NUR 210 - Sepsis/Septic Shock UNFOLDING Reasoning( Jack Holmes, 72 years old). Case Study.

NUR 210 - Sepsis/Septic Shock UNFOLDING Reasoning Case Study 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. 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 of 74/40 History of Parkinson’s Disease, COPD, CHF, HTN, depression Stage IV decubitus ulcer Found unresponsive this morning, does not respond to verbal stimuli, only sternal rubbing The blood pressure is way too low to maintain adequate perfusion of the tissues The patient has a lot of chronic illnesses that the nurse needs to take into consideration Ulcers, especially of this stage, are a large source of infection The nurse needs to start brainstorming on why the patient could be unresponsive, and it is important to note that the patient is still able to respond to verbal stimuli; the nurse also needs to be sure to document this as a baseline level of consciousness