Assessment Data
R.M. was admitted to Mercy Medical after being diagnosed with sepsis. According to his
chart, he just felt ill, like the flu, with rigor and chills. His wife noticed gangrenous changes
occurring to the second toe on his right foot. He quickly started to become confused at which
point his wife brought him to the emergency room. He presented with a fever of 103.1 F, HR-99,
BP that fluctuated between 165/75-193/64.
Sepsis occurs when microorganisms invade the body and initiate a systematic
inflammatory response. When the microorganisms enter the system, they trigger the
inflammatory response and the ensuing release of toxins causes a cascade effect that affects
clotting, causes severe vasoconstriction and cellular hypoxia. This leads to cell death, which
furthers the cascade effect. Left unchecked, the body enters a state of extreme vasodilation,
causing the blood pressure to bottom out and perpetuate the cellular hypoxia. Signs and
symptoms of sepsis include a high temperature, increased heart rate and respiratory rate and a
high white blood cell count (Lough, Stacy, Urden 2010). R.M.’s lab values still show the effects
of the sepsis with his diminished lung sounds, weakness and high WBC count but for the most
part he has responded very well to treatment. He has been taking broad spectrum antibiotics
(Zosyn) to combat the infection. His was scheduled for surgery on his 2nd toe on his right foot.
The surgeon will attempt to save the toe but he will most likely have to amputate due to the
advanced stage of gangrene. His RBC is low for which he has been receiving packed red blood
cells.
R.M. is a 69 year old male admitted for sepsis. He is a current smoker and smokes 1 pack
per day. His vitals are BP 142/67, T-98.2, P-84, R-20, O2 Sat- 95%, Pain-0. Skin is cool and dry
with skin turgor <3 seconds and capillary refill <3 seconds. Radial pulses +2 bilaterally. 1st and
3rd digits of right foot red and purple colored, warm to touch. 2nd digit of right foot black and
gangrenous, no drainage. #22 gauge heplock, rt. Forearm. Left AV fistula intact with bruit. Heart
sounds rhythmic with atrial flutter. Lung sounds diminished on right side with inspiratory
wheezes. Left side lung sounds diminished. Breathing is normal and unlabored on room air.
Occasional nonproductive cough. Bowel sounds regular x4. Patient states that he is voiding
without difficulty. Pt. does not have a catheter. R.M. is up ad lib to chair and bathroom. Hand
grasps strong bilaterally, legs weak bilaterally. Pupil response brisk and even. Pt. has cataracts
and does not wear glasses. Speech is clear and appropriate. Pt. is NPO in preparation for possible
femoral popliteal and tibial bypass.
His blood pressure is still high from a combination of the sepsis as well as his history of
hypertension and high cholesterol. His chart did not explain how the infection in his toe started
but in all likelihood it began as a result of his peripheral neuropathy. Caused by diabetes, the
neuropathy is the result of the reduced blood flow to his extremities. The tissue would then begin
to die and would be very susceptible to infection. This is probably the source of the sepsis as the
infection became systemic. With sepsis, the increased capillary permeability causes fluid to be
forced into the interstitial spaces. This fluid would also accumulate in the lungs, as in R.M.’s
case. The diminished sounds and inspiratory wheezes are a result of the fluid. The sepsis is also
the reason he is experiencing weakness in his lower extremities.
Primary Nursing Diagnosis: Risk for complications of sepsis r/t gangrene of 2nd toe on right
foot.
Definition: Describes a person experiencing or at high risk to experience a systemic
response to the presence of pathogenic bacteria, viruses, fungi or their toxins. The
microorganisms may or may not be present in the blood stream. (Carpenito 2010).
AEB: Gangrene of 2nd toe on right foot. Pt. history of type 2 diabetes and peripheral
neuropathy place patient at increased risk for complications. Pt. is an advanced age and also has
end stage kidney failure, lowering his ability to fight infection as well.
Short term goal: Pt. will not experience further signs and symptoms of infection during
hospital stay.
Outcome Criteria: Temperature below 99 F, heart rate between 60-100, oxygen saturation
>95%. White blood cell count below 10,000. Pt. will not experience changed mental status or
increased weakness, malaise or hypothermia.
Interventions: Assessed patient vital signs every hour and performed assessment every
two hours. Applied Mupirocin to pedal wounds and changed dressing. Administered Zosyn
(broad-spectrum anti-infective) to prevent further infection.
Evaluation: Pt. vital signs stayed within normal limits during shift and patient
experienced no change in mental status or showed increased weakness, malaise or hypothermia.
6 Nursing Diagnoses
1.
2.
3.
4.
5.
6.
Risk for ineffective respiratory function r/t decreased lung sounds and history of asthma.
Risk for complications of decreased cardiac output r/t atrial fibrillation.
Risk for infection r/t upcoming surgery
Ineffective peripheral tissue perfusion r/t diabetic peripheral neuropathy.
Risk for ineffective fluid balance r/t end stage kidney failure.
Risk for falls r/t lower extremity weakness
What I would do differently
The primary thing I would do differently is promote coughing and deep breathing more
effectively to help clear out R.M.’s lungs. That would help speed his recovery and increase tissue
perfusion.
References
Carpenito, L.J. (2010). Nursing Diagnosis: Application to Clinical Practice. Lippincott,
Williams and Wilkins, Philadelphia, Pennsylvania.
Deglin, J.H, Sanoski, C.A., Vallerand, A.H. (2011). Davis’ Drug Guide for Nurses, 12th Edition.
F.A. Davis Company, Philadelphia, Pennsylvania.
Lough, M.E., Stacy, K.M., Urden, L.D. (2010). Critical Care Nursing: Diagnosis and
Management. Mosby Elsevier, St. Louis, Missouri.