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Sepsis – Unfolding Case Study
History of Present Problem:
Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last
twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last
week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know
what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable
to get out of the tub and used her personal life alert button to call for medical assistance.
Personal/Social History:
Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are
active and involved in her life.
What data from the histories are important and RELEVANT and have clinical significance for the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Fatigue, fever, painful, burning, and frequent urination. Patient is having symptoms of urinary tract infection
Changes in mental status. request urinalysis.
Confusion is a common presentation of UTI in the elderly.
RELEVANT Data from Social History: Clinical Significance:
Lives independently in a senior apartment. Patient has a safe place for discharge.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current medications?
(Which medications treat which conditions?)
PMH Home Medications Pharm Classification Expected Outcome
Diabetes type 2 Decreased Production of
1. Allopurinol 100 mg PO bid
Hyperlipidemia Antigout agent uric acid to reduce gout
Hypertension fares.
(HTN) Gout Reduce platelet
2. ASA 81 mg PO daily Antiplatelet/Salicylate aggregation and clumping
to prevent clotting.
Reduce and controls
3. Pioglitazone 15 mg PO daily Thiazolidinedione/antidiabetic
blood glucose levels.
Reduce cholesterol/blood
4. Simvastatin 20 mg PO daily Antihypertensive
lipid levels.
5. Metoprolol 25 mg PO bid Beta blocker Reduce blood pressure
6. Lisinopril 10 mg PO daily Ace inhibitor Reduce blood pressure
1
, Sepsis – Unfolding Case Study
Reduce BP through
7. Furosemide 20 mg PO daily Loop diuretic
Diuresis
8. Potassium chloride 20 mEq Replaces K in the body
K supplement
PO daily last through diuresis.
Complete a Concept Map for DIABETES TYPE 2:
Disease Process 1. Characterized by peripheral insulin resistance, impaired regulation of
Complete evaluation of hepatic glucose production.
Pathophysiology: What is 2. With type 2 diabetes, the body either doesn’t produce enough insulin or
the disease? it resists insulin.
Etiology (cause) of the 3. Long term complications of type 2 diabetes are diabetic retinopathy,
disease? kidney disease, diabetic neuropathy, and macrovascular problems.
Chronicity of the 4. The prognosis can be Heart attack, stroke, kidney disease which can result
disease? What happens in premature death.
long term?
Prognosis of the patient
with this disease?
1. Overweight or obese
Risk Factors (List 3 or more) 2. Have high blood pressure
3. Have a low level of HDL cholesterol, or a high level of triglycerides.
Blurred vision
Fatigue
Increased thirst
Signs / Symptoms
Weight loss
Frequent urination
Hyperglycemia
Retinopathy
Kidney disease
Potential Complications
Nerve Damage
Macrovascular Complications
Antidiabetic medication
1. Metformin
2. Glipizide
3. Acarbose
4. Sitagliptin
Medical Interventions Labs
Medications 1. Fasting blood sugar
Labs 2. Two-hour postprandial test
Diagnostic studies. 3. Hemoglobin A1C
The labs are used to screen for high blood glucose levels, to detect and diagnose
Explain why these are used, or diabetes and prediabetes.
a specific study is done.
Nursing Diagnosis 1. Risk for unstable blood glucose related to abnormal blood glucose
List 3 or more nursing readings as evidence by blood glucose being higher than 120.
2
, Sepsis – Unfolding Case Study
diagnosis in proper NANDA 2. Risk for infection related to high glucose levels, decreased leukocyte
format: function, alterations in circulation as evidence by blood glucose being
Diagnosis higher than 120.
Related to 3.
Process causing
symptoms
As evidence by
Observed physiology or
behavior
Nursing Interventions
List 3 or more nursing
interventions relevant to the
diagnosis listed above.
Complete a Concept Map for HYPERLIPIDEMIA:
Disease Process
Complete evaluation of
Pathophysiology: What is
the disease?
Etiology (cause) of the
disease?
Chronicity of the
disease? What happens
long term?
Prognosis of the patient
with this disease?
Risk Factors (List 3 or more)
Signs / Symptoms
Potential Complications
Medical Interventions
Medications
Labs
Diagnostic studies.
Explain why these are used, or
a specific study is done.
