Sepsis/Septic Shock UNFOLDING Reasoning Case Study-Jack Holmes Sepsis

Sepsis/Septic Shock UNFOLDING Reasoning Case Study Sepsis/Septic Shock UNFOLDING Reasoning Case Study STUDENT Jack Holmes, 72 years old 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: 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. lOMoAR cPSD| 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 - MAP < 65 - O2 at 91% 2Ln/c Pt has an infection, is in septic shock SBP <90 risk for arrythmias ↓ MAP compromised tissue perfusion, compromised oxygenation - High risk for organ failure - Pt has COPD, O2 at 91% with 2L n/c can be his baseline but is insufficient at this moment