NR 341 I HUMAN CASE STUDY FOR (NR 341)SEPTIC SHOCK JACK HOLMES 72 YRS OLD CAUCASSIAN LATEST 2024

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

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 Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies  Reduction of Risk Potential  Physiological Adaptation

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

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6-12% 12-18% 9-15% 11-17%

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers 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:

RELEVANT Data from Social History:

Clinical Significance:

Patient Care Begins Current VS: T: 103.4 F/39.7 C (oral)

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators of

P: 135 (irregular) R: 32 (regular) BP: 76/39 MAP: 51 O2 sat: 91% 2 liters n/c

Quality: Region/Radiation: Severity: Timing:

pain

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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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Current Assessment: Pale and warm to touch. Appears tense.

GENERAL APPEARANCE: 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 To sound To pain Never Motor Response Obeys commands Localizes pain Normal flexion (withdrawal) Abnormal flexion Extension None Verbal Response Oriented Confused conversation Inappropriate words Incomprehensible sounds None Total

4 3 2 1 6 5 4 3 2 1 5 4 3 2 1

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:

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Cardiac Telemetry Strip:

Regular/Irregular:

P wave present?

PR:

QRS:

Interpretation: Clinical Significance:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

Results: Cardiac silhouette slightly enlarged. No infiltrates present.

Radiology: Chest X-Ray Clinical Significance:

Lab Results: Current: Most Recent:

WBC 18.5 12.4

Complete Blood Count (CBC) HGB PLTs 13.1 250 13.2 175

% Neuts 85.2 64

Bands 3 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Current: Most Recent:

Na 147 138

Basic Metabolic Panel (BMP) K Gluc.

5.2 172 4.4 98

Creat.

1.6 0.88

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Misc.

Current: Most Recent:

Lactate 7.4 n/a

PT/INR 1.6 0.9

GFR 45 >60

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Current: Most Recent:

Albumin 2.9 3.1

Total Bili 5.1 0.9

Liver Panel Alk. Phos.

285 48

ALT 134 17

AST 175 12

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Current: Most Recent:

Color: Tea Yellow

Clarity: Clear Clear

Sp. Gr. 1.050 1.025

Urinalysis + UA Micro Protein Nitrite LET NEG NEG NEG NEG NEG NEG

RBCs <5 <5

WBCs <5 <5

Bacteria NEG NEG

Epithelial None None

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)

Lab:

Lactate

Normal Value:

Clinical Significance:

Nursing Assessments/Interventions Required:

Critical Value:

Value:

7.4 Clinical Reasoning Begins…

1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)

Problem:

Pathophysiology of Problem in OWN Words:

Primary Concept:

Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders:

Rationale:

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Expected Outcome:

NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Two large bore (18 g) IVs Fluid bolus 0.9% NS 30 mL/kg (2250 mL) Blood cultures x2 Urine culture Wound culture Vancomycin 2 g IV after cultures collected Clindamycin 600 mg IV every 6 hours If MAP remains <65 after 2250 mL of 0.9% NS…start Norepinephrine 1-12 mcg/min to maintain MAP >65 If MAP remains <65 after norepinephrine at 1 mcg/kg/min…start Vasopressin 0.04 units/minute to maintain MAP >65 Continuous cardiac monitor VS every 5-15” Acetaminophen 1000 mg PR every 6 hours PRN for fever >101 Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders:  2 large bore (18 g) IVs  Vancomycin 2 gram IV after cultures collected  Clindamycin 600mg IV every 6 hours  Fluid bolus 0.9% NS 30 mL/kg (2250 mL)  Blood cultures, urine culture, wound culture  Cardiac telemetry  VS every 5-15”  Acetaminophen 1000 mg PR every 6 hours PRN for temp >101

Order of Priority:

Rationale:

Collaborative Care: Nursing 2. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY: PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

3. What body system(s) will you assess most thoroughly based on the primary/priority concern?

(Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System:

PRIORITY Nursing Assessments:

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers 4.

What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient?

(Reduction of Risk Potential/Physiologic Adaptation)

Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication:

Assessments to Identify Problem EARLY:

Nursing Interventions to Rescue:

5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?

(Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES: PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

CARE/COMFORT: Caring/compassion as a nurse Physical comfort measures EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship:  Rapport  Trust  Respect  Genuineness  Empathy CULTURAL Considerations (IF APPLICABLE)

Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift.

All physician orders that have been implemented are listed under medical management.

Two hours later…

The patient received 2,250 mL 0.9% NS, and a right internal jugular central line was placed in the ED. He has required norepinephrine 6 mcg/min to maintain a MAP >65. He was transferred to the ICU an hour ago and appears to be resting comfortably. He has received both antibiotics and acetaminophen. His lactate was repeated and is now 4.8.

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Current VS:

Most Recent:

T: 101.4 F/38.6 C (oral) P: 124 (irregular) R: 24 (regular) BP: 86/56 MAP: 66 O2 sat: 93% 2 liters n/c

T: 103.4 F/39.7 C (oral) P: 135 (irregular) R: 32 (regular) BP: 76/39 MAP: 51 O2 sat: 91% 2 liters n/c

Current PQRST: Provoking/Palliative: Denies pain Quality: Region/Radiation: Severity: Timing:

Current Assessment: Calm, body relaxed, no grimacing, appears to be resting comfortably GENERAL APPEARANCE: RESP: Breath sounds diminished with crackles in lower lobes bilat, remains tachypneic but breathing not as labored CARDIAC: Pale, warm and dry, edema to BLE, heart sounds irregular with a murmur, pulses weak & equal, cap refill 2 seconds NEURO: Opens eyes to voice obeys simple commands, oriented to person only, thought he was at nursing home and had no idea what year it was.

GI: Abdomen distended, firm/nontender, bowel sounds hypoactive per auscultation in all four quadrants GU: Foley in place with tea colored, clear urine 30 mL last two hours SKIN: Dressing on coccyx replaced in ED, no drainage present on dressing Determine current Glasgow coma scale score based on neurological assessment data:

Glasgow Coma Scale Eye Opening Spontaneous To sound To pain Never Motor Response Obeys commands Localizes pain Normal flexion (withdrawal) Abnormal flexion Extension None Verbal Response Oriented Confused conversation Inappropriate words Incomprehensible sounds None Total

4 3 2 1 6 5 4 3 2 1 5 4 3 2 1

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers 1.

What data is RELEVANT and must be interpreted as clinically significant by the nurse?

(Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

RELEVANT Assessment Data:

Clinical Significance:

2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status:

Modifications to Current Plan of Care:

3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care?

(Management of Care)

CURRENT Nursing PRIORITY: PRIORITY Nursing Interventions:

Rationale:

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Expected Outcome:

NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient: (Management of Care)

Situation: Name/age: BRIEF summary of primary problem: Day of admission/post-op #:

Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data:

Assessment: Most recent vital signs: RELEVANT body system nursing assessment data:

RELEVANT lab values:

TREND of any abnormal clinical data (stable-increasing/decreasing):

How have you advanced the plan of care?

Patient response:

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation: Suggestions to advance the plan of care:

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NR341 ihuman Case Study SEPTIC SHOCK Jack Holmes 72 yrs Old Caucassian Questions And 100% Correct Answers Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family?

(Health Promotion and Maintenance)

Education PRIORITY: PRIORITY Topics to Teach:

Rationale:

Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity)

What Patient is Experiencing:

How to Engage:

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events unfold to make a correct clinical judgment.

What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future?

What Did You Learn?

How to Use to Improve Future Patient Care:

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