Sepsis Shock Case Study part 2
History of Current Problem:
Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled
... [Show More] 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.
1. What is the RELATIONSHIP between RELEVANT current problem data and the primary medical problem?
RELEVANT Current Problem Data: 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 From Social History: Clinical Significance
Skilled Nursing Facility
Bed bound due to his parkinson’s
Depression More exposure to pathogens or iatrogenic illness at the facility
Poor skin integrity, atrophy of muscle, renal calculi, DVT, isolation
Isolation, no interest or motivation in performing ADLs, 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
2. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? [Show Less]