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 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
NCLEX Client Need Categories Percentage of Items from Covered in
Each Case Study
Category/Subcategory
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 Clinical Significance:
Present 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 –
Stage IV decubitus ulcer on coccyx – bed could be due to poor perfusion, poor nutrition, poor wound care,
bound or not participating in q2 turns while bed bound. Poor skin
integrity.
Only responsive to sternal rub –
grimacing and withdrawing from Unresponsive to anything other than a sternal rub is a sign of an
stimulus altered level of consciousness – assuming that this is not baseline
for this patient.
COPD, HTN, CHF, old age, Comorbidities that can relate to a decrease in immune function.
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,
Depression
isolation Isolation, unable to advocate
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