Sepsis/Septic Shock SKINNY Reasoning Suggested Answer Guidelines

Sepsis/Septic Shock SKINNY Reasoning Suggested Answer Guidelines Jack Holmes, 72 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Inflammation • Infection • Tissue Integrity • Clinical Judgment • Patient Education 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%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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: 74/40, MAP: 51 Altered level of consciousness, unresponsive to verbal stimuli, responds to sternal rub/painful stimuli Multiple physiologic problems including Parkinson's disease, COPD, CHF, and stage IV decubitus RED FLAG! His BP is too low, but the MAP is the best indicator of tissue perfusion. Normal MAP is 65-110. This patient’s MAP is significantly lower than normal, indicating he does not have adequate cerebral perfusion. In a critically ill individual, MAP goal is generally >60-65 for optimal cerebral perfusion RED FLAG! Altered LOC indicates poor cerebral perfusion, from the decreased low BP Stage IV decubitus is a possible source of infection. Patient meets 3/4 SIRS criteria based on VS before a WBC is drawn to confirm if he meets all four SIRS criteria. If there is a suspected or confirmed source of infection, he will meet the criteria for sepsis. At this point, it is a definitive diagnosis of SIRS based on the criteria on the VS. Half of SIRS criteria must be met to indicate SIRS Systemic Inflammatory Response Syndrome. These criteria are Temperature <36 >38 degrees celsius, HR >90, RR >20, WBC <4 >12. These criteria suggest that he has the potential for a systemic infection. Treatment should be initiated, and a potential cause should be identified. RELEVANT Data from Social History: Clinical Significance: At SNF for three years, bedbound for one year Advanced Parkinson’s disease Patient is unable to care for himself and has been bedbound for a year, indicating that he is at high risk for skin breakdown. Immobility and skin breakdown makes him a high risk for infection. Living in a SNF places him at risk for contamination in the wound from poor hand hygiene, infrequent position changes for optimal wound healing, and infrequent dressing changes. A coccyx wound requires frequent repositioning and living in a SNF does not guarantee patients will receive optimal care for wound healing due to lack of personnel, resources, and funding. At risk for skin breakdown. This patient would require someone to reposition him every two hours to heal his decubitus. Parkinson’s disease is a disorder of the central nervous system that mainly affects the motor system. It causes cell death in an area in the midbrain that causes a decrease in dopamine, a buildup of proteins called lewey bodies, and a A heavy smoker for 40 years loss of neurons. Eventually, motor function is so compromised patients with Parkinson’s are unable to move on their own and become wheelchair or bedbound, completely dependent on others for care. Heavy smokers have difficulty with wound healing and poor overall health. They do not recover from critical illness as well. His history of COPD and CHF make him a poor candidate for intubation if it becomes necessary. It is very difficult to extubate a patient with these past medical histories because it is very hard to wean them from a ventilator. 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: 103.4 F/39.7 C Heart rate: 135 irreg. RR: 32 BP: 76/39 MAP: 51 O2 sat 91% on 2 liters per n/c RED FLAG! Meets SIRS criteria. Indicates infection. At this point, source is unknown. RED FLAG! Meets SIRS criteria. His heart rate has elevated as a compensatory mechanism, for the low blood pressure, to try to increase cardiac output to perfuse the important organs (kidney, bran, heart). Irregular heart rate is also a clinical red flag for atrial fibrillation. The nurse must note: Is this a chronic rhythm for this patient or is it a new onset as a result of sympathetic nervous system stimulation seen with sepsis progressing to septic shock? RED FLAG! Caused by increased sympathetic nervous stimulation with sepsis. Could also indicate CO2 retention, respiratory acidosis, metabolic acidosis or lactic acidosis (late finding). Increases in patients with high levels of acid in the body as a compensatory mechanism to bring the CO2 down (breathe off CO2) to rid the body of any acid (CO2 is an acid) contributing to acidosis. RED FLAG! MAP is the best indicator of tissue perfusion. Normal MAP is 65-110. This patient’s MAP is significantly lower than normal indicating he does not have adequate cerebral and cellular perfusion. In a critically ill individual, MAP goal is generally >65. RED FLAG! Meets SIRS criteria. Patient O2 sat is low on oxygen but with a history of COPD that could be normal for him. May increase O2 to 3-4L, because of inadequate tissue perfusion, and continue to monitor TREND for respiratory failure. 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