63
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Nursing care plan for a patient with septic
shock: case report
Álvaro Javier Coral Revelo1
Jesús Eduardo Morán Castro2
Norma Viviana Moreno Montenegro3
To reference this article / Cómo citar este artículo /
Para citar este artigo: Coral-Revelo, Á. J., Morán-Castro,
J. E., & Moreno-Montenegro, N. V. (2025). Nursing care plan
for a patient with septic shock: case report. Revista Criterios,
32(2), 63-75. https://doi.org/10.31948/rc.v32i2.4231
Reception date: June 7, 2024
Fecha de revisión: September 28, 2024
Fecha de aprobación: May 8, 2025
Abstract
Septic shock is a critical condition that requires personalized nursing care in
the intensive care unit (ICU) due to hemodynamic compromise. This case study
aimed to document the nursing interventions provided to a patient with septic
shock admitted to an ICU in southwestern Colombia in 2023. An observational
and descriptive methodology was employed, during which a nursing care plan
was implemented based on the NANDA-NIC-NOC taxonomy. Additionally, a
systematic assessment was conducted according to Marjory Gordon’s functional
health patterns. In this case, a patient with septic shock due to peritonitis
received nursing care in the ICU, including antibiotics and other clinical care.
After executing the nursing activities, it was determined that the interventions
were sufficient to meet the care objectives. Based on the physiological and
psychological needs of the individual, it is concluded that nursing care for this
type of patient is indispensable and requires solid knowledge on the part of the
nursing staff.
Keywords: septic shock; pelvic infection; critical care; nursing care
1 Nurse, Traumedical.
2 Nurse, Hospital Civil de Pasto. E-mail: jesus.eduardo.moran@gmail.com
3 Master in Health Administration. Professor, Universidad Mariana. E-mail: nomoreno@umariana.edu.co
Case report article, result of research conducted by the Specialization in Nursing for the Care of Critically Ill Patients: Estudio
de caso: paciente con shock séptico por Escherichia coli Enteropatógena, atendido en la UCI en una institución de III nivel de
atención, año 2023.
64
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Plan de cuidados de enfermería para un
paciente con choque séptico: caso clínico
Resumen
El choque séptico es un estado crítico en el que el paciente presenta compromiso
hemodinámico, lo cual requiere de cuidados personalizados de enfermería en la
unidad de cuidados intensivos (UCI). Por lo tanto, el objetivo del presente estudio
de caso fue establecer las intervenciones del profesional de enfermería en un
paciente con choque séptico internado en la UCI de una institución de salud del
suroccidente colombiano en el año 2023. Para ello, se empleó una metodología
de tipo observacional y descriptiva, en la cual se aplicó un plan de cuidados
de enfermería, mediante el uso de la taxonomía NANDA-NIC-NOC; además, se
realizó una valoración sistemática basada en los patrones funcionales de salud
de Marjory Gordon. En este caso, se brindó cuidado de enfermería a un paciente
que presentaba choque séptico secundario a peritonitis. El paciente fue tratado
con antibiótico y cuidados clínicos en la UCI. Una vez ejecutadas las actividades
de enfermería, se comprobó que las intervenciones fueron adecuadas para
alcanzar los objetivos de cuidado propuestos. Finalmente, se concluye que el
cuidado de enfermería en este tipo de paciente es indispensable y requiere de
conocimientos sólidos por parte del personal de enfermería, basados en las
necesidades fisiológicas y psicológicas del individuo.
