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
...
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:
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 Data 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 per.................................CONTINUE
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