Sepsis/Septic Shock
UNFOLDING Reasoning Case Study
STUDENT
JackiHolmes,i72iyearsiold
Primary Concept
Perfusion
InterrelatediConceptsi(Iniorderiofiemphasis)
• Inflammation
• Infection
• TissueiIntegrity
• ClinicaliJudgment
• PatientiEducation
• Communication
NCLEXiClientiNeediCategories PercentageiofiItemsifromiEach Coverediin
Category/Subcategory CaseiStudy
SafeiandiEffectiveiCareiEnvironment
✓ ManagementiofiCare 17-23%
✓ SafetyiandiInfectioniControl 9-15%
HealthiPromotioniandiMaintenance 6-12%
PsychosocialiIntegrity 6-12%
PhysiologicaliIntegrity
✓ BasiciCareiandiComfort 6-12%
✓ PharmacologicaliandiParenteraliTherapies 12-18%
✓ ReductioniofiRiskiPotential 9-15%
✓ PhysiologicaliAdaptation 11-17%
, HistoryiofiPresentiProblem:
JackiHolmesiai72-year-
oldiCaucasianimaleibroughtitoitheiEDibyiambulanceifromiaiskilledinursingifacilityi(SNF).iAccordingitoireportifromitheipa
ramedic,iwhenitheiSNFinursingistaffiattempteditoiwakeihimithisimorning,iheiwouldinotirespond,iandihisiBPiwasi74/40iwith
iaiMAPiofi51.iHeihasiaihistoryiofiParkinson’sidisease,iCOPD,iCHF,iHTN,idepression,iandiaistageiIVidecubitusiulcerionihi
sicoccyxithatidevelopedithreeimonthsiago.iHeidoesinotifollowicommands,iisiunresponsiveitoiverbalistimuli,ibutirespondsit
oiaisternalirubiwithigrimacingiandiwithdrawingifromistimulus.
Personal/SocialiHistory:
HeihasilivediinitheiskilledinursingifacilityitheipastithreeiyearsiandihasibeenibedibounditheipastiyearidueitoihisiadvancediParkinson
disease.iHeiwasiaiheavyismoker,i1iPPDifori40iyearsiuntiliheimoveditoitheiSNF.
WhatidataifromitheihistoriesiareiRELEVANTiandimustibeiinterpretediasiclinicallyisignificantibyitheinurse?
(ReductioniofiRiskiPotential)
RELEVANTiDataifromiPresentiProblem: ClinicaliSignificance:
BPiofi74/40 Theibloodipressureiisiwayitooilowitoimaintainiadequateiperfusioniofitheitissu
es
HistoryiofiParkinson’siDisease,iCOPD,iCHF,i Theipatientihasiailotiofichroniciillnessesithatitheinurseineedsitoitakeiintoicons
HTN,idepression ideration
StageiIVidecubitusiulcer Ulcers,iespeciallyiofithisistage,iareiailargeisourceiofiinfection
Foundiunresponsiveithisimorning,idoesinotires Theinurseineedsitoistartibrainstormingioniwhyitheipatienticouldibeiunrespon
ponditoiverbalistimuli,ionlyisternalirubbing sive,iandiitiisiimportantitoinoteithatitheipatientiisistilliableitoiresponditoiverb
alistimuli;itheinurseialsoineedsitoibeisureitoidocumentithis
asiaibaselineilevelioficonsciousness
RELEVANTiDataifromiSocialiHistory: ClinicaliSignificance:
Bediboundiforitheipastiyear Patient’siwhoiareibediboundiareiatiaimuchihigherichanceiofiillnessidueitoidec
reasedimovement,itheiformationiofibedisores,idecreasediexerciseiandimostili
kelyipoorinutrition
Wasiaiheavyismoker Heavyismokersiareiatiaigreateririskiofidevelopingirespiratoryiinfections
andiimpairmentidueitoitheidamageidoneitoitheialveoliiandilungitissueiafteriye
arsiofismoking
PatientiCareiBegins
CurrentiVS: P-Q-R-S-TiPainiAssessment:
T:i103.4iF/39.7iCi(oral) Provoking/Palliative: Notiresponsiveiverbally,iwithdrawsitoipain,inoiotheriindicatorsiof
pain
P:i135i(irregular) Quality:
R:i32i(regular) Region/Radiation:
BP:i76/39iMAP:i51 Severity:
O2isat:i91%i2ilitersin/c Timing:
, WhatiVSidataiareiRELEVANTiandimustibeiinterpretediasiclinicallyisignificantibyitheinurse?
