Jack Holmes, 72 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
• Inflammation
• Infection
• Tissue Integrity
• Clinical Judgment
• Patient Education
• Communication
NCLEX Clien
...
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
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