Palabras clave: choque séptico; infección pélvica; cuidados críticos; atención
de enfermería
Plano de cuidados de enfermagem para um
paciente com choque séptico: relato de caso
Resumo
O choque séptico é uma condição crítica que exige cuidados de enfermagem
personalizados na unidade de terapia intensiva (UTI) devido ao comprometimento
hemodinâmico. Este estudo de caso teve como objetivo, documentar as
intervenções de enfermagem fornecidas a um paciente com choque séptico
internado em uma UTI no sudoeste da Colômbia em 2023. Foi empregada
uma metodologia observacional e descritiva, durante a qual foi implementado
um plano de cuidados de enfermagem com base na taxonomia NANDA-NIC-
NOC. Além disso, foi realizada uma avaliação sistemática de acordo com os
padrões de saúde funcional de Marjory Gordon. Nesse caso, um paciente com
choque séptico devido a peritonite recebeu cuidados de enfermagem na UTI,
incluindo antibióticos e outros cuidados clínicos. Após a execução das atividades
de enfermagem, foi determinado que as intervenções foram suficientes para
atender aos objetivos do atendimento. Com base nas necessidades fisiológicas
e psicológicas do indivíduo, conclui-se que a assistência de enfermagem a esse
tipo de paciente é indispensável e exige sólidos conhecimentos por parte da
equipe de enfermagem.
Palavras-chave: choque séptico; infecção pélvica; cuidados críticos; cuidados
de enfermagem
65
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Introduction
According to the Pan American Health
Organization (PAHO) and the World Health
Organization (WHO) (n.d.), septic shock is so
serious that it increases the risk of mortality:
Each year, approximately 31 million people
have an episode of sepsis. Of these, about
6 million people die from sepsis. In low and
middle-income countries, the burden of
sepsis is higher and represents one of the
leading causes of maternal and neonatal
death. Despite this, it is very difficult to
assess the burden of disease worldwide due
to limitations in diagnosis and notification.
(para. 6)
«Sepsis is the systemic response to infection»
(Espinoza et al., 2015, p. 5), presenting with
two or more of the following conditions:
1. Heart rate > 90/min
2. Respiratory rate > 20/min or PaCO2 < 22
mm Hg
3. Leukocytes > 12,000 mm3, < 4,000 mm3,
or > 10% band cells
4. Temperature above 38.3 °C or below 36
°C. (Sanabria et al., 2015, p. 31)
Septic shock is a leading cause of morbidity and
mortality in hospitals. It is a severe condition
involving hemodynamic compromise:
Sepsis-induced hypotension (systolic blood
pressure < 90 mm Hg or a reduction of 40
mm Hg from baseline) despite adequate fluid
resuscitation. With perfusion abnormalities
that may include (but are not limited to)
lactic acidosis, oliguria, or acute altered
mental status. (Sanabria et al., 2015, p. 31)
It is important to have a professional team with
adequate knowledge to make an early diagnosis
and evaluation and provide timely treatment.
This ensures a comprehensive approach
for the patient, since it is a time-dependent
pathology. Interventions aimed at managing,
prognosing, and evolving the condition depend
on early diagnosis and the initiation of effective
treatment and care.
In a study carried out in Mexico by González et
al. (2020), it was found that the mortality rate
was higher in patients over 65 years of age
with septic shock (67.5%), compared to those
under 65 years of age (36%). These patients
had comorbidities, such as type 2 diabetes
mellitus and systolic arterial hypertension.
Notably, the abdominal origin of septic shock
was the most frequent, at 39.7% in patients
under 65 years of age and 62.5% in patients
over 65 years of age.
Another study conducted in Quito by Ruilova
et al. (2021) states that healthcare providers
caring for patients with this condition should
have access to updated information to help
improve patient outcomes.
Font et al. (2020) report that 1.7 million cases
of sepsis are admitted to intensive care units
(ICUs) in the United States annually, with an
increasing trend every year. Almost 250,000
people die from this condition each year,
making it the leading cause of death in non-
cardiac ICUs. This emphasizes the importance
of nursing care for patients with septic shock
and the need for comprehensive care to ensure
positive outcomes.
A study by Soto et al. (2022) in Colombia reports
that the main foci of sepsis were pulmonary
(38.5%), urinary (16.3%), and biliary (10.4%).
Isolations of Escherichia coli, Staphylococcus
aureus, and Streptococcus pneumoniae also
predominated. Additionally, the mortality rate
was 18.5%.
The study by Rangel-Vera et al. (2019) points out
that the incidence of this event is increasing due
to the rapid aging of the population. The authors
found that 60% of septic patients are 65 years
of age or older. Additionally, comorbidities and
immunosuppressive treatments are present.
