication: hypersensitivity to simvastatin products, active liver disease, pregnancy

and lactation

Dose: 20mg on

Route: tablet

Side effects: abdominal pain, flatulence, constipation, headache, hypersensitivity syndrome,

upper respiratory infection, forgetfulness, confusion, increase HbA1c and fasting blood
glucose

 TAB AMLODIPINE 10MG OD

Indications: hypertension

Contraindication: hypersensitivity to amlodipine, symptomatic hypotension, persistent

dermatologic reactions, congestive heart failure

Dose: 10mg od

Route: tablet

Side effects: headache, dizziness, gingival hyperplasia, tachycardia, peripheral oedema

 S/C HEPARIN 5000 UNIT BD

Indications: prophylaxis and treatment of venous thrombosis and pulmonary embolism

Contraindication: hypersensitivity, active bleeding, haemophilia, insufficient blood

coagulation

Dose: 5000 unit bd

Route: subcute

Side effects: haemorrhage, cutaneous necrosis, thrombocytopenia, anaphylaxis,

hyperkalaemia

pg. 11
  IV MEROPENEM 1G TDS

Indications: empirical treatment for presume infections in patients with febrile neutropenia,
monotherapy in combination with anti-viral or anti-fungal agent, septicaemia, serious
infections in renal impaired patients

Contraindication: hypersensitivity to meronem, carbapenems, penicillin or other beta-lactam

antibiotics

Dose: 1000mg tds

Route: intravenous

Side effects: local injection site reactions, rash, pruritus, urticarial, abdominal pain, nausea,
vomiting, diarrhoea, headache, paraesthesia, oral and vaginal candidiasis, reversible
thrombocytopenia, leucopoenia, eosinophilia, neutropenia

 IV PANTOPRAZOLE 40MG OD

Indications: bleeding peptic ulcer and acute stress ulceration

Contraindication: pregnancy, lactation, moderate to severe hepatic or renal impairment

Dose: 40mg od

Route: intravenous

Side effects: GI disturbances such as nausea, vomiting, diarrhoea, constipation, upper

abdominal pain, flatulence, skin rash, pruritus, dizziness, oedema, fever, depression, vision
disturbances, headache, liver enzyme changes, raised triglycerides

 IV CEFEPIME 2G TDS

Indications: febrile neutropenia, septicaemia, lower respiratory tract infection, urinary tract
infection, skin and skin structure infections, gynaecologic and intra-abdominal infections

Contraindication: hypersensitivity to cephalosporins, penicillin or beta-lactam antibiotics

Dose: 2000mg tds

Route: intravenous

Side effects: GI disturbances such as diarrhoea, nausea, vomiting, respiratory and CNS
disorders including headache

pg. 12
D. Investigation

FBC 3/5@2am 3/5@6am 3/5 4/5 5/5 6/5 7/5

post op

HB 11.3 10.9 10.1 9.5 7.6 7.5 8.0

TWBC 9.11 8.21 7.08 8.17 12.5 14.64 12.52

HCT 32.7 31.1 29.1 27.1 22.1 21.1 22.4

PLATLET 310 317 266 214 165 180 210

COAGULATION

PT 15.1 13.8 14.0 11.7 10.6 11.0 11.3

PTT 31.3 32.3 39.6 43.3 33.9 31.9 31.0

INR 1.41 1.26 1.30 1.06 0.96 1.0 1.3

LFT

T.BILI 38.3 31.4

ALT 81 26

ALP 71 168

T.PROTEIN 45 50

BUSE

NA 134 135 139 135 132 132 134

K 4.0 4.1 4.3 3.8 3.6 3.9 3.6

UREA 9.8 10.1 10.5 13.3 15.7 10.8 11.7

CREATININE 106.1 104.4 107.8 138.1 164.2 118.8 64.3

CRCL 55.6 42.7

CL 105 113 109 106 104 104

PHOS 1.63 1.58

CA 2.34 2.34

pg. 13
 DATE INVESTIGATIONS RESULT

30/4/2018 CHEST X-RAY -Haziness at right lung

-No blunted costophrenic angle

2/5/2018 CHEST X-RAY -Poor respiratory effort

-Blunted costophrenic angle

-Post intubation ETT into right

bronchus re-anchored at 18cm

2/5/2018 ECG Sinus tachycardia

2/5/2018 Urine culture and sensitivity Negative

2/5/2018 Blood culture and sensitivity Negative

2/5/2018 Tracheal aspiration culture and Negative

sensitivity

E. Nursing Assessment

pg. 14
1. Current Health Status

Vital sign

i. Body temperature

(Oral/axillary/rectal/ear) : 37.2 ̊ c (axillary)

