NR341 ihuman Case Study SEPTIC SHOCK Jack
Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
NR341 ihuman Case Study SEPTIC
SHOCK Jack
Holmes 72 yrs Old Caucassian
Questions And 100% Correct
Answers
Sepsis/Septic Shock
UNFOLDING Reasoning Case StudY
Jack Holmes, 72 years old
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, NR341 ihuman Case Study SEPTIC SHOCK Jack
Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
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 Covered in
Each 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%
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:
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, NR341 ihuman Case Study SEPTIC SHOCK Jack
Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
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 Clinical Significance:
Problem:
RELEVANT Data from Social Clinical Significance:
History:
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment:
T: 103.4 F/39.7 C Provoking/Palliative: Not responsive verbally, withdraws to pain, no other
(oral) indicators of
pain
P: 135 (irregular) Quality:
R: 32 (regular) Region/Radiation:
BP: 76/39 MAP: 51 Severity:
O2 sat: 91% 2 liters Timing:
n/c
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:
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Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
NR341 ihuman Case Study SEPTIC
SHOCK Jack
Holmes 72 yrs Old Caucassian
Questions And 100% Correct
Answers
Sepsis/Septic Shock
UNFOLDING Reasoning Case StudY
Jack Holmes, 72 years old
Downloaded by charity nimo ()
, NR341 ihuman Case Study SEPTIC SHOCK Jack
Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
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 Covered in
Each 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%
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:
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, NR341 ihuman Case Study SEPTIC SHOCK Jack
Holmes 72 yrs Old Caucassian Questions And 100%
Correct Answers
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 Clinical Significance:
Problem:
RELEVANT Data from Social Clinical Significance:
History:
Patient Care Begins
Current VS: P-Q-R-S-T Pain Assessment:
T: 103.4 F/39.7 C Provoking/Palliative: Not responsive verbally, withdraws to pain, no other
(oral) indicators of
pain
P: 135 (irregular) Quality:
R: 32 (regular) Region/Radiation:
BP: 76/39 MAP: 51 Severity:
O2 sat: 91% 2 liters Timing:
n/c
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:
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