Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
Sepsis/Septic Shock
UNFOLDING 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% ✓
, Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
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:
Patient would not respond when tried to wake Patient was found unresponsive when found this morning with a BP of
him, his BP was 74/40, Hx of Parkinson’s 74/40 which is extremely low. His Hx is significant because it can help us
disease, COPD, CHF, HTN, depression and has decide the cause of the low BP and his unresponsiveness.
a stage IV decubitus ulcer on his coccyx that
developed 3 months ago. He does not follow
commands, is unresponsive to verbal stimuli,
but responds to a sternal rub with grimacing
and withdrawing from stimulus.
RELEVANT Data from Social History: Clinical Significance:
He was a heavy smoker of 40 years (1PPD), he His smoker contributed to his Dx of COPD, and probably his HTN.
has been bedbound for the past year due to his Being bedbound and advancing progression of PD could be a
advanced Parkinson’s disease. contributing factor of his depression.
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:
UNFOLDING Reasoning Case Study
STUDENT
Sepsis/Septic Shock
UNFOLDING 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% ✓
, Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
✓ Physiological Adaptation 11-17% ✓
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
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:
Patient would not respond when tried to wake Patient was found unresponsive when found this morning with a BP of
him, his BP was 74/40, Hx of Parkinson’s 74/40 which is extremely low. His Hx is significant because it can help us
disease, COPD, CHF, HTN, depression and has decide the cause of the low BP and his unresponsiveness.
a stage IV decubitus ulcer on his coccyx that
developed 3 months ago. He does not follow
commands, is unresponsive to verbal stimuli,
but responds to a sternal rub with grimacing
and withdrawing from stimulus.
RELEVANT Data from Social History: Clinical Significance:
He was a heavy smoker of 40 years (1PPD), he His smoker contributed to his Dx of COPD, and probably his HTN.
has been bedbound for the past year due to his Being bedbound and advancing progression of PD could be a
advanced Parkinson’s disease. contributing factor of his depression.
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:
