Sepsis/Septic Shock RAPID Reasoning Case Study STUDENT

Sepsis/Septic Shock RAPID 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 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%  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: Low BP with MAP of 51 Stage 4 Ulcer on his coccyx that developed 3 months ago COPD, CHF, HTN, Parkinson’s disease and old age Unresponsiveness to verbal stimuli Hypoperfusion of the tissue which can hinder oxygenation Ulcer not healing due to inadequate tissue perfusion Altered immune response due to these comorbidities and lowered functioning immune system given the patient’s age. Altered LOC RELEVANT Data from Social History: Clinical Significance: Skilled Nursing Facility More exposure to pathogens or iatrogenic illness at the facility Bed bound due to his Parkinson’s Poor skin integrity, atrophy of muscle, renal calculi, DVT, isolation Depression Isolation, no interest or motivation in performing ADL’s, unable to self-advocate, withdrawing from peers 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 is high There is an active infection in the body, this can also cause higher metabolism which can lead to fatigue Respiration is high BP is low Compensating for low BP in order to adequately oxygenate the tissues O2 Sat is low (91%) This is an indication of septic shock Could be normal for a patient with COPD who is a heavy former smoker with a history of 1 PPD for 40 years. Determine current Glasgow coma scale score based on neurological assessment data: 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. 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 7 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: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light Low blood pressure and low level of oxygen can lead to tachypnea in order to compensate for poor oxygenation. It could indicate that the lungs aren’t functioning properly due to presence of fluids in the lungs as a result of CHF. crackles in lower lobes bilat. Nail beds have noticeable clubbing, barrel chest present. Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds 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. Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants 50 mL tea-colored urine with no sediment, and no odor present 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 Chronic hypo-oxygenation of the tissues can lead to clubbing, COPD can lead to barrel chest. Pitting edema due to his CHF, sluggish cap refill due to low BP Altered level of consciousness because the brain is not being adequately perfused due to shock Distended abdomen indicates patient has ascites; firm bowel, hypo-active sounds indicate peritonitis. This reinforces patient’s diagnosis of septic shock. This indicates patient’s liver and kidneys and not working properly. Tea colored urine is also a sign of pyelonephritis and failing liver. This could be a sign that the patient is starting to develop multi organ dysfunction syndrome. Ulcer is not healing or progressively getting worse due to lack of oxygen to the tissues. Purulent drainage indicates active infection. Pt is dehydrated.