Sepsis Case History and Initial Assessment

History Taking and Initial Care 👀 Pyelonephritis – Check for fever and urination pain and monitor body temperature rise 👀 FEMORAL FRACTURE – Check accident progress and pain area, check blood pressure and pain score 👀 Pulmonic embolism – Check for shortness of breath and oxygen saturation 👀 Pneumonia – Cough, phlegm color change, body temperature, respiratory rate check 👀 Congestion heart failure (CHF) – Check swelling and shortness of breath, monitor weight change 👀 Myocardial infarction (MI) – Check the location and duration of chest pain, check blood pressure and heart rate 👀 Stroke – Check the time and speech impairment of symptoms, observe blood pressure 👀 Diabetic ketoacidosis (DKA) – Check thirst and frequency of urination, check respiratory rate (Kussmaul breathing) 👀 Sepsis – Check fever, history of infection, monitor changes in body temperature and heart rate

 

 

 

 

 

 

 

Comprehensive Simulation Scenario for Nurse Training: Sepsis Case History and Initial Assessment

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Scenario Title: Structured Interview, Vital Signs Monitoring, and Diagnostic Preparation for Sepsis

Setting: Emergency Department / Medical Ward

Characters:

• Nurse (RN) – Responsible for the complete initial nursing assessment
• Mr. Jinho Park (Patient) – 53-year-old male presenting with signs of sepsis

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Phase 1: Patient Identification and Introduction

Nurse: Good morning, Mr. Park. I’m the nurse assisting you today. Could you please confirm your full name and date of birth?

 

Patient: Good morning. My name is Jinho Park, and my date of birth is September 15, 1970.

 

Nurse: Thank you, Mr. Park. I’ll ask you a few questions to understand your current condition better. Please share as much detail as you can. Everything you tell me will remain confidential. If you feel uncomfortable at any point, let me know.

 

 

 

 

Phase 2: History of Present Illness (HPI)

 

Nurse: When did the fever or other symptoms first begin?

 

Patient: It started two days ago.

 

Nurse: On a scale of 1 to 10, how severe are your discomfort and symptoms?

 

Patient: I’d say it’s around 7 or 8.

 

Nurse: Have you experienced any associated symptoms, such as chills, a rapid heartbeat, or difficulty breathing?

 

Patient: Yes, I’ve been feeling chills and my heart is racing. I also feel slightly out of breath.

 

Nurse: Do you feel unusually cold, confused, or dizzy?

 

Patient: Yes, I feel cold most of the time, and I’ve been light-headed since yesterday.

 

Nurse: Do your symptoms get worse or better in certain situations?

 

Patient: They seem to worsen when I try to walk around or do anything active.

 

 

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Phase 3: Past Medical History (PMH)

Nurse: Have you had any infections, hospitalizations, or surgeries in the past?

 

Patient: Yes, I had minor surgery on my leg about two weeks ago.

 

Nurse: Have you ever been diagnosed with a condition that weakens your immune system?

 

Patient: No, I haven’t.

 

 

 

 

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Phase 4: Family History (FH)

Nurse: Has anyone in your family recently experienced similar symptoms?

 

Patient: No, not that I know of.

 

Nurse: Does your family have a history of genetic or inherited diseases?

 

Patient: No, we don’t have any genetic conditions in the family.

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Phase 5: Social History (SH)

Nurse: Have you traveled recently? If so, where?

 

Patient: No, I haven’t traveled recently.

 

Nurse: Have you been in contact with anyone who was sick or had an infection?

 

Patient: Not that I’m aware of.

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Phase 6: Medication History and Allergies

Nurse: Are you currently taking any medications or supplements?

 

Patient: I’ve been taking antibiotics prescribed after my leg surgery.

 

Nurse: Have you ever had an allergic reaction to any medications?

 

Patient: No, I’ve never had an allergic reaction.

 

Nurse: Do you have any known allergies to food or environmental factors?

 

Patient: No, I don’t have any allergies.

 

 

 

 

 

 

 

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Phase 7: Vital Signs Assessment

Nurse: Mr. Park, I will now measure your vital signs to assess your current condition. Please let me know if you feel any discomfort during the process.

7.1 Temperature

Nurse: First, I’ll measure your temperature using a tympanic thermometer.

(Nurse performs hand hygiene, attaches a probe cover, gently pulls the ear upward to straighten the canal, inserts thermometer, and reads the result.)

 

Nurse: Your temperature is 38.9°C, which is above the normal range and indicates a fever.

 

 

7.2 Blood Pressure

Nurse: Next, I’ll measure your blood pressure. Please rest your arm at heart level.

