Sepsis/Septic Shock UNFOLDING Reasoning Case Study Septic shock Keith RN Jack Holmes, 72 years old

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 Category/Subcategory Covered in 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 History of Parkinson’s Disease, COPD, CHF, HTN, depression Stage IV decubitus ulcer Found unresponsive this morning, does not respond to verbal stimuli, only sternal rubbing The blood pressure is way too low to maintain adequate perfusion of the tissues The patient has a lot of chronic illnesses that the nurse needs to take into consideration Ulcers, especially of this stage, are a large source of infection The nurse needs to start brainstorming on why the patient could be 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 Was a heavy smoker 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 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: 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: Temperature of 103.4 F Irregular pulse, 135 bpm Respiration rate of 32 BP of 76/39 O2 sat of 91% on 2L NC Unresponsive, by withdraws from pain A significant temperature, a sign of infection or inflammation occurring in the body Pules is fast and irregular, could be due to an electrolyte imbalance and could also be due to the heart trying to compensate for some other disease process going on Respirations are increased due to poor oxygenation and the body trying to compensate for poor perfusion Blood pressure is significantly low, the body tissues are not able to be perfused as well as they should be Oxygen level is low due to poor perfusion; this is the cause of the increased respiration rate The nurse should be brainstorming on why he patient is unresponsive; in this case the nurse could infer that it is also a result of the decreased perfusion Current Assessment: GENERAL APPEARANCE: Pale and warm to touch. Appears tense. RESP: Tachypneic and working hard to breathe, intercostal and suprasternal retractions present. Breath sounds diminished and light crackles in lower lobes bilat. Nail beds have noticeable clubbing, barrel chest present. CARDIAC: Pale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds NEURO: Does not open eyes to sound or pain, withdraws to pain, incomprehensible sounds to painful stimuli, does not follow commands but does not resist when moved on a stretcher. PERRL GI: Distended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants GU: Foley catheter placed to monitor urine output. 50 mL tea-colored urine with no sediment, and no odor present SKIN: Stage IV decubitus to coccyx 1 cm x 0.5 cm x 0.5 cm depth, wound bed with visual bone noted at the base with large areas of necrosis on both sides of the sacrum bone. When dressing was removed, a large amount of yellow/green purulent drainage on dressing with a foul odor. Mucus membranes dry and pale. Determine current Glasgow coma scale score based on neurological assessment data: Glasgow Coma Scale Eye Opening Spontaneous 4 To sound 3 To pain 2 Never 1 Motor Response Obeys commands 6 Localizes pain 5 Normal flexion (withdrawal) 4 Abnormal flexion 3 Extension 2 None 1 Verbal Response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Total 8 What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Pale skin color Tachypneic, working hard to breathe Diminished breath sounds, crackles in lower lobes Nail clubbing and barrel chest +1 pitting edema in lower extremities Systolic murmur Irregular heart rhythm, weak thready radial pulses Cap refill = 3 seconds Won’t open eyes, only responds to pain PERRL Firm, distended abdomen with hypoactive bowel sounds Tea colored urine with no odor or sediment Stage IV decubitus ulcer on sacrum; areas of necrosis Yellow/green drainage from pressure wound with foul odor Mucous membranes dry GCS of 8 Pale skin is a result of decreased blood flow and poor perfusion The patient is really trying hard to breathe to compensate for poor perfusion and to compensate for metabolic acidosis Crackles in the lower lobes indicate that there is fluid built up- did the patient potentially aspirate? Or is this fluid build up a result of poor cardiac output? Nail clubbing and barrel chest are long term effects of poor perfusion, most likely due to the patients extensive history of smoking and COPD There is slight pitting edema as a result of poor blood return to the heart (the blood is pooling) and as a result of capillary leak (which occurs in septic shock) Systolic murmurs are commonly heard when there are issues with the valves of the heart, but can also result from pulmonary or aortic stenosis, which could be a result of his PMH Irregular rhythms are a result of an electrolyte imbalance, weak pulses are a result of the heart being unable to pump well enough Cap refill is 3 seconds which indicates that it takes longer than it should for blood to return to the tissues Patient is unresponsive, but responds to pain; important for the nurse to note this as a baseline for the patient, which can be used to indicate if the patient’s condition is getting better or worse Pupils are equal, round and reactive, which indicates that there is not a brain injury occurring A distended abdomen can indicate an infection in the abdomen (peritonitis), but it can also indicate an obstruction, especially since there is hypoactive bowel sounds Urine is dark in color which indicates that the patient may be dehydrated; it is important to note that there is no sediment, which can be an indicator of a UTI There is a large ulcer on the sacrum, stage IV indicates that there is damage down to the bone, necrosis indicates that the tissue around the wound is now dead Yellow/green drainage is an indicator that there is infection occurring Dry mucous membranes helps to support the assumption that the patient is dehydrated GCS should be reevaluated often (hourly) to indicate if there is a change in the patient’s status; he is close to having a GCS low enough to indicate the need for intubation Cardiac Telemetry Strip: Regular/Irregular: irregular Interpretation: Atrial fibrillation P wave present? NO PR: regular length QRS: regular length Clinical Significance: The patient’s rhythm is very fast, very irregular, it looks like atrial fibrillation I would say that this bizarre rhythm is a result of an electrolyte imbalance; I believe the random firings are occurring in the atria because there is an obvious QRS complex and it is within a normal size range (3 small boxes).