ii. Pulse/apical pulse : 86 beats/min (radial pulse)

iii. Respiration : 23 respiration/min

iv. Blood pressure : 137 systolic 92 diastolic (mm/Hg)

v. Pain score : scale 2/10 (during movement),

scale 0/10 (in rest)

vi. Weight (kg) & Height (cm) : 99.8kg, 163cm

vii. BMI : 37.5kgm2 (Obese)

Daily Activities

i. Nutrition :-client has good appetite

-client tolerating food well

-client have good fluid intake

ii. Elimination :-client has normal bowel habit except the days she

presented with diarrhoea and went to HKP

-no complaint of abnormalities when passing

urine

-no dysuria or haematuria claimed by client

iii. Sleep/rest :-client have normal sleep pattern and

able to sleep and rest at night

iv. Hygiene :-client is good in her daily self-hygiene and no need

to be assisted

v. Mobility :-client able to ambulate and walk by herself

vi. Lifestyle :-client is a non-alcoholic and non-smoker

pg. 15
vii. Sexual history/activity :-client did not married yet

2) Others :-client has good relationship with her family

3) Immunization :-client’s immunisation is complete

F. Physical Examination

1. General observation

Client is resting well on bed, conscious but not fully alert around her surroundings. Her
airway is assisted by venturi mask and shows good spo2 reading. Client is improving well
after extubated at 7th of May 2018. Client able to open her eyes when called, obey simple
command and able to speak simple words. Bed bath done at morning shift and she is in
good hygiene and no pressure sore noted at any pressure point. There is oedema noted at
client’s upper limbs. Client is using intermittent pneumatic compression devices at both of
her lower limb for the prevention of deep vein thrombosis. Client has intravenous line at
right radial which is her arterial line, central venous line at right IJC both are intact and no
thrombophlebitis noted. Other than that, client is very cooperative in every procedure that
was done to her.

2. Head to Toe assessment

i. Head :-client has good hair hygiene

-no abnormalities found at client’s head

-have small amount of grey hair

due to aging factor

ii. Face :-wrinkly due to aging factor

-client’s has freckles on her face

iii. Eyes :-client claimed that she has good eye sight and clear

iv. Nose :-client has Ryle’s tube at her left nostril

-no discharge was found

v. Mouth :-client’s lips is dry and pale

pg. 16
 -client is not using any dentures

vi. Ears :-client both ears are in good hygiene

-no abnormal discharge was found

-client responds when someone call her

vii. Neck :-client’s neck is in line with the body

and head

-no symptom of thyroid dysfunction

(Goitre) found

viii. Thorax & lungs :-rib cage and sternum are in normal

align

-client’s respiratory rate is normal

-no wheezing sound heard during breathing

ix. Breast & axillae :-no discharge was found

-no lump palpable

-no erythematous skin noted

x. Heart :-client’s blood pressure controlled by hypertensive

medications

-client has normal pulse rate

xi. Abdomen :-client’s abdomen is slightly distended

-progressively improve from before that is

tender to touch and very tense

-drain wounds at right hypochondriac region,

right lumbar region noted with no signs

of infection present

-16cm laparotomy wound intact with no signs of infection

present

xii. Genitalia :-client’s genital area is clean

pg. 17
 -urinary catheter in situ

-no signs of infection noted

xiii. Musculoskeletal :-because client is still very weak, she only

can mobilise both of her hand by raise it up slightly

while on bed when asked

-client still has to be assisted for her daily needs

xiv. Skin & nails :-client’s skin is moist and well hydrated

-client’s nails are short and clean

-no bedsore noted at any pressure points

3. Neurological status :-client is conscious but not alert

-all clients’ 5 senses function well

-client’s GCS score is full E4V5M6

(Post op day 5, post extubation day 1)

