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 Covered in
Category/Subcategory 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 Hypoperfusion of the tissue which can hinder
oxygenation
Stage 4 Ulcer on his coccyx
that developed 3 months Ulcer not healing due to inadequate tissue
ago perfusion
COPD, CHF, HTN, Altered immune response due to these
Parkinson’s disease and comorbidities and lowered functioning immune
old age system given the patient’s age.
Unresponsiveness to verbal Altered LOC
stimuli
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 Poor skin integrity, atrophy of muscle, renal
Parkinson’s 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 There is an active infection in the body, this can also cause
high higher metabolism which can lead to fatigue
Respiration is Compensating for low BP in order to adequately oxygenate
high the tissues
BP is low
This is an indication of septic shock
O2 Sat is low
(91%)
Could be normal for a patient with COPD who is a heavy
former smoker with a history of 1 PPD for 40 years.
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 Covered in
Category/Subcategory 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 Hypoperfusion of the tissue which can hinder
oxygenation
Stage 4 Ulcer on his coccyx
that developed 3 months Ulcer not healing due to inadequate tissue
ago perfusion
COPD, CHF, HTN, Altered immune response due to these
Parkinson’s disease and comorbidities and lowered functioning immune
old age system given the patient’s age.
Unresponsiveness to verbal Altered LOC
stimuli
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 Poor skin integrity, atrophy of muscle, renal
Parkinson’s 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 There is an active infection in the body, this can also cause
high higher metabolism which can lead to fatigue
Respiration is Compensating for low BP in order to adequately oxygenate
high the tissues
BP is low
This is an indication of septic shock
O2 Sat is low
(91%)
Could be normal for a patient with COPD who is a heavy
former smoker with a history of 1 PPD for 40 years.