Nursing Diagnosis
List 3 or more nursing
3
Sepsis – Unfolding Case Study
History of Present Problem:
Jean Kelly is an 82-year-old woman who has been feeling more fatigued the last three days and has had a fever the last
twenty-four hours. She reports a painful, burning sensation when she urinates as well as frequency of urination the last
week. Her daughter became concerned and brought her to the emergency department (ED) when she did not know
what day it was. She is mentally alert with no history of confusion. While taking her bath today, she was weak and unable
to get out of the tub and used her personal life alert button to call for medical assistance.
Personal/Social History:
Jean lives independently in a senior apartment retirement community. She is widowed and has two daughters who are
active and involved in her life.
What data from the histories are important and RELEVANT and have clinical significance for the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Fatigue, fever, painful, burning, and frequent urination. Patient is having symptoms of urinary tract infection
Changes in mental status. request urinalysis.
Confusion is a common presentation of UTI in the elderly.
RELEVANT Data from Social History: Clinical Significance:
Lives independently in a senior apartment. Patient has a safe place for discharge.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current medications?
(Which medications treat which conditions?)
PMH Home Medications Pharm Classification Expected Outcome
Diabetes type 2 Decreased Production of
1. Allopurinol 100 mg PO bid
Hyperlipidemia Antigout agent uric acid to reduce gout
Hypertension fares.
(HTN) Gout Reduce platelet
2. ASA 81 mg PO daily Antiplatelet/Salicylate aggregation and clumping
to prevent clotting.
Reduce and controls
3. Pioglitazone 15 mg PO daily Thiazolidinedione/antidiabetic
blood glucose levels.
Reduce cholesterol/blood
4. Simvastatin 20 mg PO daily Antihypertensive
lipid levels.
5. Metoprolol 25 mg PO bid Beta blocker Reduce blood pressure
6. Lisinopril 10 mg PO daily Ace inhibitor Reduce blood pressure
1
, Sepsis – Unfolding Case Study
Reduce BP through
7. Furosemide 20 mg PO daily Loop diuretic
Diuresis
8. Potassium chloride 20 mEq Replaces K in the body
K supplement
PO daily last through diuresis.
Complete a Concept Map for DIABETES TYPE 2:
Disease Process 1. Characterized by peripheral insulin resistance, impaired regulation of
Complete evaluation of hepatic glucose production.
Pathophysiology: What is 2. With type 2 diabetes, the body either doesn’t produce enough insulin or
the disease? it resists insulin.
Etiology (cause) of the 3. Long term complications of type 2 diabetes are diabetic retinopathy,
disease? kidney disease, diabetic neuropathy, and macrovascular problems.
Chronicity of the 4. The prognosis can be Heart attack, stroke, kidney disease which can result
disease? What happens in premature death.
long term?
Prognosis of the patient
with this disease?
1. Overweight or obese
Risk Factors (List 3 or more) 2. Have high blood pressure
3. Have a low level of HDL cholesterol, or a high level of triglycerides.
Blurred vision
Fatigue
Increased thirst
Signs / Symptoms
Weight loss
Frequent urination
Hyperglycemia
Retinopathy
Kidney disease
Potential Complications
Nerve Damage
Macrovascular Complications
Antidiabetic medication
1. Metformin
2. Glipizide
3. Acarbose
4. Sitagliptin
Medical Interventions Labs
Medications 1. Fasting blood sugar
Labs 2. Two-hour postprandial test
Diagnostic studies. 3. Hemoglobin A1C
The labs are used to screen for high blood glucose levels, to detect and diagnose
Explain why these are used, or diabetes and prediabetes.
a specific study is done.
Nursing Diagnosis 1. Risk for unstable blood glucose related to abnormal blood glucose
List 3 or more nursing readings as evidence by blood glucose being higher than 120.
2
, Sepsis – Unfolding Case Study
diagnosis in proper NANDA 2. Risk for infection related to high glucose levels, decreased leukocyte
format: function, alterations in circulation as evidence by blood glucose being
Diagnosis higher than 120.
Related to 3.
Process causing
symptoms
As evidence by
Observed physiology or
behavior
Nursing Interventions
List 3 or more nursing
interventions relevant to the
diagnosis listed above.
Complete a Concept Map for HYPERLIPIDEMIA:
Disease Process
Complete evaluation of
Pathophysiology: What is
the disease?
Etiology (cause) of the
disease?
Chronicity of the
disease? What happens
long term?
Prognosis of the patient
with this disease?
Risk Factors (List 3 or more)
Signs / Symptoms
Potential Complications
Medical Interventions
Medications
Labs
Diagnostic studies.
Explain why these are used, or
a specific study is done.
Nursing Diagnosis
List 3 or more nursing
3
