The case study is a hypothetical case study of Mr X

Nursing
Student name
Institution

1. Patient case
The case study is a hypothetical case study of Mr X, who is a 68-year-old male who was brought
to the intensive care department on Monday 8:00 am. The patient was diagnosed with septicemia
secondary to pressure sore infection. The patient was connected to a cardiorespiratory monitor.
D = DANGER
All equipment to manage the patient was present and in good working condition, which included
a cardiorespiratory monitor. The patient is at risk of further infection.
R = RESPONSE
Mr X is a 68-year-old male who was brought to the intensive care department on Monday 8:00
am in a confused state.
A = AIRWAY
The airway was clear and open
No artificial airway
B = BREATHING
Shortness of breath and fast breathing
Use of accessory muscles and chest in drawing
Respiratory Rate of 34 breaths per minute
The patient was put on non-invasive ventilation parameters to the cardiopulmonary ventilator
SP02 of 82%
C = CIRCULATION
Central and peripheral pulses present skin clammy and sweaty
Capillary refill at 3 seconds
The heart rate of 120 bpm and irregular in rhythm
D = DISABILITY
Pupils equal in size and not dilated and reactive to light

On normal saline infusion via an intravenous line 500 mls
GCS of 12
The patient has a urinary catheter to drain urine and intravenous infusion line
Glucose
E = ENVIRONMENT & EXCRETION (Both internal - fluids and electrolyte and external
- clear surroundings related to danger)
A third-degree pressure sore on the right sacral area
Urine through a urinary catheter
Full blood count results within 14 days show an increase in sodium and hydrogen levels in the
blood.
The skin has red patches all over the body. Temperature 38.4 degrees Celsius
F = FULL SET OF VITAL SIGNS & FLUIDS
Fluids normal saline 500 mls
Was accompanied by his daughter to the hospital
Urine output of 150 mls within the last hour
Temperature 38.4 degrees Celsius, heart rate 120bpm, blood pressure 128/82 mmHg and RR 34
breaths per minute
This includes presenting problems, drugs and diagnostic tests, equipment and technological
devices and allergies. A full safety check of the patient and the patient environment
especially at the beginning of patient care is routine. Then a thorough head to toe, system
by system assessment process is performed including psychosocial assessment.
Airway and
Breathing
The patient was connected to a cardiorespiratory monitor with a supply of
oxygen 10 litres. On inspection, there was the use of accessory muscles
with the chest in drawing while breathing. There were no scars or bruises
on the chest area. On auscultation of the lungs, there was bilateral air entry