Jack Holmes Sepsis|Septic Shock UNFOLDING Reasoning | Primary Concept | Perfusion | Interrelated Concepts

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Sepsis|Septic Shock UNFOLDING Reasoning Case Study STUDENT Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Inflammation • Infection • Tissue Int... egrity • Clinical Judgment • Patient Education • Communication NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment ✓ Management of Care 17-23% ✓ ✓ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity ✓ Basic Care and Comfort 6-12% ✓ ✓ Pharmacological and Parenteral Therapies 12-18% ✓ ✓ Reduction of Risk Potential 9-15% ✓ ✓ Physiological Adaptation 11-17% ✓ History of Present Problem: Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to wake him this morning, he would not respond, and his BP was 74/40 with a MAP of 51. He has a history of Parkinson’s disease, COPD, CHF, HTN, depression, and a stage IV decubitus ulcer on his coccyx that developed three months ago. He does not follow commands, is unresponsive to verbal stimuli, but responds to a sternal rub with grimacing and withdrawing from stimulus. Personal/Social History: He has lived in the skilled nursing facility the past three years and has been bed bound the past year due to his advanced Parkinson’s disease. He was a heavy smoker, 1 PPD for 40 years until he moved to the SNF. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: BP of 74/40 (51) Stage IV decubitus ulcer on coccyx – bed bound Only responsive to sternal rub – grimacing and withdrawing from stimulus COPD, HTN, CHF, old age, and Parkinson’s Low blood pressure and low MAP – indicator of poor perfusion Has had stage IV ulcer for 3 months. No signs of healing – could be due to poor perfusion, poor nutrition, poor wound care, or not participating in q2 turns while bed bound. Poor skin integrity. Unresponsive to anything other than a sternal rub is a sign of an altered level of consciousness – assuming that this is not baseline for this patient. Comorbidities that can relate to a decrease in immune function. RELEVANT Data from Social History: Clinical Significance: Lives in SNF for past 3 years Bed bound Depression Higher risk for infection or illness due to exposure and living conditions at facility Is the family involved? What kind of care does he receive at this facility? Skin integrity, muscle atrophy, isolation Isolation, unable to advocate for self Patient Care Begins Current VS: P-Q-R-S-T Pain Assessment: T: 103.4 F/39.7 C (oral) Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators of pain P: 135 (irregular) Quality: R: 32 (regular) Region/Radiation: BP: 76/39 MAP: 51 Severity: O2 sat: 91% 2 liters n/c Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: High temp Increased HR Low BP Oxygen sat is low Sign of infection in the body Compensating for the low BP – trying to oxygenate the tissues One indicator of sepsis and septic shock. Oxygen saturation is on the lower side; however, this could be a normal reading for someone who has COPD. The patient has COPD and a history of heavy smoking (1 pack/day for 40 years). Current Assessment: GENERAL APPEARANCE: Pale and warm to touch. Appears tense. RESP: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light crackles in lower lobes bilat. Nail beds have noticeable clubbing, barrel chest present. CARDIAC: Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds NEURO: Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. PERRL GI: Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants GU: Foley catheter placed to monitor urine output. 50 mL tea-colored urine with no sediment, and no odor present SKIN: Stage IV decubitus to coccyx 1 cm x 0.5 cm x 0.5 cm depth, wound bed with visual bone noted at the base with large areas of necrosis on both sides of the sacrum bone. When dressing was removed, a large amount of yellow/green purulent drainage on dressing with a foul odor. Mucus membranes dry and pale. Determine current Glasgow coma scale score based on neurological assessment data: - - - - - - - - -- - - - Continued [Show More]

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