Intra-abdominal infections were the most
frequent cause at 18.6%, followed by hospital-
acquired pneumonia at 17% and community-
acquired pneumonia at 12.4%.
In Cali, Colombia, the abdominal cavity was
the most common septic focus among ICU
patients, according to the study by Chávez-
Vivas et al. (2018). It should be noted that the
causative microorganisms corresponded to
66
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Gram-negative bacteria, with E. coli being the
most frequent, at 19.2%.
According to the Instituto Departamental de
Salud de Nariño (IDSN, 2022), there were two
cases of sepsis in the department of Nariño in
2018 and 51 cases in 2022. Notably, the most
frequent age range was 60 years or older.
Similarly, in the city of Pasto, there was one
case of septic shock in the 27-44-year age
range in 2018; however, the number of cases
increased to 16 in 2022. These data show that
older people are most likely to suffer from this
clinical condition.
Because sepsis is a critical condition that
severely affects a person, nursing care plays
an essential role. Therefore, it is a priority for
nurses to promptly identify the early signs and
symptoms of infection, as doing so may allow
for the implementation of interventions that
prevent the condition from progressing to a
more serious state (Suarez, 2023).
In this context, developing a care plan based
on the NANDA, NIC, and NOC taxonomies
provides a structured guide for clinical decision-
making. This approach favors personalized,
effective, and evidence-based interventions
that identify not only physical needs but also
emotional and social needs. This contributes to
humanized care. The objective is to establish
the interventions of the nursing professional for
a patient with septic shock who is hospitalized in
the ICU of a health institution in southwestern
Colombia in 2023.
Methodology
Observational, descriptive case study, oriented
to a patient attended in the ICU of a third-level
public hospital in the city of Pasto, Nariño,
Colombia, during the year 2023. During this
time, through the Nursing Care Plan (PAE),
comprehensive care was implemented during
her stay in the ICU. The assessment was
based on Marjory Gordon’s conceptual model.
The NANDA, NOC, and NIC taxonomies were
utilized to document the nursing interventions.
(Butcher & Moorhead, 2021).
Results
Case description
A 19-year-old patient with a pathological
history of polycystic ovary syndrome consulted
at the first level of care for abdominal pain in
the epigastrium, associated with discomfort
and vomiting. Despite receiving outpatient
treatment, her condition worsened. The following
day, she returned due to continued pain; an
ultrasound of the abdomen was performed,
which was positive for urinary tract infection
(UTI), with positive uroculture, isolation of
Escherichia coli sensitive to cephalexin. She
was discharged for outpatient management
again, but she decided to consult a third time
due to a worsening of her clinical condition.
She presented with increased abdominal pain,
vomiting, dehydration, mucocutaneous pallor,
and refractory hypotension; therefore, she was
referred as an emergency.
Upon admission to the Level III clinic, the patient
was in poor condition. She was hypotensive with
a mean arterial pressure (MAP) of 50 mmHg,
which was refractory to volume. She required
titratable vasoactive support to improve her
MAP and perfusion. She was also dehydrated
and had acidosis that was compensated by
hyperlactatemia, as well as signs of shock. The
physician decided to admit her to the ICU for
invasive monitoring and mechanical ventilation.
The diagnosis was septic shock of an abdominal-
pelvic focus, with a Sequential Organ Failure
Assessment (SOFA) score of seven.
Valuation
A nursing assessment was performed using
anamnesis, a physical examination, and
data from the reviewed medical records.
The nursing care plan was based on Marjory
Gordon’s conceptual model of functional
health patterns (Álvarez et al., 2010). The data
obtained from the pattern-based assessment
are detailed below:
67
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Pattern 1. Health perception-management
The patient has no known drug allergies; she
has a pathological history of polycystic ovary
syndrome; leukocytosis and neutrophilia are
present.
Pattern 2. Metabolic Nutrition
• Size: 1,60 cm
• Weight: 50 kg
• Body mass index: 19.8 (adequate).
