Sepsis/Septic Shock UNFOLDING Reasoning Case Study

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:

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RELEVANT Data from Social History: Clinical Significance:

Patient Care Begins

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:

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:

Determine current Glasgow coma scale score based on neurological assessment data:

Glasgow Coma Scale Eye Opening

Spontaneous 4

To sound 3

To pain 2

Never 1

Motor Response

Obeys commands 6

Localizes pain 5

Normal flexion (withdrawal) 4

Abnormal flexion 3

Extension 2

None 1

Verbal Response

Oriented 5

Confused conversation 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Total

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

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.

Cardiac Telemetry Strip:

Regular/Irregular: P wave present? PR: QRS:

Interpretation:

Clinical Significance:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

Radiology: Chest X-Ray

Results: Clinical Significance:

Cardiac silhouette slightly

enlarged. No infiltrates present.

Lab Results: Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands

Current: 18.5 13.1 250 85.2 3

Most Recent: 12.4 13.2 175 64 0

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What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 147 5.2 172 1.6

Most Recent: 138 4.4 98 0.88

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