Sepsis Shock Case Study part 2
Sepsis Shock Case Study part 2
History of Current 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.
1. What is the RELATIONSHIP between RELEVANT current problem data and the
primary medical problem?
RELEVANT Current Problem Clinical Significance
Data:
Low BP with MAP of 51 Hypoperfusion of the tissue which can hinder
oxygenation
Stage 4 Ulcer on his coccyx that
developed 3 months ago Ulcer not healing due to inadequate tissue perfusion
COPD, CHF, HTN, Altered immune response due to these comorbidities
Parkinson’s disease and old and lowered functioning immune system given the
age patient’s age.
Unresponsiveness to verbal Altered LOC
stimuli
RELEVANT From Social Clinical Significance
History:
, Sepsis Shock Case Study part 2
Skilled Nursing Facility More exposure to pathogens or iatrogenic illness at the
facility
Bed bound due to his
parkinson’s Poor skin integrity, atrophy of muscle, renal calculi, DVT,
isolation
Isolation, no interest or motivation in performing ADLs,
Depression
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
2. What VS data are RELEVANT and must be interpreted as clinically significant by
the nurse?
RELEVANT VS Data Clinical Significance
Sepsis Shock Case Study part 2
History of Current 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.
1. What is the RELATIONSHIP between RELEVANT current problem data and the
primary medical problem?
RELEVANT Current Problem Clinical Significance
Data:
Low BP with MAP of 51 Hypoperfusion of the tissue which can hinder
oxygenation
Stage 4 Ulcer on his coccyx that
developed 3 months ago Ulcer not healing due to inadequate tissue perfusion
COPD, CHF, HTN, Altered immune response due to these comorbidities
Parkinson’s disease and old and lowered functioning immune system given the
age patient’s age.
Unresponsiveness to verbal Altered LOC
stimuli
RELEVANT From Social Clinical Significance
History:
, Sepsis Shock Case Study part 2
Skilled Nursing Facility More exposure to pathogens or iatrogenic illness at the
facility
Bed bound due to his
parkinson’s Poor skin integrity, atrophy of muscle, renal calculi, DVT,
isolation
Isolation, no interest or motivation in performing ADLs,
Depression
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
2. What VS data are RELEVANT and must be interpreted as clinically significant by
the nurse?
RELEVANT VS Data Clinical Significance