4. Mental health status

i. General behaviour :-client shows good behaviour during

interview not agitated and very cooperative

ii. Conversation :-during the interview, I was assisted by client’s niece

so that the interview process will run smoothly

-client only speaks simple words because she still

very weak

-client also communicates non-verbally by using hand gestures

and facial expression

-topic of conversation was about the

client herself and the condition she

encounter

iii. Moods :-client’s emotion is calm during the whole interview

pg. 18
iv. Abnormal belief :-client is not experiencing any abnormal beliefs

v. Orientation :-client is orientated to time, place and person

-client can recognise people around her

vi. Memory :-client has good memory and can remember what happened

to her for the past few days before she intubated at HKP

-client able to answer question that is related to her past

vii. Focus :-client is a bit sleepy during the interview because

she still very weak

-client not able to focus during the whole interview

but she can focus on short period of time

-client still able to answer questions that given to her,

relevant and coherent

viii. Judgement :-client able to give her judgement regarding her condition

and treatment she received

-client satisfied with treatment she received and feel

less pain and more comfortable

ix. Reaction during interview:-client shows willingness to participate

and to be interviewed

-patient comfortable during the whole interview and very

cooperative

Patient weaning process progress

pg. 19
 -Admitted at Hospital Kuala Penyu came with AGE-like symptoms and also on
and off cough
29/5-
1/5/18 -Started intravenous fluid replacement therapy for 2 days then patient started
to have several times of temperature spike and tachypniec
(Hospita
l -Iv Ceftrozidime given with 1 pint of normal saline running for 24 hours

Kuala -Patient intubated with ETT size 7cm, anchored at 19cm due to respiratory
distress
Penyu)
-Supported with Iv Noradrenaline because patient presented with low blood
pressure on post intubation

-Iv Cefepime 2g tds

2/5/18 -Iv Morphine 1g tds

(ETD -Ivd 5 pint normal saline running for 24 hours

QEH2)
-To refer surgical team

-Plan for CT-abdomen

-DXT QID

-Ventilated under SIMV/VC mode

3/5/18 -FIO2 0.6, RR 12, TV 350, I:E RATIO 1:2:0, PEEP 6, O2 FLOWRATE 0.98, PS 0

(GICU, -ABG: PH 7.337, PCO2 24.8, PO2 92.9, HCO3 13.4, B:E -9.9,SPO2 96.9%

OT DAY) -GCS 2T/15(E1VTM1) with pupil bilateral pinpoint(patient sedated and

ventilated)

-Titrate inotropic aim for MAP >65

-Ivd NSD5% 4 pint running for 24 hours, keep patient NBM

-Iv Meropenem 1g tds

-Iv insulin sliding scale 1

-Patient go to OT today

pg. 20
4/5/18 -Ventilated under SIMV/PC mode

(POST OP -FIO2 0.5, RR 12, PS 14, PEEP 6

DAY 1)
-Plan to change ventilator setting to FIO2 0.5, PS 16, RR 16, PEEP 8

-Ivd 1 pint normal saline running for 1 hour

5/5/18 -Ventilated under CPAP mode

(POST OP -FIO2 0.4, RR 12, PS 10, PEEP 8, TV 351, I:E RATIO 1:2:0
DAY 2)
-ABG: PH 7.341, PCO2 24.6, PO2 95.7, HCO3 13.4, B:E -9.8,SPO2 97.2%

7/5/2018 -Ventilated under NIV(Non Invasive Ventilator) mask mode

(POST OP -FIO2 0.4, RR 12, PS 14, PEEP 8, TV 351, I:E RATIO 1:2:0
DAY
-ABG: PH 7.332, PCO2 24.1, PO2 99.8, HCO3 12.9, B:E -10.4,SPO2 97.5%
4,Patient
extubated) -Patient put on venturi mask 50% 8L(day), NIV mask(night)

-GCS E4V5M6(15/15)

-Ivd 3 pint QSD5% + Iv KCL 1g in each pint running at 60cc per hour

8/5/18 -Patient wean off completely to venturi mask only(day and night) at 50% 8L

(POST OP -ABG: PH 7.338, PCO2 23.1, PO2 99.8, HCO3 12.4, B:E -10.2,SPO2 98.5%
DAY 5,DAY 2
-Iv insulin sliding scale 1 decrease to scale 0.5
EXTUBATED)
-Kangaroo feeding through Ryle’s tube 3 hourly then rest (Glucerna)

-Physiotherapy and to teach incentive spirometer

-To transfuse 1 pint packed cell over 4 hour

-Monitor abdominal gert

PROGRESS OF CLIENT IN THE WARD (DAILY NURSING REPORT)

pg. 21
 1. THURSDAY (PM SHIFT)

