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
... [Show More] 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
RELEVANT Data from Social History: Clinical Significance:
Bed bound for the past year
Was a heavy smoker
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
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
Irregular pulse, 135 bpm
Respiration rate of 32
BP of 76/39
O2 sat of 91% on 2L NC
Unresponsive, by
withdraws from pain
A significant temperature, a sign of infection or inflammation occurring in the body
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
Respirations are increased due to poor oxygenation and the body trying to compensate for poor
perfusion
Blood pressure is significantly low, the body tissues are not able to be perfused as well as they
should be
Oxygen level is low due to poor perfusion; this is the cause of the increased respiration rate
The nurse should be brainstorming on why he patient is unresponsive; in this case the nurse
could infer that it is also a result of the decreased perfusion
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.
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 8What 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:
Pale skin color
Tachypneic, working hard to breathe
Diminished breath sounds, crackles in lower
lobes
Nail clubbing and barrel chest
+1 pitting edema in lower extremities
Systolic murmur
Irregular heart rhythm, weak thready radial
pulses
Cap refill = 3 seconds
Won’t open eyes, only responds to pain
PERRL
Firm, distended abdomen with hypoactive
bowel sounds
Tea colored urine with no odor or sediment
Stage IV decubitus ulcer on sacrum; areas of
necrosis
Yellow/green drainage from pressure wound
with foul odor
Mucous membranes dry
GCS of 8
Pale skin is a result of decreased blood flow and poor perfusion
The patient is really trying hard to breathe to compensate for poor perfusion and to
compensate for metabolic acidosis
Crackles in the lower lobes indicate that there is fluid built up- did the patient
potentially aspirate? Or is this fluid build up a result of poor cardiac output?
Nail clubbing and barrel chest are long term effects of poor perfusion, most likely due
to the patients extensive history of smoking and COPD
There is slight pitting edema as a result of poor blood return to the heart (the blood is
pooling) and as a result of capillary leak (which occurs in septic shock)
Systolic murmurs are commonly heard when there are issues with the valves of the
heart, but can also result from pulmonary or aortic stenosis, which could be a result of
his PMH
Irregular rhythms are a result of an electrolyte imbalance, weak pulses are a result of
the heart being unable to pump well enough
Cap refill is 3 seconds which indicates that it takes longer than it should for blood to
return to the tissues
Patient is unresponsive, but responds to pain; important for the nurse to note this as a
baseline for the patient, which can be used to indicate if the patient’s condition is
getting better or worse
Pupils are equal, round and reactive, which indicates that there is not a brain injury
occurring
A distended abdomen can indicate an infection in the abdomen (peritonitis), but it can
also indicate an obstruction, especially since there is hypoactive bowel sounds
Urine is dark in color which indicates that the patient may be dehydrated; it is
important to note that there is no sediment, which can be an indicator of a UTI
There is a large ulcer on the sacrum, stage IV indicates that there is damage down to
the bone, necrosis indicates that the tissue around the wound is now dead
Yellow/green drainage is an indicator that there is infection occurring
Dry mucous membranes helps to support the assumption that the patient is dehydrated
GCS should be reevaluated often (hourly) to indicate if there is a change in the
patient’s status; he is close to having a GCS low enough to indicate the need for
intubationRadiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray
Results: Clinical Significance:
Cardiac silhouette slightly
enlarged. No infiltrates present.
Heart is enlarged, it has been working hard, which essentially builds up the muscle and
makes the heart larger
Lab Results:
Complete Blood Count (CBC)
WBC HGB PLTs % Neuts Bands
Current: 18.5 13.1 250 85.2 3
Most Recent: 12.4 13.2 175 64 0
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
WBC of 18.5
Neutrophils of 85.2%
Bands 3
WBC count is elevated about normal limits, indicating
infection
Neutrophils are elevated, which supports the assumption that
there is an infection occurring
Bands are elevated, normally they are 0; this indicates that
there are immature neutrophils in the blood, which indicates
that there is a large systemic infection
Worsening
Worsening
Worsening
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 147 5.2 172 1.6
Most Recent: 138 4.4 98 0.88
Cardiac Telemetry Strip:
Regular/Irregular: irregular P wave present? NO PR: regular length QRS: regular length
Interpretation: Atrial fibrillati [Show Less]