Question

A newly admitted patient is in septic shock. Based on his diagnosis of High Risk for Injury (related to clotting disorder). Which of the following are appropriate entries in the nursing care plan? Select All That Apply.

A) Monitor for signs of bleeding
B) Administer anticoagulants
C) Encourage ambulation
D) Apply warm compresses

Answer 1

For a septic shock patient with a clotting disorder, monitoring for bleeding and administering anticoagulants as prescribed are appropriate care actions, alongside careful encouragement of ambulation and application of warm compresses.

Step-by-step explanation:

For a patient in septic shock with a high risk for injury related to a clotting disorder, appropriate entries in the nursing care plan would include the following actions:

• Monitor for signs of bleeding: Keeping a close watch for any signs of bleeding is crucial due to the patient's clotting disorder, which can be exacerbated by septic shock.
• Administer anticoagulants: If prescribed by the physician, anticoagulants may be given, but with caution, considering the patient's bleeding risk must be balanced with the need to prevent clots.
• Encourage ambulation: This may help to prevent blood clots, but should be done carefully considering the patient's overall condition and stability.
• Apply warm compresses: This can help with circulation and comfort, but should not interfere with clotting processes.

Considering the patient's high risk of injury from a clotting disorder, interventions must be carefully selected to address both the potential for bleeding and clot formation.