Sepsis/Septic Shock UNFOLDING Reasoning Case Study
STUDENT
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:
RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins
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:
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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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
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:
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.
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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)
Radiology: Chest X-Ray
Results: Clinical Significance:
Cardiac silhouette slightly
enlarged. No infiltrates present.
Lab Results: Complete Blood Count (CBC)
WBC HGB PLTs % Neuts Bands
Current: 18.5 13.1 250 85.2 3
Most Recent: 12.4 13.2 175 64 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:
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 147 5.2 172 1.6
Most Recent: 138 4.4 98 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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Misc.
Lactate PT/INR GFR
Current: 7.4 1.6 45
Most Recent: n/a 0.9 >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:
Liver Panel
Albumin Total Bili Alk. Phos. ALT AST
Current: 2.9 5.1 285 134 175
Most Recent: 3.1 0.9 48 17 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:
Urinalysis + UA Micro
Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial
Current: Tea Clear 1.050 NEG NEG NEG <5 <5 NEG None
Most Recent: Yellow Clear 1.025 NEG NEG NEG <5 <5 NEG 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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)
Lab: Normal
Value:
Clinical Significance: Nursing Assessments/Interventions Required:
Lactate
Value:
7.4
Critical Value:
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: Expected Outcome:
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.
PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale:
• 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
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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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.
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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
Current VS: Most Recent: Current PQRST: T: 101.4 F/38.6 C (oral) T: 103.4 F/39.7 C (oral) Provoking/Palliative: Denies pain P: 124 (irregular) P: 135 (irregular) Quality: R: 24 (regular) R: 32 (regular) Region/Radiation: BP: 86/56 MAP: 66 BP: 76/39 MAP: 51 Severity: O2 sat: 93% 2 liters n/c O2 sat: 91% 2 liters n/c Timing:
Current Assessment:
GENERAL
APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably
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
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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: Expected Outcome:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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:
Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.
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:
- NCLEX Client Need Categories:
- Safe and Effective Care Environment:
- Management of Care:
- Safety and Infection Control:
- 915:
- Health Promotion and Maintenance:
- Psychosocial Integrity:
- Physiological Integrity:
- Basic Care and Comfort:
- Reduction of Risk Potential:
- Physiological Adaptation:
- RELEVANT Data from Present ProblemRow1:
- Clinical SignificanceRow1:
- RELEVANT Data from Social HistoryRow1:
- Clinical SignificanceRow1_2:
- Current VS:
- PQRST Pain Assessment:
- T 1034 F397 C oral:
- ProvokingPalliative:
- Not responsive verbally withdraws to pain no other indicators of painQuality:
- R 32 regular:
- Not responsive verbally withdraws to pain no other indicators of painRegionRadiation:
- Not responsive verbally withdraws to pain no other indicators of painSeverity:
- Not responsive verbally withdraws to pain no other indicators of painTiming:
- RELEVANT VS DataRow1:
- Clinical SignificanceRow1_3:
- Current Assessment:
- Pale and warm to touch Appears tense:
- RESP:
- CARDIAC:
- NEURO:
- GI:
- GU:
- SKIN:
- Spontaneous:
- To sound:
- To pain:
- Never:
- Obeys commands:
- Localizes pain:
- Abnormal flexion:
- Extension:
- None:
- Oriented:
- Confused conversation:
- Inappropriate words:
- None_2:
- 1Total:
- RELEVANT Assessment DataRow1:
- Clinical SignificanceRow1_4:
- Cardiac Telemetry StripRow2:
- Clinical SignificanceRow1_5:
- Results:
- Clinical SignificanceCardiac silhouette slightly enlarged No infiltrates present:
- Complete Blood Count CBCRow1:
- Current:
- RELEVANT LabsRow1:
- Clinical SignificanceRow1_6:
- TREND ImproveWorseningStableRow1:
- Basic Metabolic Panel BMPRow1:
- Creat:
- Current_2:
- 16:
- 088:
- RELEVANT LabsRow1_2:
- Clinical SignificanceRow1_7:
- TREND ImproveWorseningStableRow1_2:
- MiscRow1:
- GFR:
- Current_3:
- 45:
- 60:
- RELEVANT LabsRow1_3:
- Clinical SignificanceRow1_8:
- TREND ImproveWorseningStableRow1_3:
- Liver PanelRow1:
- Current_4:
- RELEVANT LabsRow1_4:
- Clinical SignificanceRow1_9:
- TREND ImproveWorseningStableRow1_4:
- Urinalysis UA MicroRow1:
- RBCs:
- Current_5:
- RELEVANT LabsRow1_5:
- Clinical SignificanceRow1_10:
- TREND ImproveWorseningStableRow1_5:
- Lab:
- Clinical SignificanceCritical Value:
- Nursing AssessmentsInterventions RequiredCritical Value:
- ProblemRow1:
- Pathophysiology of Problem in OWN WordsRow1:
- Primary ConceptRow1:
- Care Provider Orders:
- RationaleTwo large bore 18 g IVs Fluid bolus 09 NS 30 mLkg 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 09 NSstart Norepinephrine 112 mcgmin to maintain MAP 65 If MAP remains 65 after norepinephrine at 1 mcgkgminstart Vasopressin 004 unitsminute to maintain MAP 65 Continuous cardiac monitor VS every 515 Acetaminophen 1000 mg PR every 6 hours PRN for fever 101:
- Expected OutcomeTwo large bore 18 g IVs Fluid bolus 09 NS 30 mLkg 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 09 NSstart Norepinephrine 112 mcgmin to maintain MAP 65 If MAP remains 65 after norepinephrine at 1 mcgkgminstart Vasopressin 004 unitsminute to maintain MAP 65 Continuous cardiac monitor VS every 515 Acetaminophen 1000 mg PR every 6 hours PRN for fever 101:
- Order of Priority2 large bore 18 g IVs Vancomycin 2 gram IV after cultures collected Clindamycin 600mg IV every 6 hours Fluid bolus 09 NS 30 mLkg 2250 mL Blood cultures urine culture wound culture Cardiac telemetry VS every 515 Acetaminophen 1000 mg PR every 6 hours PRN for temp 101:
- Rationale2 large bore 18 g IVs Vancomycin 2 gram IV after cultures collected Clindamycin 600mg IV every 6 hours Fluid bolus 09 NS 30 mLkg 2250 mL Blood cultures urine culture wound culture Cardiac telemetry VS every 515 Acetaminophen 1000 mg PR every 6 hours PRN for temp 101:
- Nursing PRIORITY:
- PRIORITY Nursing InterventionsRow1:
- RationaleRow1:
- Expected OutcomeRow1:
- PRIORITY Body SystemRow1:
- PRIORITY Nursing AssessmentsRow1:
- Worst PossibleMost Likely Complication to Anticipate:
- Nursing Interventions to PREVENT this ComplicationRow1:
- Assessments to Identify Problem EARLYRow1:
- Nursing Interventions to RescueRow1:
- Psychosocial PRIORITIES:
- RationaleCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
- Expected OutcomeCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
- RationaleEMOTIONAL How to develop a therapeutic relationship Discuss the following principles needed as conditions essential for a therapeutic relationship Rapport Trust Respect Genuineness Empathy:
- Expected OutcomeEMOTIONAL How to develop a therapeutic relationship Discuss the following principles needed as conditions essential for a therapeutic relationship Rapport Trust Respect Genuineness Empathy:
- RationaleCULTURAL Considerations IF APPLICABLE:
- Expected OutcomeCULTURAL Considerations IF APPLICABLE:
- Current VS_2:
- Most Recent:
- Current PQRST:
- P 124 irregular:
- Denies painQuality:
- R 24 regular:
- R 32 regular_2:
- Denies painRegionRadiation:
- Denies painSeverity:
- Denies painTiming:
- Current Assessment_2:
- Calm body relaxed no grimacing appears to be resting comfortably:
- RESP_2:
- CARDIAC_2:
- NEURO_2:
- GI_2:
- GU_2:
- SKIN_2:
- Spontaneous_2:
- To sound_2:
- To pain_2:
- Never_2:
- Obeys commands_2:
- Localizes pain_2:
- Abnormal flexion_2:
- Extension_2:
- None_3:
- Oriented_2:
- Confused conversation_2:
- Inappropriate words_2:
- None_4:
- 1Total_2:
- RELEVANT VS DataRow1:
- Clinical SignificanceRow1_11:
- RELEVANT Assessment DataRow1_2:
- Clinical SignificanceRow1_12:
- Evaluation of Current StatusRow1:
- Modifications to Current Plan of CareRow1:
- CURRENT Nursing PRIORITY:
- PRIORITY Nursing InterventionsRow1_2:
- RationaleRow1_2:
- Expected OutcomeRow1_2:
- Situation:
- Nameage BRIEF summary of primary problem Day of admissionpostop:
- Background:
- Primary problemdiagnosis RELEVANT past medical history RELEVANT background data:
- Assessment:
- Recommendation:
- Suggestions to advance the plan of care:
- Education PRIORITY:
- PRIORITY Topics to TeachRow1:
- RationaleRow1_3:
- What Patient is ExperiencingRow1:
- How to EngageRow1:
- What Did You LearnRow1:
- How to Use to Improve Future Patient CareRow1:
- Answer1:
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