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Reduction of Risk Potential 9-15% ✓ ✓ Physiological Adaptation 11-17% ✓ 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: BP of 74/40 (51) Stage IV decubitus ulcer on coccyx – bed bound Only responsive to sternal rub – grimacing and withdrawing from stimulus COPD, HTN, CHF, old age, and Parkinson’s Low blood pressure and low MAP – indicator of poor perfusion Has had stage IV ulcer for 3 months. No signs of healing – could be due to poor perfusion, poor nutrition, poor wound care, or not participating in q2 turns while bed bound. Poor skin integrity. Unresponsive to anything other than a sternal rub is a sign of an altered level of consciousness – assuming that this is not baseline for this patient. Comorbidities that can relate to a decrease in immune function. RELEVANT Data from Social History: Clinical Significance: Lives in SNF for past 3 years Bed bound Depression Higher risk for infection or illness due to exposure and living conditions at facility Is the family involved? What kind of care does he receive at this facility? Skin integrity, muscle atrophy, isolation Isolation, unable to advocate for self Patient Care Begins 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 [Show More]

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