(ReductioniofiRiskiPotential/HealthiPromotioniandiMaintenance)
RELEVANTiVSiData: ClinicaliSignificance:
Temperatureiofi103.4iFiI Aisignificantitemperature,iaisigniofiinfectionioriinflammationioccurringiinitheibody
rregularipulse,i135ibpm Pulesiisifastiandiirregular,icouldibeidueitoianielectrolyteiimbalanceiandicouldialsoibeidueitoitheihe
artitryingitoicompensateiforisomeiotheridiseaseiprocessigoingion
Respirationirateiofi32i Respirationsiareiincreasedidueitoipoorioxygenationianditheibodyitryingitoicompensateiforipooripe
rfusion
BPiofi76/39 Bloodipressureiisisignificantlyilow,itheibodyitissuesiareinotiableitoibeiperfusediasiwelliasitheyisho
uldibe
O2isatiofi91%ioni2LiNCi Oxygenileveliisilowidueitoipooriperfusion;ithisiisitheicauseiofitheiincreasedirespirationirateiT
Unresponsive,iby heinurseishouldibeibrainstormingioniwhyiheipatientiisiunresponsive;iinithisicaseitheinurse
withdrawsifromipain couldiinferithatiitiisialsoiairesultiofitheidecreasediperfusion
CurrentiAssessment:
GENERAL Paleiandiwarmitoitouch.iAppearsitense.
APPEARANCE:
RESP: Tachypneiciandiworkingiharditoibreathe,iintercostaliandisuprasternaliretractionsipresent.
Breathisoundsidiminishediandilighticracklesiinilowerilobesibilat.iNailibedsihaveinoticeableiclub
bing,ibarrelichestipresent.
CARDIAC: Pale,i1+ipittingiedemailoweriextremities,isystolicimurmuriwithianiirregularirhythm,iradial
pulsesiweakiandithready,icapirefilli3iseconds
NEURO: Doesinotiopenieyesitoisoundioripain,iwithdrawsitoipain,iincomprehensibleisoundsitoipainful
stimuli,idoesinotifollowicommandsibutidoesinotiresistiwhenimovedioniaistretcher.iPERRL
GI: Distendediabdomen,ifirm/nontender,ibowelisoundsihypoactiveiinialliquadrants
GU: Foleyicatheteriplaceditoimonitoriurineioutput.i50imLitea-colorediurineiwithinoisediment,
andinoiodoripresent
SKIN: StageiIVidecubitusitoicoccyxi1icmixi0.5icmixi0.5icmidepth,iwoundibediwithivisualiboneinotedi
atitheibaseiwithilargeiareasiofinecrosisionibothisidesiofitheisacrumibone.iWhen
dressingiwasiremoved,iailargeiamountiofiyellow/greenipurulentidrainageionidressingiwithiaifou
liodor.iMucusimembranesidryiandipale.