• Presence of parenteral nutrition by central
venous catheter, located in the subclavian
region.
• In the operating room, exploratory
laparoscopy, laparotomy, appendectomy,
release of adhesions, and peritoneal
lavage were performed, which showed
pelviperitonitis, bilateral salpingitis,
edematous cecal appendix, peritoneal fluid
of serous inflammatory reaction, 500 cc.
• After surgery, the patient presented soft
abdomen, depressible, surgical wound
in the midline of approximately 10 cm,
covered with sterile dressing, without
bleeding, with a Hemovac drain in the
right hemiabdomen with serohematic
production.
Pattern 3. Elimination
• Carrier of Foley urethral catheter type N.◦
16, coluric urine, without sediment.
• Urine culture report of Escherichia coli
sensitive to cephalexin.
• Positive ultrasound of abdomen for urinary
tract infection (UTI), with positive urine
culture.
• Patient under mechanical ventilation, CT
of the thorax with report of pulmonary
atelectasis and mild pleural effusion.
Pattern 4. Activity-exercise
• Mean arterial pressure on admission: 50
mmHg
• Heart rate: 115 bpm
• Respiratory rate: 16 rpm and oxygen
saturation at 96% under mechanical
ventilation
• Mobility: limited, patient under sedation,
with assessment according to the
Richmond Agitation and Sedation Scale
(RASS) at -4
• Braden score of 9: high risk.
Pattern 5. Sleep-rest
Patient at the time of assessment under
sedoanalgesia.
Pattern 6. Cognitive-perceptual
• Unconscious, Glasgow 3/15 under
sedoanalgesia (fentanyl 100 mcg/hour,
midazolam 10 mg/hour).
• Rass at -4 (no response to verbal call, but
with response to physical stimulus); refers
to slight residual pain in the perineal area
of up to 3 points out of 10 on a verbal
numerical scale, which is controlled using
prescribed analgesia.
• For hypotension with vasopressor support,
noradrenaline 0.1 mcg/kg/min.
• SOFA Score with a value of 7.
Pattern 7. Self-perception - self-concept
Patient does not refer, due to her clinical
condition.
Pattern 8. Role relationships
The patient was accompanied by her mother
and sister, with whom she shares a family unit.
Pattern 9. Sexuality-reproduction
Gestations: 1
Abortions: 1
Births: 0
68
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Cesarean Sections: 0
Alive: 0
Pattern 10. Stress coping-tolerance
Due to the patient’s unstable condition at the time, this pattern was not assessed.
Pattern 11. Values-beliefs
The family members state that they belong to the Catholic religion.
After performing the analysis of the data collected, dysfunctional patterns were identified, namely:
• Pattern 2. Nutritional-metabolic
• Pattern 3. Elimination
• Pattern 4. Activity-exercise
• Pattern 6. Cognitive-perceptual.
Pathology study
The patient’s septic shock was caused by an infection of the pelvic peritoneum (pelviperitonitis).
Inflammatory septic involvement of the internal genitalia and adjacent organs was found. The
most common cause is an ascending infection resulting from an alteration in the balance of normal
vaginal flora or structural changes (Puente et al., 2021).
The patient initially presented with appendicitis caused by an obstruction of the proximal lumen of
the appendix. In these cases, two processes occur:
a. Over distension and increased intraluminal pressure, which produces increased secretion
in the appendicular mucosa, where visceral afferent pathways are activated and result in
nonspecific visceral pain.
b. Vascular engorgement and congestion of the lymphatic, venous, and arterial vessels increase
pressure, resulting in ischemia, necrosis, and perforation. Additionally, bacterial proliferation
occurs, which the body attempts to control. This process generates an appendicular plastron
and stromal tissue, where inflammatory substances are released. This produces a tissue
response, including exudate and fibrin. These substances cause the migration of macrophages,
neutrophils, and fibroblasts, which form collagen. This results in appendicular phlegmon,
which is formed by the omentum, terminal ileum loops, colon, and inflamed appendix (Puente
et al., 2021).
