UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
UNFOLDING Clinical Reasoning Case Study: Sepsis/Septic Shock
I. Data Collection
History of Present Problem:
John Budd, a 72-year-old, arrived in the emergency department unconscious, with stab
wounds to the upper-right abdomen and lower-right chest that were sustained in his home while
fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his
right and left antecubital spaces and infused lactated Ringer’s solution wide open in both sites.
An endotracheal tube was inserted, and ventilation with a resuscitation bag at 100% oxygen was
begun. Pressure dressings to both wounds were secured.
A 5-cm (2-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab wound to
his upper-right abdomen were inspected. Chest tubes were inserted into the upper-right and
lower-right mid-axillary regions. Immediately, 500 ml of red drainage returned via the lower
chest tube. His heart rate (HR) was 125 bpm, and the monitor showed sinus tachycardia without
ectopy. His blood pressure (BP) was 70/50 mm Hg. Inserting a Foley catheter resulted in
drainage of 400 mL clear, dark yellow urine. After infusion of more than 2000 mL of lactated
Ringer’s solution, Mr. Budd was sent to surgery, still in a hypotensive state. Preoperative body
weight was 74 kg (165 lb).
Personal/Social History:
Unable to obtain due to current condition.
What data from the scenario is important & RELEVANT; therefore it has clinical significance
to the nurse?
RELEVANT Data from Present Clinical Significance:
Problem:
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
Unconscious state Current level of consciousness prevents
nurse from obtaining a medical history.
Penetrating trauma of R chest and upper R Penetrating wound to the chest may result
abdomen. in a pneumo- and hemo-thorax.
Penetrating wound to the upper R abdomen
may involve the liver and intestine which
increases risk of severe bleeding and
potential for spillage of intestinal contents
into peritoneum.
Intubated and bagged with 100% oxygen.
Intubation protects and stabilizes the client
airway. Bagging with ambu bag and 100%
oxygen ensures adequate ventilation and
oxygenation.
Chest tube inserted upper R and lower R
7/30/19
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
mid-axillary regions with 500 mL of red Chest tube inserted in R upper chest is to
drainage from lower CT. treat pneumothorax and allow for lung re-
expansion. Chest tube inserted in R lower
chest is to treat hemothorax. 500 mL of
blood indicates he is bleeding into pleural
space. The pneumothorax and hemothorax
impair ventilation and oxygenation.
HR 125 (sinus tachycardia without ectopy)
Increased heart rate is a compensatory
response for decreased cardiac output. No
ectopy is a good sign because the heart is
maintaining adequate perfusion and
BP 70/50 mm Hg. oxygenation.
Decreased BP indicates that cardiac output
and tissue perfusion are impaired. MAP is
Foley catheter inserted with 400 mL clear 56.6 mm. Hg confirms poor tissue
dark yellow urine. perfusion.
Remains hypotensive after 2000 mL of LR. Dark yellow urine indicates that the kidneys
are concentrating urine to hold on to fluid.
Fluid replacement is not adequate to
Preoperative body weight 74 kg (165 lb). replace what is being lost. Source of
bleeding needs to be stopped (surgical
intervention).
Weight is important to calculate dosage for
vasopressor medications and to assess for
fluid retention.
RELEVANT Data from Social History: Clinical Significance:
72 years old. His age places him at higher risk for post-
operative complications and decreased
ability to physiologically compensate.
II. Patient Care Begins:
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
RELEVANT VS Clinical Significance:
DATA:
T: 97º F (oral) Low, could be due to age.
P: 125 (regular) Increased heart rate is an indication of compensatory response for
low cardiac output
R: 22 (labored) Pneumo- and hemothorax impairs ventilation and gas exchange.