(Nurse positions cuff 2–3 cm above elbow, inflates, auscultates using a stethoscope.)

 

Nurse: Your blood pressure is 90/60 mmHg, which is hypotensive and may reflect sepsis-induced circulatory compromise.

 

 

7.3 Pulse

Nurse: Now I’ll check your pulse.

(Nurse places fingers on radial artery and counts for one full minute.)

 

Nurse: Your pulse rate is 115 beats per minute. That’s tachycardic and consistent with systemic infection.

 

 

7.4 Respiratory Rate

Nurse: Lastly, I’ll assess your breathing.

(Nurse observes chest movement discreetly for one minute.)

 

Nurse: Your respiratory rate is 24 breaths per minute, which is elevated and may indicate respiratory compensation.

 

 

 

 

 

 

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Phase 8: Clinical Summary and Immediate Nursing Actions

Nurse: Based on your vital signs and symptoms:

• Fever (38.9°C): Suggests systemic infection
• Low blood pressure (90/60 mmHg): Suggestive of circulatory compromise
• Tachycardia (115 bpm): Indicates increased cardiac workload
• Tachypnea (24 bpm): May be compensating for metabolic acidosis

These signs are consistent with suspected sepsis and require urgent medical attention. We will proceed with the following diagnostic investigations.

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Phase 9: Diagnostic Testing and Rationale

Nurse: Mr. Park, we need to run some tests to help confirm the diagnosis and guide treatment:

1. Blood Tests:
   • Complete Blood Count (CBC)
   • Serum lactate (to evaluate tissue perfusion)
   • C-reactive protein (CRP) and Procalcitonin (infection markers)
   • Renal and liver function
   • Blood glucose
2. Blood Cultures:
   • Two sets of cultures before starting IV antibiotics, to identify causative organisms
3. Urinalysis and Urine Culture:
   • To detect urinary tract infections, a common source of sepsis
4. Imaging Tests:
   • Chest X-ray (to assess for pneumonia)
   • Abdominal ultrasound or CT if intra-abdominal infection is suspected
5. ECG Monitoring:
   • To detect sepsis-related arrhythmias or electrolyte imbalance

 

 

 

 

 

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Phase 10: Patient Education and Reassurance

Nurse: These tests are mostly non-invasive and generally well-tolerated. The blood draw may cause slight discomfort, but we’ll try to minimize any pain.

While we wait for the test results:

• Stay in bed and avoid unnecessary movement
• Stay hydrated as permitted
• Notify staff immediately if you experience worsening dizziness, chest pain, confusion, or difficulty breathing

We are monitoring you closely, and your care team will administer IV fluids, oxygen (if needed), and start antibiotics promptly once cultures are taken.

 

Patient: Will I need to stay in the hospital?

 

Nurse: Most likely, yes. Sepsis often requires inpatient care for close monitoring, IV medications, and supportive treatment. We’ll coordinate with your physician right away.

 

Patient: Thank you for explaining everything clearly.

 

Nurse: You’re welcome, Mr. Park. Let’s begin with the blood draw and cultures. If you feel worse at any time, press the call button immediately.

 

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Learning Objectives for Nurse Trainees

• Conduct a structured case history focused on infection onset and systemic impact
• Recognize early signs of sepsis through symptoms and abnormal vital signs
• Implement urgent assessment and initiate sepsis protocol steps (fluid resuscitation, early cultures, labs)
• Communicate clearly and empathetically with patients in crisis
• Prepare patients for diagnostic procedures while promoting comfort and safety

End of Scenario

 

 

 

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Dialysis nursing

 

Continuous Ambulatory Peritoneal Dialysis (CAPD) Patient Care :Comprehensive Simulation Scenario for Nurse Training

 

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History Taking and Initial Care
👀 Pyelonephritis – Check for fever and urination pain and monitor body temperature rise
👀 FEMORAL FRACTURE – Check accident progress and pain area, check blood pressure and pain score
👀 Pulmonic embolism – Check for shortness of breath and oxygen saturation
👀 Pneumonia – Cough, phlegm color change, body temperature, respiratory rate check
👀 Congestion heart failure (CHF) – Check swelling and shortness of breath, monitor weight change
👀 Myocardial infarction (MI) – Check the location and duration of chest pain, check blood pressure and heart rate
👀 Stroke – Check the time and speech impairment of symptoms, observe blood pressure
👀 Diabetic ketoacidosis (DKA) – Check thirst and frequency of urination, check respiratory rate (Kussmaul breathing)
👀 Sepsis – Check fever, history of infection, monitor changes in body temperature and heart rate

 

Sepsis Case History and Initial Assessment