DetermineicurrentiGlasgowicomaiscaleiscoreibasedionineurologicaliassessmentidata:
GlasgowiComaiScale
EyeiOpening
Spontaneous 4
Toisound 3
Toipain 2
Never 1
MotoriResponse
Obeysicommands 6
Localizesipain 5
Normaliflexioni(withdrawal) 4
Abnormaliflexion 3
Extension 2
None 1
VerbaliResponse
Oriented 5
Confusediconversation 4
Inappropriateiwords 3
Incomprehensibleisounds 2
None 1
Total 8
UNFOLDING Reasoning Case Study
STUDENT
JackiHolmes,i72iyearsiold
Primary Concept
Perfusion
InterrelatediConceptsi(Iniorderiofiemphasis)
• Inflammation
• Infection
• TissueiIntegrity
• ClinicaliJudgment
• PatientiEducation
• Communication
NCLEXiClientiNeediCategories PercentageiofiItemsifromiEach Coverediin
Category/Subcategory CaseiStudy
SafeiandiEffectiveiCareiEnvironment
✓ ManagementiofiCare 17-23%
✓ SafetyiandiInfectioniControl 9-15%
HealthiPromotioniandiMaintenance 6-12%
PsychosocialiIntegrity 6-12%
PhysiologicaliIntegrity
✓ BasiciCareiandiComfort 6-12%
✓ PharmacologicaliandiParenteraliTherapies 12-18%
✓ ReductioniofiRiskiPotential 9-15%
✓ PhysiologicaliAdaptation 11-17%
, HistoryiofiPresentiProblem:
JackiHolmesiai72-year-
oldiCaucasianimaleibroughtitoitheiEDibyiambulanceifromiaiskilledinursingifacilityi(SNF).iAccordingitoireportifromitheipa
ramedic,iwhenitheiSNFinursingistaffiattempteditoiwakeihimithisimorning,iheiwouldinotirespond,iandihisiBPiwasi74/40iwith
iaiMAPiofi51.iHeihasiaihistoryiofiParkinson’sidisease,iCOPD,iCHF,iHTN,idepression,iandiaistageiIVidecubitusiulcerionihi
sicoccyxithatidevelopedithreeimonthsiago.iHeidoesinotifollowicommands,iisiunresponsiveitoiverbalistimuli,ibutirespondsit
oiaisternalirubiwithigrimacingiandiwithdrawingifromistimulus.
Personal/SocialiHistory:
HeihasilivediinitheiskilledinursingifacilityitheipastithreeiyearsiandihasibeenibedibounditheipastiyearidueitoihisiadvancediParkinson
disease.iHeiwasiaiheavyismoker,i1iPPDifori40iyearsiuntiliheimoveditoitheiSNF.
WhatidataifromitheihistoriesiareiRELEVANTiandimustibeiinterpretediasiclinicallyisignificantibyitheinurse?
(ReductioniofiRiskiPotential)
RELEVANTiDataifromiPresentiProblem: ClinicaliSignificance:
BPiofi74/40 Theibloodipressureiisiwayitooilowitoimaintainiadequateiperfusioniofitheitissu
es
HistoryiofiParkinson’siDisease,iCOPD,iCHF,i Theipatientihasiailotiofichroniciillnessesithatitheinurseineedsitoitakeiintoicons
HTN,idepression ideration
StageiIVidecubitusiulcer Ulcers,iespeciallyiofithisistage,iareiailargeisourceiofiinfection
Foundiunresponsiveithisimorning,idoesinotires Theinurseineedsitoistartibrainstormingioniwhyitheipatienticouldibeiunrespon
ponditoiverbalistimuli,ionlyisternalirubbing sive,iandiitiisiimportantitoinoteithatitheipatientiisistilliableitoiresponditoiverb
alistimuli;itheinurseialsoineedsitoibeisureitoidocumentithis
asiaibaselineilevelioficonsciousness
RELEVANTiDataifromiSocialiHistory: ClinicaliSignificance:
Bediboundiforitheipastiyear Patient’siwhoiareibediboundiareiatiaimuchihigherichanceiofiillnessidueitoidec
reasedimovement,itheiformationiofibedisores,idecreasediexerciseiandimostili
kelyipoorinutrition
Wasiaiheavyismoker Heavyismokersiareiatiaigreateririskiofidevelopingirespiratoryiinfections
andiimpairmentidueitoitheidamageidoneitoitheialveoliiandilungitissueiafteriye
arsiofismoking
PatientiCareiBegins
CurrentiVS: P-Q-R-S-TiPainiAssessment:
T:i103.4iF/39.7iCi(oral) Provoking/Palliative: Notiresponsiveiverbally,iwithdrawsitoipain,inoiotheriindicatorsiof
pain
P:i135i(irregular) Quality:
R:i32i(regular) Region/Radiation:
BP:i76/39iMAP:i51 Severity:
O2isat:i91%i2ilitersin/c Timing:
, WhatiVSidataiareiRELEVANTiandimustibeiinterpretediasiclinicallyisignificantibyitheinurse?