After taking over report from morning staff nurse, client is resting on bed and unconscious.
Sedated and ventilated under SIMV/VC mode with FIO2 0.6, RR 12, TV 350, I:E RATIO
1:2:0, PEEP 6, O2 FLOWRATE 0.98 and PS 0. Client’s GCS score is 2T/15(E1VTM1) with
pupil bilateral pinpoint. Client is not presented with any shortness of breath with SPO2
reading 96%. ABG result on PM shift is PH 7.337, PCO2 24.8, PO2 92.9, HCO3 13.4, B:E
-9.9. Client is on inotrope support and for titrate if MAP >65. IVD NSD5% 4 pint running for
24 hours and client is keep NBM. Client also is on IVI Meropenem 1g TDS and IVI Insulin
sliding scale one with QID DXT monitoring. Client have intravenous line at right radial which
is her arterial line, central venous line at right IJC both are intact and no thrombophlebitis
noted. Client is waiting to be called by OT department. Other than that, client still presented
with abdominal distension and tense. Client’s skin is intact with no pressure sore noted with
implementation of ripple mattress. Client’s hygiene maintained with ADLs assisted.

2. FRIDAY (PM SHIFT)

After taking over report from morning staff nurse, client is resting on bed and still
unconscious. Today is the client’s post-operation day one. Client has laparotomy wound on
her abdomen, drain wounds at right hypochondriac region and right lumbar region noted
with no signs of infection present. Client is still sedated and ventilated under SIMV/PC mode
with FIO2 0.5, RR 12, TV 350, I:E RATIO 1:2:0, PEEP 8, O2 FLOWRATE 0.98 and PS 10.
Client’s GCS score is still 2T/15(E1VTM1) with pupil bilateral pinpoint because client is still
sedated and unconscious. Client breathes normally and no signs of respiratory distress
noted. Current treatment plan for this client is the same as yesterday plan with addition of
one pint normal saline running for one hour. Both client’s intravenous line is intact and no
signs of infection noted. Other than that, client is still presented with abdominal distension.
Client’s skin is still intact with implementation of ripple mattress. Daily bed bath done at
morning shift.

3. MONDAY (AM SHIFT)

pg. 22
After taking over report from overnight staff nurse, the staff nurse inform that client’s
ventilator mode changed at 5/5/18(Saturday) to CPAP mode with FIO2 0.4, RR 12, TV 351,
I:E RATIO 1:2:0, PEEP 8, O2 FLOWRATE 0.98 and PS 10 as client progressing well in her
weaning process. Client’s ABG result also shows improvement with PH 7.341, PCO2 24.6,
PO2 95.7, HCO3 13.4, B:E -9.8, SPO2 97.2% on Saturday. Today, client is extubated at
11am and ventilator mode change to NIV mode with FIO2 0.4, RR 12, TV 351, I:E RATIO
1:2:0, PEEP 8, O2 FLOWRATE 0.98 and PS 14. Morning shift ABG taken with result PH
7.332, PCO2 24.1, PO2 99.8, HCO3 12.9, B:E -10.4, SPO2 97.5%. Client is put on NIV mode
at night and venturi mask on day. All clients’ treatment plan continues with addition of IVD 3
pint QSD5% plus KCL 1g in each pint. Other than that, client is conscious, respond when
called, able to obey command and resting well on bed. Client is not presented with signs of
respiratory distress and progressing well. Client’s wounds, intravenous lines are intact and
daily bed bath done.

4. TUESDAY (AM SHIFT)

After taking over report from overnight staff nurse, client is conscious and resting well on
bed. Today, client is completely weaned off from ventilator but still supported with venturi
mask 50% in 8L. Today ABG already took with result PH 7.338, PCO2 23.1, PO2 99.8, HCO3
12.4, B:E -10.2, SPO2 98.5%. Client’s IVI Insulin sliding scale 1 decreased to scale 0.5.
Client’s is on Kangaroo feeding through Ryle’s tube for 3 hours then rest. Both client’s drain
on her abdomen had been disconnect and off by doctor. Client also put on pressure cuff on
both of her lower limb for the prevention of deep vein thrombosis. Physiotherapists come
and do passive exercise with client. Client already been teach on how to use the incentive
spirometer by the physiotherapist. Client is due to transfuse one pint packed cells today
waiting for the blood to arrive. Other than that, no signs of respiratory distress, no signs of
infection, no pressure sore noted and daily bed bath done.

