SEPSIS/SEPTIC SHOCK UNFOLDING lOMoARcPSD|56342273
REASONING CASE STUDY, NEWEST
2025 |ALREADY GRADED A+||BRAND
NEW!!| LATEST VERSION |Jack
Holmes, 72 years old
Student-Sepsis-Septic Shock- Unfolding Reasoning copy
Clinical For Nrsg 4502 (Northeastern University)
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, lOMoARcPSD|56342273
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 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%
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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, lOMoARcPSD|56342273
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:
Living in a assisted care facility Indicates he cannot care for himself and may need extra support
Unarousable this morning Indicates there was a change
BP 74/40 MAP 51 BP is decreased and MAP is low which means blood is not
History of Parkinson’s, COPD, HF, perfusing to vital organs
HTN, and stage IV ulcer on coccyx He will have tremors with Parkinson’s and is a fall risk. COPD
Does not follow commands indicates he may have trouble breathing and should be aware of his
Responds to eternal rub oxygenation. The pressure Euler indicates he has not been out of
bed or bathed
Not following commands can make treatment more difficult but
knowing he responds to stimuli is helpful
RELEVANT Data from Social History: Clinical Significance:
Skilled nursing facility, bed bound for Indicates he will need help with moving and is a fall risk. He needs
past year because of advancing to be moved every 2 hrs to prevent further ulcers
Parkinson’s disease Smoking heavily for long periods of time can lead to HTN,
Heavy smoker 1 PPD for 40 years COPF,CHF
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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Downloaded by Legit Actualexams ()
REASONING CASE STUDY, NEWEST
2025 |ALREADY GRADED A+||BRAND
NEW!!| LATEST VERSION |Jack
Holmes, 72 years old
Student-Sepsis-Septic Shock- Unfolding Reasoning copy
Clinical For Nrsg 4502 (Northeastern University)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by Legit Actualexams ()
, lOMoARcPSD|56342273
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 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%
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Downloaded by Legit Actualexams ()
, lOMoARcPSD|56342273
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:
Living in a assisted care facility Indicates he cannot care for himself and may need extra support
Unarousable this morning Indicates there was a change
BP 74/40 MAP 51 BP is decreased and MAP is low which means blood is not
History of Parkinson’s, COPD, HF, perfusing to vital organs
HTN, and stage IV ulcer on coccyx He will have tremors with Parkinson’s and is a fall risk. COPD
Does not follow commands indicates he may have trouble breathing and should be aware of his
Responds to eternal rub oxygenation. The pressure Euler indicates he has not been out of
bed or bathed
Not following commands can make treatment more difficult but
knowing he responds to stimuli is helpful
RELEVANT Data from Social History: Clinical Significance:
Skilled nursing facility, bed bound for Indicates he will need help with moving and is a fall risk. He needs
past year because of advancing to be moved every 2 hrs to prevent further ulcers
Parkinson’s disease Smoking heavily for long periods of time can lead to HTN,
Heavy smoker 1 PPD for 40 years COPF,CHF
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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Downloaded by Legit Actualexams ()