BP: 70/50 (Map=56.6 Low BP is indication of decreased cardiac output and poor tissue
7/30/19
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
Case Study: Sepsis/Septic Shock
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
UNFOLDING Clinical Reasoning Case Study: Sepsis/Septic Shock
I. Data Collection
History of Present Problem:
John Budd, a 72-year-old, arrived in the emergency department unconscious, with stab
wounds to the upper-right abdomen and lower-right chest that were sustained in his home while
fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his
right and left antecubital spaces and infused lactated Ringer’s solution wide open in both sites.
An endotracheal tube was inserted, and ventilation with a resuscitation bag at 100% oxygen was
begun. Pressure dressings to both wounds were secured.
A 5-cm (2-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab wound to
his upper-right abdomen were inspected. Chest tubes were inserted into the upper-right and
lower-right mid-axillary regions. Immediately, 500 ml of red drainage returned via the lower
chest tube. His heart rate (HR) was 125 bpm, and the monitor showed sinus tachycardia without
ectopy. His blood pressure (BP) was 70/50 mm Hg. Inserting a Foley catheter resulted in
drainage of 400 mL clear, dark yellow urine. After infusion of more than 2000 mL of lactated
Ringer’s solution, Mr. Budd was sent to surgery, still in a hypotensive state. Preoperative body
weight was 74 kg (165 lb).
Personal/Social History:
Unable to obtain due to current condition.
What data from the scenario is important & RELEVANT; therefore it has clinical significance
to the nurse?
RELEVANT Data from Present Clinical Significance:
Problem:
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
Unconscious state Current level of consciousness prevents
nurse from obtaining a medical history.
Penetrating trauma of R chest and upper R Penetrating wound to the chest may result
abdomen. in a pneumo- and hemo-thorax.
Penetrating wound to the upper R abdomen
may involve the liver and intestine which
increases risk of severe bleeding and
potential for spillage of intestinal contents
into peritoneum.
Intubated and bagged with 100% oxygen.
Intubation protects and stabilizes the client
airway. Bagging with ambu bag and 100%
oxygen ensures adequate ventilation and
oxygenation.
Chest tube inserted upper R and lower R
7/30/19
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
mid-axillary regions with 500 mL of red Chest tube inserted in R upper chest is to
drainage from lower CT. treat pneumothorax and allow for lung re-
expansion. Chest tube inserted in R lower
chest is to treat hemothorax. 500 mL of
blood indicates he is bleeding into pleural
space. The pneumothorax and hemothorax
impair ventilation and oxygenation.
HR 125 (sinus tachycardia without ectopy)
Increased heart rate is a compensatory
response for decreased cardiac output. No
ectopy is a good sign because the heart is
maintaining adequate perfusion and
BP 70/50 mm Hg. oxygenation.
Decreased BP indicates that cardiac output
and tissue perfusion are impaired. MAP is
Foley catheter inserted with 400 mL clear 56.6 mm. Hg confirms poor tissue
dark yellow urine. perfusion.
Remains hypotensive after 2000 mL of LR. Dark yellow urine indicates that the kidneys
are concentrating urine to hold on to fluid.
Fluid replacement is not adequate to
Preoperative body weight 74 kg (165 lb). replace what is being lost. Source of
bleeding needs to be stopped (surgical
intervention).
Weight is important to calculate dosage for
vasopressor medications and to assess for
fluid retention.
RELEVANT Data from Social History: Clinical Significance:
72 years old. His age places him at higher risk for post-
operative complications and decreased
ability to physiologically compensate.
II. Patient Care Begins:
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
, UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
RELEVANT VS Clinical Significance:
DATA:
T: 97º F (oral) Low, could be due to age.
P: 125 (regular) Increased heart rate is an indication of compensatory response for
low cardiac output
R: 22 (labored) Pneumo- and hemothorax impairs ventilation and gas exchange.
BP: 70/50 (Map=56.6 Low BP is indication of decreased cardiac output and poor tissue
7/30/19
UNFOLDING Clinical Reasoning
Case Study: Sepsis/Septic Shock
