Sepsis/Septic Shock UNFOLDING Reasoning Case Study STUDENT Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Inflammation • Infection • Tissue Integrity • 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: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Jack Holmes, 72 years old Downloaded by SAMUEL WAM (samek2029@gmail.com) lOMoARcPSD|13778330 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 74/40 MAP 51 - IV decubitus ulcer on coccyx 3 months old - Pt unresponsive to verbal stimuli but responds to sternal rub pain stimulus by grimacing and withdrawing from stimulus. - 72 y/o advance stage of Parkinson’s disease - Pt hx of COPD, CHF, HTN, depression - infection plus low blood pressure signs for septic shock. - pt is still breathing and responding to stimuli, no CPR needed when found. Sign of progressive stage of septic shock - compromise oxygenation and tissue perfusion due to pt hx of cardiac and respiratory issues - Parkinson is a debilitating neurogenerative disease, stick muscles and depressions ( decline production of dopamine) are signs of an advance stage. RELEVANT Data from Social History: Clinical Significance: - leave at the nursing home for 3 years. Being on bed from a year now. Former smoker 1 package a day for 40 years - no family support - depression due to diagnosis, lack of independence - lung damage, heart, and vascular damage due to smoking, COPD 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: -↑ temp - ↑ H R -↑respirations - ↓ BP/ systolic BP <90>