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.
, 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 The blood pressure is way too low to maintain adequate perfusion of the
tissues
History of Parkinson’s Disease, COPD, CHF, The patient has a lot of chronic illnesses that the nurse needs to take into
HTN, depression consideration
Stage IV decubitus ulcer Ulcers, especially of this stage, are a large source of infection
Found unresponsive this morning, does not The nurse needs to start brainstorming on why the patient could be
respond to verbal stimuli, only sternal rubbing 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
RELEVANT Data from Social History: Clinical Significance:
Bed bound for the past year Patient’s who are bed bound are at a much higher chance of illness due to
decreased movement, the formation of bed sores, decreased exercise and
most likely poor nutrition
Was a heavy smoker Heavy smokers are at a greater risk of developing respiratory infections
and impairment due to the damage done to the alveoli and lung tissue after
years of smoking
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:
Temperature of 103.4 F A significant temperature, a sign of infection or inflammation occurring in the body
Irregular pulse, 135 bpm Pules is fast and irregular, could be due to an electrolyte imbalance and could also be due to the
heart trying to compensate for some other disease process going on
Respiration rate of 32 Respirations are increased due to poor oxygenation and the body trying to compensate for poor
perfusion
BP of 76/39 Blood pressure is significantly low, the body tissues are not able to be perfused as well as they
should be
O2 sat of 91% on 2L NC Oxygen level is low due to poor perfusion; this is the cause of the increased respiration rate
Unresponsive, by The nurse should be brainstorming on why he patient is unresponsive; in this case the nurse
withdraws from pain could infer that it is also a result of the decreased perfusion
Current Assessment:
GENERAL Pale and warm to touch. Appears tense.
APPEARANCE:
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.
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 8
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.
, 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 The blood pressure is way too low to maintain adequate perfusion of the
tissues
History of Parkinson’s Disease, COPD, CHF, The patient has a lot of chronic illnesses that the nurse needs to take into
HTN, depression consideration
Stage IV decubitus ulcer Ulcers, especially of this stage, are a large source of infection
Found unresponsive this morning, does not The nurse needs to start brainstorming on why the patient could be
respond to verbal stimuli, only sternal rubbing 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
RELEVANT Data from Social History: Clinical Significance:
Bed bound for the past year Patient’s who are bed bound are at a much higher chance of illness due to
decreased movement, the formation of bed sores, decreased exercise and
most likely poor nutrition
Was a heavy smoker Heavy smokers are at a greater risk of developing respiratory infections
and impairment due to the damage done to the alveoli and lung tissue after
years of smoking
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:
Temperature of 103.4 F A significant temperature, a sign of infection or inflammation occurring in the body
Irregular pulse, 135 bpm Pules is fast and irregular, could be due to an electrolyte imbalance and could also be due to the
heart trying to compensate for some other disease process going on
Respiration rate of 32 Respirations are increased due to poor oxygenation and the body trying to compensate for poor
perfusion
BP of 76/39 Blood pressure is significantly low, the body tissues are not able to be perfused as well as they
should be
O2 sat of 91% on 2L NC Oxygen level is low due to poor perfusion; this is the cause of the increased respiration rate
Unresponsive, by The nurse should be brainstorming on why he patient is unresponsive; in this case the nurse
withdraws from pain could infer that it is also a result of the decreased perfusion
Current Assessment:
GENERAL Pale and warm to touch. Appears tense.
APPEARANCE:
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.
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 8
