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.

• What is the RELATIONSHIP between RELEVANT current problem data and the primary

medical problem?RELEVANT Current Problem

Data:

Clinical Significance Low BP with MAP of 51 Stage 4 Ulcer on his coccyx that developed 3 months ago COPD, CHF, HTN, Parkinson’s disease and old age Unresponsiveness to verbal stimuli Hypoperfusion of the tissue which can hinder oxygenation Ulcer not healing due to inadequate tissue perfusion Altered immune response due to these comorbidities and lowered functioning immune system given the patient’s age.Altered LOC RELEVANT From Social

History:

Clinical Significance

Skilled Nursing Facility Bed bound due to his parkinson’s Depression More exposure to pathogens or iatrogenic illness at the facility Poor skin integrity, atrophy of muscle, renal calculi, DVT, isolation Isolation, no interest or motivation in performing ADLs, unable to self advocate, withdrawing from peers

Patient Care Begins Current VSP-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/cTiming

• What VS data are RELEVANT and must be interpreted as clinically significant by the

nurse?RELEVANT VS DataClinical Significance

Temperature is high Respiration is high BP is low O2 Sat is low (91%)

There is an active infection in the body, this can also cause higher metabolism which can lead to fatigue Compensating for low BP inorder to adequately oxygenate the tissues This is an indication of septic shock Could be normal for a patient with COPD who is a heavy former smoker with a history of 1 PPD for 40 years.

Current Assessment General appearancePale and warm to touch. Appears tense.RespirationsTachypneic 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.CardiacPale, 1+ pitting edema lower extremities, systolic murmur with an irregular rhythm, radial pulses weak and thready, cap refill 3 seconds NeuroDoes 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 GIDistended abdomen, firm/nontender, bowel sounds hypoactive in all quadrants GUFoley catheter placed to monitor urine output. 50 mL tea-colored urine with no

sediment, and no odor present SkinStage 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.

• What Jack’s Glasgow Coma Scale score?

Eye opening ___1___ Verbal Response ___2________ Motor Response ___4_____ Total ___7_____

• What assessment data are RELEVANT and must be interpreted as clinically significant by

the nurse?RELEVANT assessment DataClinical Significance 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.

Pale, 1+ pitting edema lower extremities,

Low blood pressure and low level of oxygen can lead to tachypnea inorder to compensate for poor oxygenation.It could indicate that the lungs aren’t functioning properly due to presence of fluids in the lungs as a result of CHF.Chronic hypo-oxygenation of the tissues can lead to clubbing, COPD can lead to barrel chest.Pitting edema due to his CHF, sluggish cap refill due to low BP