NUR 210 - Sepsis/Septic Shock UNFOLDING Reasoning Case Study
Jack Holmes, 72 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of
... [Show More] 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 [Show Less]