This process forms a purulent secretion in the cavity, creating an appendicular abscess and allowing
microorganisms, such as Escherichia coli, to migrate to the peritoneal cavity. The migration of
microorganisms and the proximity of structures affect the fallopian tubes, causing an inflammatory
reaction with vasodilation, plasma transudation, and purulent exudate within the open tubal lumen.
The exudate then leaks through the fimbriae into the pelvic cavity, ultimately causing pelvic
peritonitis (Chiscano-Camón et al., 2022).
69
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Figure 1
Pathophysiology of septic shock associated with pelviperitonitis
Note. Taken from Chiscano-Camón et al., 2022.
The body’s advanced response to microorganisms allows pathogen-associated molecular patterns
(PAMPs) to be recognized by cells of the innate immune system. PAMPs are present in the
lipopolysaccharides of bacterial cell walls and are recognized by cells such as leukocytes. This
recognition occurs through pattern-recognition receptors (PRRs), including Toll-like receptors
(TLRs), NOD-like receptors (NLRs), and C-type lectin receptors (CLRs). These receptors activate
two main types of immune response:
1. They bind with PAMP, triggering an inflammatory response.
2. They produce inflammatory mediators that stimulate other lymphocytes, activating them. Upon
activation, these lymphocytes release cytokines that increase the inflammatory response,
causing further damage.
This response chain also includes damage-associated molecular patterns (DAMPs), which can cause:
1. Activation of lymphocytes to create new pattern recognition receptors TLR (Toll-like receptors),
NLR (NOD-like receptors), CLR (C-type lectin receptors), and continuation of the response.
2. They cause endothelial dysfunction, allowing plasma to leak into the extravascular space. As
a result, tissue edema and an increase in diffusion distance occur, as the accumulated fluid
separates the vessel walls from the surrounding cells.
This is triggered by difficulty passing oxygen into the cell. Decreased oxygenation leads to
vasodilation, hypotension, and hypovolemia. Additionally, there is a decrease in proteins, such as
protein C, as well as in fibrinolysis.
70
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Similarly, difficulty in oxygen transfer leads to altered mitochondrial function. This is characterized
by increased electron transport chain activity, decreased ATP production, and increased release
of hydrogen ions and lactate. These changes trigger definitive alterations in microvascular flow
(Chiscano-Camón et al., 2022).
Nursing care plan for the patient with septic shock
After examining the patient and reviewing the clinical data recorded in the medical history, we
developed a care plan that considered the activities to be carried out in an interdependent manner.
Table 1
Nursing care plan for the patient with septic shock
Diagnosis NOC
(Results)
NIC
Intervention Activity
Domain 03: Disposal
and Exchange
Need 01: breathe
normally
Pattern 04: activity
and rest
Class 04:
Respiratory function
Diagnosis 00030:
oxygen support
deficit R/C pleural
inflammatory
process S/A,
infectious process
Domain 02:
Physiological
health
Pattern 04:
activity and rest
Class E:
cardiopulmonary
NOC 0402:
monitor
respiratory status
(gas exchange)
Class K:
respiratory
control
NIC 3350:
oxygen
monitoring
NIC 3320:
oxygen
therapy
Administration of medications
such as antibiotics, diuretics, and
vasoactive drugs
Suctioning of secretions
Prepare the O2 equipment and
administer through a humidified
system
Watch for signs of hypoventilation
Observe signs of toxicity in the
patient
Use nebulizers
Determine the need for aspiration
Hyper oxygenate between each
suction pass and after the last
pass
Record the type and amount of
secretions aspirated.