(ReductioniofiRiskiPotential/HealthiPromotioniandiMaintenance)
RELEVANTiVSiData: ClinicaliSignificance:
Temperatureiofi103.4iFiI Aisignificantitemperature,iaisigniofiinfectionioriinflammationioccurringiinitheibody
rregularipulse,i135ibpm Pulesiisifastiandiirregular,icouldibeidueitoianielectrolyteiimbalanceiandicouldialsoibeidueitoitheihe
artitryingitoicompensateiforisomeiotheridiseaseiprocessigoingion
Respirationirateiofi32i Respirationsiareiincreasedidueitoipoorioxygenationianditheibodyitryingitoicompensateiforipooripe
rfusion
BPiofi76/39 Bloodipressureiisisignificantlyilow,itheibodyitissuesiareinotiableitoibeiperfusediasiwelliasitheyisho
uldibe
O2isatiofi91%ioni2LiNCi Oxygenileveliisilowidueitoipooriperfusion;ithisiisitheicauseiofitheiincreasedirespirationirateiT
Unresponsive,iby heinurseishouldibeibrainstormingioniwhyiheipatientiisiunresponsive;iinithisicaseitheinurse
withdrawsifromipain couldiinferithatiitiisialsoiairesultiofitheidecreasediperfusion
CurrentiAssessment:
GENERAL Paleiandiwarmitoitouch.iAppearsitense.
APPEARANCE:
RESP: Tachypneiciandiworkingiharditoibreathe,iintercostaliandisuprasternaliretractionsipresent.
Breathisoundsidiminishediandilighticracklesiinilowerilobesibilat.iNailibedsihaveinoticeableiclub
bing,ibarrelichestipresent.
CARDIAC: Pale,i1+ipittingiedemailoweriextremities,isystolicimurmuriwithianiirregularirhythm,iradial
pulsesiweakiandithready,icapirefilli3iseconds
NEURO: Doesinotiopenieyesitoisoundioripain,iwithdrawsitoipain,iincomprehensibleisoundsitoipainful
stimuli,idoesinotifollowicommandsibutidoesinotiresistiwhenimovedioniaistretcher.iPERRL
GI: Distendediabdomen,ifirm/nontender,ibowelisoundsihypoactiveiinialliquadrants
GU: Foleyicatheteriplaceditoimonitoriurineioutput.i50imLitea-colorediurineiwithinoisediment,
andinoiodoripresent
SKIN: StageiIVidecubitusitoicoccyxi1icmixi0.5icmixi0.5icmidepth,iwoundibediwithivisualiboneinotedi
atitheibaseiwithilargeiareasiofinecrosisionibothisidesiofitheisacrumibone.iWhen
dressingiwasiremoved,iailargeiamountiofiyellow/greenipurulentidrainageionidressingiwithiaifou
liodor.iMucusimembranesidryiandipale.
DetermineicurrentiGlasgowicomaiscaleiscoreibasedionineurologicaliassessmentidata:
GlasgowiComaiScale
EyeiOpening
Spontaneous 4
Toisound 3
Toipain 2
Never 1
MotoriResponse
Obeysicommands 6
Localizesipain 5
Normaliflexioni(withdrawal) 4
Abnormaliflexion 3
Extension 2
None 1
VerbaliResponse
Oriented 5
Confusediconversation 4
Inappropriateiwords 3
Incomprehensibleisounds 2
None 1
Total 8