G.Nursing Care Plan

pg. 23
 NO DATE NURSING DIAGNOSIS DATE
RESOLVED

1 3/5/2018 Ineffective airway clearance related to 8/5/2018

endotracheal intubation as evidenced by client
present with secretions

2 3/5/2018 Ineffective breathing pattern related to post 8/5/2018

extubation as evidenced by client present with
slightly tachypniec

3/5/2018 Risk for infection related to surgical wounds on 8/5/2018

client’s abdomen post operatively
3

4 3/5/2018 Risk of aspiration related to continuous feeding 8/5/2018

5 3/5/2018 Risk for impaired skin integrity related to less 8/5/2018

mobility

Nursing Care Plan

pg. 24
Date : 3/5/2018

Nursing Diagnosis : Ineffective airway clearance related to endotracheal intubation as

evidenced by client present with secretions

Goal / Expected Outcome : Client will maintain clear, open airway as evidenced by
normal breath sounds after suctioning

Nursing Interventions :

1. Observe the colour, odour, quantity and consistency of sputum

R: Thick, tenacious secretions increase airway resistance and the work of breathing.
A sign of infection is discoloured odoriferous sputum
2. Monitor oxygen saturation prior and after suctioning using pulse oximetry
R: This assessment provides an evaluation of the effectiveness of therapy
3. Assess arterial blood gases(ABGs)
R: Signs of respiratory compromise including decreasing pao2 and increasing paco2
4. Turn the client every 2 hours
R: Turning mobilizes secretions and helps prevent ventilator-associated pneumonia
5. Implement airway suctioning as indicated based on the presence of adventitious
breath sounds
R: Frequency of suctioning should be based on the client’s clinical status. Over
suctioning can cause hypoxia and injury to bronchial and lung tissue
6. Avoid saline instillation before suctioning
R: Saline instillation before suctioning has an adverse effect on oxygen saturation
7. Hyperoxygenated as ordered
R: Hyperoxygenation before, during and after endotracheal suctioning decreases
hypoxia

Evaluation: Client maintain clear and open airway with normal breath sounds after
suctioning

Date : 3/5/2018

pg. 25
Nursing Diagnosis : Ineffective breathing pattern related to post extubation as evidenced
by client present with slightly tachypniec

Goal / Expected Outcome : Client will present with normal breathing pattern with no
signs of respiratory distress

Nursing Intervention :

1. Assess and record respiratory rate and depth at least every 4 hours
R: It is important to take action when there is an alteration in the pattern of
breathing to detect early signs of respiratory compromise
2. Assess ABGs as indicated
R: This monitors oxygenation and ventilation status
3. Place patient with proper body alignment for maximum breathing pattern
R: A sitting position permits maximum lung expansion
4. Encourage deep breathing exercise by utilising incentive spirometer
R: This technique promotes deep inspiration which increases oxygenation
5. Maintain a clear airway by encouraging patient to mobilise own secretions with
coughing exercise
R: This facilitates adequate clearance of secretions
6. Suction secretions as necessary
R: To clear blockage in the airway
7. Help patient with ADLs as necessary
R: To help patient to conserve energy and avoids overexertion and fatigue

Evaluation: At the end of the interventions, client progressively improve as evidenced

by normal breathing pattern with no signs of respiratory distress

Date : 3/5/2018

pg. 26
Nursing Diagnosis : Risk for infection related to surgical wounds on client’s abdomen
post operatively

Goal / Expected Outcome : Client will free from any signs of infection such as purulent
drainage, erythema and fever

Nursing Interventions :

1. Practice good hand washing and aseptic wound care. Provide perineal care

R: To reduce the risk spread of bacteria

2. Inspect incision and dressing. Note characteristics of drainage from wound and any
presence of erythema

R: Provides for early detection of developing infectious process

3. Monitor vital signs. Note onset of fever, chills, diaphoresis, change in mentation and
any reports of increasing abdominal pain

R: Suggestive of presence of infection or developing sepsis or abscess

4. Administer antibiotics as appropriate

R: To help fight infection in client’s body

5. Watch closely for possible surgical complications

R: Continuing pain and fever may signal an abscess

6. Monitor white blood cells count

R: Increased WBCs indicates our body effort to combat pathogen

7. Keep the surgical wounds dry. Wipe with aseptic technique if there is moist area
surround the wounds

R: These steps keep the wounds clean and dry. Clean and dry wounds help prevent wounds
irritation