71
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Diagnosis NOC
(Results)
NIC
Intervention Activity
Domain 11: Safety
and security
Need 08: hygiene/
skin
Pattern 02:
Nutritional metabolic
Class 02: physical
injury
Diagnosis 00047:
Risk of skin integrity
impairment R/C
decreased physical
mobility
Domain 02:
Physiological
health
Pattern 02:
Nutritional
metabolic
Class L: Tissue
integrity
NOC 1101: Skin
condition
Class L: skin
and wound
control
NIC 3590:
monitoring
skin integrity
Class V: risk
control
NIC 3540:
prevention
of pressure
ulcers
Place the patient on a suitable
therapeutic bed/mattress
Position the patient with proper
body alignment
Keep bedding clean, dry, and
wrinkle-free
Monitor skin condition
Postural changes at least every
two hours
Help with hygiene measures
Perform a thorough assessment
of peripheral circulation (check
peripheral pulses, edema,
capillary refill, color, and
temperature of extremities)
Apply anti-embolism measures
Eliminate excessive moisture on
the skin
Inspect the skin on bony
prominences and areas of
pressure/friction
Domain 04: activity/
rest
Need 04: move
Pattern 04: activity/
rest
Class 5: Self-care
Diagnosis 00182:
Self-care deficit R/C
sedation, manifested
by total dependence
for basic self-care
activities
Domain 01:
Functional health
Pattern 04:
Activity/Exercise
Class D: Self-care
NOC 0300: Self-
care, feeding,
bathing, dressing,
elimination
Class F:
Facilitating
self-care
NIC 1800:
Assistance
with self-care
Make sure the person receives
the proper nutrition according to
the doctor’s orders
Instruct support staff on the
water temperature for bathing
Provide privacy during bathing
and observe the condition of the
skin (at the time of integration)
Obtain comfortable clothing
(hospital gown)
Keep track of urine and fecal
output
Monitor fluid intake
Monitor urine retention
Monitor kidney function tests and
report
Position changes to prevent
pressure ulcers (PUs)
Skin hydration
72
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Diagnosis NOC
(Results)
NIC
Intervention Activity
Domain 04: activity/
rest
Need 01: breathe
normally
Pattern 01:
perception of health
management
Class 04:
cardiovascular/
pulmonary
responses
Diagnosis 00228:
risk of ineffective
tissue perfusion R/C
decreased mean
arterial pressure
Domain 02:
Physiological
health
Pattern 01:
perception
of health
management
Class E:
Cardiopulmonary
NOC 0422:
Monitor perfusion
status
Class N:
perfusion
control
Code 0422:
hemodynamic
monitoring
Monitor level of consciousness
Keep head elevated at 30-45°
Keep head and trunk aligned to
avoid jugular compression
Monitor vital signs
Observe the need to administer
active vasopressors
Avoid hyperglycemia or
hypoglycemia
Maintain oxygen saturation above
93%
Monitor lactate (currently at 0.8
mmol/L)
Monitor arterial gases
Monitor electrocardiographic
recording (patient with sinus
tachycardia)
Prevent fever
Ensure good oxygenation: patient
saturated at 92%, with FiO2 30%
and hemoglobin value at 8.2 g/
dL.
Maintain TAM above 70 mmHg
Monitor the patient’s blood
volume
Avoid hypoxemia
Note. Based on Butcher and Moorhead (2021).
Evaluation of interventions
After undergoing surgery and staying in the ICU, the patient had a remarkable recovery. With the
help of various healthcare professionals, including nursing staff, all of her needs were addressed
effectively. Notably, the patient did not develop pressure ulcers, and her nutritional status was
optimal. Additionally, she achieved adequate elimination, and a significant improvement in
spontaneous ventilation was observed, contributing to her recovery.
Discussion
This case study focuses on a 19-year-old female patient who was diagnosed with septic shock of
abdominal origin secondary to pelviperitonitis. According to Enríquez (2019), this type of shock has a
poor prognosis because it is a systemic response to an infectious process. However, early detection
and appropriate intervention can help maintain physiological balance and prevent complications.
73
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
On the other hand, as Macas et al. (2021)
mentioned, septic shock is one of the most
frequent causes of mortality. Despite advances in
scientific knowledge and available technological
means, there has been an increase in cases in
recent years.
Therefore, early diagnosis is essential. In
this case, the patient was initially diagnosed
with a urinary tract infection that became
complicated over time. This coincides with the
case of a patient classified as having an acute
inflammatory abdomen who was not given
adequate treatment, leading to complications,
as reported by Haro et al. (2021).
