Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
Septic shock Keith RN Jack Holmes, 72
years old
STUDENTSeptic Shock Keith RN
Case Study
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:
BP of 74/40 The blood pressure is way too low to maintain adequate perfusion of the
tissues
History of Parkinson’s Disease, COPD, The patient has a lot of chronic illnesses that the nurse needs to take into
CHF, HTN, depression consideration
Stage IV decubitus ulcer Ulcers, especially of this stage, are a large source of infection
Found unresponsive this morning, does not The nurse needs to start brainstorming on why the patient could be
respond to verbal stimuli, only sternal rubbing unresponsive, and it is important to note that the patient is still able to
respond to verbal stimuli; the nurse also needs to be sure to document this
as a baseline level of consciousness
RELEVANT Data from Social History: Clinical Significance:
Bed bound for the past year Patient’s who are bed bound are at a much higher chance of illness due to
decreased movement, the formation of bed sores, decreased exercise and
most likely poor nutrition
Was a heavy smoker Heavy smokers are at a greater risk of developing respiratory infections
and impairment due to the damage done to the alveoli and lung tissue after
years of smoking
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:
UNFOLDING Reasoning Case Study
Septic shock Keith RN Jack Holmes, 72
years old
STUDENTSeptic Shock Keith RN
Case Study
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:
BP of 74/40 The blood pressure is way too low to maintain adequate perfusion of the
tissues
History of Parkinson’s Disease, COPD, The patient has a lot of chronic illnesses that the nurse needs to take into
CHF, HTN, depression consideration
Stage IV decubitus ulcer Ulcers, especially of this stage, are a large source of infection
Found unresponsive this morning, does not The nurse needs to start brainstorming on why the patient could be
respond to verbal stimuli, only sternal rubbing unresponsive, and it is important to note that the patient is still able to
respond to verbal stimuli; the nurse also needs to be sure to document this
as a baseline level of consciousness
RELEVANT Data from Social History: Clinical Significance:
Bed bound for the past year Patient’s who are bed bound are at a much higher chance of illness due to
decreased movement, the formation of bed sores, decreased exercise and
most likely poor nutrition
Was a heavy smoker Heavy smokers are at a greater risk of developing respiratory infections
and impairment due to the damage done to the alveoli and lung tissue after
years of smoking
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:
