Jack Holmes Sepsis PDF

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Summary

case study about sepsis
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...

Description

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

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

✓ ✓ ✓

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

✓ ✓ ✓ ✓

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

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: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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:

- BP 74/40 MAP 51 - IV decubitus ulcer on coccyx 3 months old - Pt unresponsive to verbal stimuli but responds to sternal rub pain stimulus by grimacing and withdrawing from stimulus. - 72 y/o advance stage of Parkinson’s disease - Pt hx of COPD, CHF, HTN, depression

- infection plus low blood pressure signs for septic shock.

RELEVANT Data from Social History: - leave at the nursing home for 3 years. Being on bed from a year now. Former smoker 1 package a day for 40 years

- pt is still breathing and responding to stimuli, no CPR needed when found. Sign of progressive stage of septic shock - compromise oxygenation and tissue perfusion due to pt hx of cardiac and respiratory issues - Parkinson is a debilitating neurogenerative disease, stick muscles and depressions ( decline production of dopamine) are signs of an advance stage. Clinical Significance: - no family support - depression due to diagnosis, lack of independence - lung damage, heart, and vascular damage due to smoking, COPD

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: -↑ temp -↑HR -↑respirations - ↓ BP/ systolic BP 65 indication appropriate medicines will help regulate BP, and CO, tissue perfusion, cells getting tissue perfusion appropriate oxygenation and elements to survive. ↓ hypoxia

- administering antibiotic

- administering pain medicine

- constant VS, ABG, respiratory status, LOC, lab values like BUN, creatinine, AST, PT, etc..

- fight infection - provide comfort, reduce anxiety. Pt is unresponsive but that does not mean is not in pain - constant monitoring is important: A) with critical care pt, to intervene soon when a sudden change is detected . B) to evaluate if current treatment and interventions are working or need to be changed.

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

- pt will not be on septic shock anymore - pt will not be in pain.

- pt will not be on the progressive

stage, pt will be on the compensatory stage or initial to non-stages of shock

- oxygen is important to promote tissue perfusion . - mechanical ventilation will prevent lungs for collapsing

- administer appropriate oxygenation/ if mechanical ventilated proper care is required

- gas exchange and lung function will be WNL

- pt at high risk for Vfib or Vtach - liver is not able to process glucose, to much glucose on vascular system makes - heart function will be preserved the blood thick, this increase heart work. Insulin will help cell to accept glucose - glucose level WNL and use it to produce energy and function right

- monitoring heart rhythm - possible order insulin to help glucose entering cells

-Important to prevent nosocomial infection like VAP, MRSA, or C-diff when treating the pt that is already in a very critical state

- PT will be free of nosocomial infections while receiving care

- keep an aseptic technique with all the interventions.

- important to monitor kidney function and hydration status, internal hemorrhages

- assess and monitor O/I

- as the septic shock advances the GI - kidney will be functioning. Pt will be system deteriorates, wall become less hydrated. No internal hemorrhages resistant to GI acid causing ulcer, causing detected hemorrhages. Coagulation system overwhelmed and depleted. Pt starts bleeding from every orifice. IV site start bleeding a little bit, an early sing of DIC - pt condition wont progress to ulcer, internal hemorrhage, or DIC

- assess IV and other opening access for infections and signs of DIC

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:

Circulatory system, but on a septic shock all the systems are failing and must be monitored.

- constant monitoring

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 Septic shock progressing to the Death Complication to Anticipate: irreversible stage Nursing Interventions to PREVENT this Complication: ALL above number 2

Assessments to Identify Problem EARLY: Lab values, respirations, LOC, BP, MAP

Nursing Interventions to Rescue: Fluid resuscitation and assess/monitor VS

5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

Communicate with pt even when he is

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

PRIORITY Nursing Interventions: CARE/COMFORT: Caring/compassion as a nurse

unresponsive Rationale: - provide companionship. Talk soft to him, be kind. - Trying to communicate with any family member.

Physical comfort measures EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: 1. Rapport 2. Trust 3. Respect 4. Genuineness 5. Empathy

CULTURAL Considerations (IF APPLICABLE)

- turn pt, provide oral care, touch hand or shoulder when talking to him 1) maintain eye contact, show empathy, open communication, active listening

Expected Outcome: -rapport, trust pt-RN communication - pt will be aware of the RN presence

- Stablished trust PT-RN relationship.

2) Be open and honest, no sugar coating patient condition, keep promises. Example, if RN tell pt she will be back in 15 min, be back in 15 min. 3) Show respect when talking to pt, honor his desires, even if family members do not agree, respect pt autonomy. 4) Looking at the eye, be honest, listening, smile, try to answer all pt questions or get help with other health team members. 5) Show your humanity, serve pt as you want others to serve you, as he was a family member, provide excellent care, keep pt safe. - be aware of any rituals, or religious practices that the pt or family need. Advocate for it, provide space, help, inform Dr. about it. Honor pt wishes when possible

- pt beliefs, religion, desires will be taken in consideration in his care plan.

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.

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:

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Current Assessment: GENERAL Calm, body relaxed, no grimacing, appears to be resting comfortably 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 13

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: ↑HR,RR, O2 sat MAP 66, SBP close to 90 trending ↑ ↓Temp

Clinical Significance: - Pt is reacting positive to fluid resuscitation and antibiotics - tissue perfusion is now happening - Vascular fluid is increasing, CO increasing too. System trying to compensate to reach homeostasis

RELEVANT Assessment Data:

Clinical Significance:

Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved.

- Pain no sign, comfortable, relaxed - Eyes opening to voice, LOCx1 - breathing less laboring, still crackles on the lower part of lungs -skin warm, dry, pale cap refill...