Similarly, Llamas et al. (2022) describe the
case of a 23-year-old female patient who
received empirical treatment with ceftriaxone
and doxycycline due to clinical suspicion of
complicated pelvic inflammatory disease.
However, due to her poor progress, an
exploratory laparoscopy was performed. During
the procedure, a sample of peritoneal fluid was
obtained for culture, and the patient received
appropriate pharmacological treatment.
Puente et al. (2021) point out that making a
correct diagnosis is challenging in clinical
practice because numerous pathologies cause
abdominal pain. If not treated promptly, these
pathologies can lead to septic shock. It is
also important to consider the professional’s
diagnostic capacity and knowledge to ensure
timely and appropriate care.
Various case studies of septic shock reveal
similarities in the signs and symptoms presented
by patients, though these depend on the
affected organ or system. Enríquez (2019), for
example, argues that septic shock of abdominal
origin manifests with abdominal pain, low blood
pressure, and abdominal distension.
In this case, the patient remained with a
Hemovac drain in the right hemi abdomen,
with serosanguineous discharge. She also
received broad-spectrum antibiotic treatment
while awaiting the results of the peritoneal fluid
culture. Once the results were obtained and
Escherichia coli was identified, treatment with
carbapenems was initiated to cover anaerobes.
According to Restrepo-Álvarez et al. (2019),
Escherichia coli is a common cause of a wide
range of infections, from uncomplicated urinary
tract infections to severe sepsis and septic
shock. These infections are associated with
high-impact outcomes, such as ICU admission
and mortality. León-Ruiz et al. (2000)
indicate that the female genital tract is the
most common entry point for Gram-negative
bacteria. Therefore, a thorough gynecological
examination should be performed in cases of
sepsis caused by these microorganisms.
Similar to the study conducted by Enríquez
(2019), in which the patient was discharged
in a hemodynamically stable condition,
the patient in this clinical case improved
significantly as a result of teamwork,
treatment, and appropriate care. Several
factors influence the outcome of patients’
clinical conditions, including age, underlying
conditions, care, and treatment provided.
Conclusions
This case study emphasizes the importance of
taking a thorough medical history, performing
a physical examination, conducting a general
assessment, and using diagnostic tools. These
steps facilitate early diagnosis and enable
rapid, priority care depending on the patient’s
condition and complexity. It also highlights the
need to perform a comprehensive assessment
of patients with abdominal pain to prevent
complications, stabilize them promptly, and
promote a favorable outcome and prognosis.
The development of an individualized nursing
care plan made it possible to identify
problems, establish nursing diagnoses, and
define interventions that optimized the care of
this patient with septic shock, which requires
nursing staff to have up-to-date and sufficient
knowledge to contribute to improving the
patient’s quality of life and promoting rapid
recovery.
Conict of interest
None declared by the authors.
74
Álvaro Javier Coral Revelo
Jesús Eduardo Morán Castro
Norma Viviana Moreno Montenegro
Nursing care plan for a patient with septic shock: case report
Revista Criterios - vol. 32 n.o 2 Julio-Diciembre 2025 - pp. 63-75
Rev. Criterios ISSN: 0121-8670, e-ISSN: 2256-1161
https://doi.org/10.31948/rev.criterios
Ethical Responsibilities
The patient’s consent was obtained before
sharing any information related to the case
study analyzed. The study was based on
Resolution 8430 of 1993.
Sources of funding
The authors declare that they have not received
any financial support for this work.
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Contribution
Álvaro Javier Coral Revelo: preparation of the
introduction, results, discussion, conclusions,
and bibliographical references.
Jesús Eduardo Morán Castro: preparation
of the introduction, results, discussion,
conclusions, and bibliographical references.
Norma Viviana Moreno Montenegro:
development of methodology, critical review
of article, participation in introduction,
methodology, analysis of results, discussion,
and conclusions.
The authors participated in the preparation of
the manuscript, read it, and approved it.