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% 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: Temperature of 103.4 F Irregular pulse, 135 bpm Respiration rate of 32 BP of 76/39 O2 sat of 91% on 2L NC Unresponsive, by withdraws from pain A significant temperature, a sign of infection or inflammation occurring in the body Pules is fast and irregular, could be due to an electrolyte imbalance and could also be due to the heart trying to compensate for some other disease process going on Respirations are increased due to poor oxygenation and the body trying to compensate for poor perfusion Blood pressure is significantly low, the body tissues are not able to be perfused as well as they should be Oxygen level is low due to poor perfusion; this is the cause of the increased respiration rate The nurse should be brainstorming on why he patient is unresponsive; in this case the nurse could infer that it is also a result of the decreased perfusion 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. 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