Jack Holmes, 72 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
• Inflammation
• Infection
• Tissue
... [Show More] 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.
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