Evaluation: Client’s surgical wounds still remain free from any infection

Date : 3/5/2018

pg. 27
Nursing Diagnosis : Risk of aspiration related to continuous feeding

Goal / Expected Outcome : Client will remain free from any aspiration related to
continuous feeding

Nursing Intervention :

1. Monitor respiratory rate, depth and effort. Note any signs of aspiration such as
dyspnoea, cough, cyanosis, wheezing or fever
R: Signs of aspiration should be identified as soon as possible to prevent further
aspiration and to initiate treatment that can be life saving
2. Check residuals every 4 hours for continuous feeding. Hold feeding if amount of
residuals is large and notify the physician
R: Large amounts of residuals indicate delayed gastric emptying and can cause
distension of the stomach leading to reflux emesis.
3. Keep suction machine available when feeding high risk patients. If aspiration does
occur, suction immediately
R: A patient with aspiration needs immediate suctioning
4. Inform the physician instantly of noted decrease in cough reflex
R: Early intervention protects the patient’s airway and prevents aspiration
5. Keep head of bed elevated when feeding
R: Maintaining a sitting position after feeding may help decrease aspiration
6. Position patient with decrease level of consciousness on left lateral or right lateral
side
R: This position decreases the risk for aspiration by promoting the drainage of
secretions out of the mouth instead of down the pharynx where they could be
aspirated
7. Stop continual feeding temporarily when turning or moving patient
R: When turning or moving a patient, it is difficult to keep the head elevated to
prevent regurgitation and possible aspiration

Evaluation: Client remain free from aspiration related to continuous feeding

Date : 3/5/2018

pg. 28
Nursing Diagnosis : Risk for impaired skin integrity related to less mobility

Goal / Expected Outcome : Client will remain free from any pressure ulcers

Nursing Intervention :

1. Observe all high risk areas such as bony prominences, skin folds, sacrum and heels
during bed bathing procedure
R: Systematic inspection can identify impending problems early
2. Monitor site that risk for impaired tissue integrity at least once daily for colour
changes, redness, swelling, warmth and pain
R: Specific plan for tissue integrity is necessary to patient’s skin condition and needs
3. Apply topical cream to bony prominence or pressure points
R: To keep the patient’s skin moist
4. Monitors patient’s continence status and minimise exposure at sacral area from
moisture of incontinence and perspiration
R: This is to prevent exposure to chemicals in urine and stool that can strip or erode
the skin
5. Tell patient to avoid rubbing and scratching. Provide gloves or clip the nails if
necessary
R: Rubbing and scratching can cause tissue injury
6. Turn and position patient at least every 2 hours and carefully transfer patient
R: This is to avoid adverse effects of external mechanical forces such as pressure,
friction and shear
7. Implement the use of pillows, ripple mattress and other pressure-reducing devices
R: To prevent pressure injury

Evaluation: At the end of the intervention, client remain free from any impaired
tissue integrity

H.Summary

pg. 29
MS.J that has been diagnosed with septic shock secondary to perforated appendicitis have
successfully went through her operation procedure which is laparotomy appendectomy plus
washout and get her treatment and medication in Queen Elizabeth Hospital 2. MS.J has
achieved most of the goals that I have made and she also gets better progressively by day.
MS.J seems happy because she received good medication and treatment in the hospital and
served respectfully. She also shows positive progress and improvement changes day by day
until 8/5/2018. Now MS.J still receiving treatments at General Incentive Care Unit (GICU)
QEH2 and still managed at GICU for further management until her stable enough to be
transfer to general ward.

I.References

1. KOZIER&ERB’S.Fundamentals of Nursing (8th edition).Upper Saddle River, New Jersey

07458. PEARSON Education.

2. Lippincott Williams and Wilkins.2008.Professional Guide to Disease (9th edition).

United State.Wolters Kluwer Health.

3. JOYCE M.BLACK, JANE HOKANSON HAWKS.MEDICAL-SURGICAL NURSING

(8th edition).Omaha, Nebraska. SAUNDERS ELSEVIER.

4. Textbook of medical-surgical nursing. (2nd edition).Authored by

Basavanthappa, Bengaluru, Karnataka and Goa.published by Jaypee

Brothers Medical Publishers (P) Ltd

5. Cynthia A.Sanoski.Davis’s Drug Guide for Nurses (13th edition).Philadelphia,

Pennsylvania.F.A. Davis.

Student signature & Date :

Supervisor’s comments

pg. 30