NUR 3047 Sepsis/Septic Shock UNFOLDING Reasoning Case Study,100% CORRECT
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NUR 3047 Sepsis/Septic Shock
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NUR 3047 Sepsis/Septic Shock
NUR 3047 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...
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NUR 3047Sepsis/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 Covered in
Category/Subcategory 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 Clinical Significance:
Problem:
BP of 74/40 (51) Low blood pressure and low MAP – indicator of poor perfusion
Has had stage IV ulcer for 3 months. No signs of healing – could
Stage IV decubitus ulcer on coccyx – bed be due to poor perfusion, poor nutrition, poor wound care, or not
bound participating in q2 turns while bed bound. Poor skin integrity.
Only responsive to sternal rub – Unresponsive to anything other than a sternal rub is a sign of an
grimacing and withdrawing from altered level of consciousness – assuming that this is not baseline
stimulus for this patient.
Comorbidities that can relate to a decrease in immune function.
COPD, HTN, CHF, old age, and
Parkinson’s
RELEVANT Data from Social History: Clinical Significance:
Lives in SNF for past 3 years 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?
Bed bound
Skin integrity, muscle atrophy, isolation
Depression
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 Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators
(oral) of pain
P: 135 (irregular) Quality:
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 Clinical Significance:
Data:
High temp Sign of infection in the body
Increased HR Compensating for the low BP – trying to oxygenate the tissues
Low BP One indicator of sepsis and septic shock.
Oxygen sat is low 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 Pale and warm to touch. Appears tense.
APPEARANCE:
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:
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