Osteomyelitis and Acute Kidney Injury Care Plan PDF

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Osteomyelitis and AKI Care Plan...

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Page | 1 Basic Adult Health Concept Map Student Name:

Date:

Client Data: Initials: T.L.

Age: 66-years-old

Gender: Male

Weight: 63.4 kg / 139.5 lb.

Height: 167.65 cm / 5’5”

Race/Ethnicity: Caucasian

Diet: Diabetic, low sugar

Religion: Christian

Room Number: 73-1

Allergies: NKA

Marital Status: Unable to obtain

Code Status: Full code

Past Surgeries: 1. Appendectomy 2. Tonsillectomy 3. Bifemoral bypass graft with vein 4. Bypass of femoral artery by anastomosis of femoral artery to perineal artery using vein graft 5. Bypass femoral popliteal (Right) 6. I&D debridement lower extremity 7. Amputation below the knee (Right)

Consults: 1. Vascular 2. Nephrology 3. Psychiatric 4. Infectious disease 5. Surgery 6. Physical therapy 7. Occupational therapy 8. Social worker

Social Habits: Quit smoking 12 years ago, Current beer drinker (1-2 times a month), Current everyday coffee drinker (1-2 times a day), Lives alone. Christian.

Vital Signs: Admission:

B/P: 126/86

P: 82 bpm

R: 14

T: 97.7 oral

SAO2 sat: 95% RA

Date of care:

146/84

84 bmp

20

98.2 oral

97% RA

Page | 2 Basic Adult Health Concept Map Present History: Admitting Medical Diagnosis: A. Why client is in hospital: Patient was found by home health nurse laying in his sofa covered in stool and urine. Home health nurse called 911.

B. Admitting Diagnosis Information: Osteomyelitis, Acute Kidney Injury, Urinary Tract Infection

Definition/Etiology/Pathophysiology: Osteomyelitis is inflammation of the bone caused by an infecting organism (Kishner, 2020). Bone usually is resistant to infection. However, infections can reach the bone by traveling through the bloodstream, spreading nearby tissue, or from direct inoculation related to surgery or trauma, osteomyelitis can occur (Mayo Clinic Staff, 2020). Bone infection may also result from trauma treatment, which can allow pathogens to enter the bone and proliferate in the traumatized tissue (Kishner, 2020). Smokers and people with chronic conditions, such as diabetes mellitus or kidney failure, are more likely to develop osteomyelitis. A diabetic patient may also develop osteomyelitis in their feet if they have foot ulcers (Mayo Clinic Staff, 2020). When bone infection persists for months, the resulting infection is referred to as chronic osteomyelitis and may be polymicrobial. Although all bones can suffer osteomyelitis, the lower extremities are most affected (Kishner, 2020). Osteomyelitis can be classified as acute, subacute,

Page | 3 Basic Adult Health Concept Map or chronic, depending on its duration. Osteomyelitis was considered incurable; it now can be successfully treated. Most people need people to remove areas of the bone that have died. After surgery, strong intravenous antibiotics are needed (Mayo Clinic Staff, 2020). According to Stephen Kishner, MD (2020), “Important factors in the pathogenesis of osteomyelitis include: 

Virulence of the infecting organism

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Underlying disease

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Immune status of the host

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Type, location, and vascularity of the bone

Bacteria may possess various factors that may contribute to the development of osteomyelitis. For example, factors promoted by Staphylococcus aureus may promote bacterial adherence, resistance to host defense mechanisms, and proteolytic activity”. The best way to prevent osteomyelitis is to keep things clean. Flushing out any open wound under running water for five minutes, then bandage it in sterile bandages (Baker, 2021). For chronic osteomyelitis, patient-provider communication is essential. The provider should be aware of the medical history to work together to keep the condition under control. People with diabetes should pay close attention to their feet and contact their medical provider at the first sign of infection (Baker, 2021). The sooner osteomyelitis is treated, the better the outcome will be. In cases of acute osteomyelitis, early treatment prevents the condition from becoming a chronic problem that requires continuous treatment. Besides the pain and inconvenience of repeated infections, getting osteomyelitis under control early provides the best opportunity for recovery (Baker, 2021).

Page | 4 Basic Adult Health Concept Map Clinical Manifestations/signs and symptoms: Acute osteomyelitis develops rapidly over a 7-10 day period. The symptoms for acute and chronic osteomyelitis are very similar and include (Baker, 2021): 

Fever

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Irritability

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Fatigue

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Tenderness, redness, and warmth in the area of the infection

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Swelling around the affected bone

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Lost range of motion

Sometimes osteomyelitis causes no signs and symptoms, or the signs and symptoms are hard to distinguish from other problems. This proves to be more evident in infants, older adults, and immunocompromised people (Mayo Clinic Staff, 2020).

Medical Management: The medical management of osteomyelitis may require a multidimensional, multidisciplinary plan involving a team consisting of the orthopedic surgeon, an infectious disease consultant, a plastic surgeon (depending on the location), a microbiologist, and others, depending on the location and severity (Kishner, 2020). The first step is to determine if the disease is acute, chronic, or an acute exacerbation of a chronic condition or a partially treated subacute osteomyelitis (Kishner, 2020). Determining the severity of the disease is surprisingly tricky. Doctors rely on X-rays, blood tests, MRI, and bone scans to get a picture of what's going on (Baker, 2021). A bone biopsy may also be needed to de-

Page | 5 Basic Adult Health Concept Map termine the type of organism causing the infection so the proper medication can be given (Baker, 2021). Acute osteomyelitis must be treated surgically to drain pus and prevent bone necrosis. Antibiotics suitable to the patient's age and the organism are given to control the hematogenous spread and treat the local infection. In other words, antibiotics save a life, and surgery helps save bone. Debridement of necrotic tissues, removal of foreign materials, and sometimes skin closure of chronic unhealed wounds is necessary in some cases (Kishner, 2020). Treatment of osteomyelitis is focused on stopping the infection in its track and preserving as much function as possible in the affected area. Treatment usually consists of antibiotic therapy, surgery, or both (Baker, 2021). For more severe or chronic osteomyelitis, surgery is required to remove the infected tissue and bone. Amputation is the last resort and is only used when other options have been exhausted (Baker, 2021).

Page | 6 Basic Adult Health Concept Map Past History/Secondary Diagnosis: Acute Kidney Injury (AKI)

Definition/Etiology/Pathophysiology: Acute kidney injury (AKI) is the leading cause of nephrology consultation and is associated with a high mortality rate (Palevsky, 2021). It occurs when the kidneys suddenly become unable to filter waste products from the blood. When the kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and the blood's chemical makeup may get out of balance (Mayo Clinic Staff, 2020). The damage that leads to AKI may be caused by (American Kidney Fund, 2021).:

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Not enough blood flowing through your kidneys

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An injury directly to your kidneys or a problem with your kidneys

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A blockage in your ureters, the tubes that take urine from your kidneys to your bladder

Acute kidney injury, also called an acute renal failure or acute kidney failure, develops rapidly, usually in less than a few days. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care (Mayo Clinic Staff, 2020). Acute kidney injury can be fatal and requires intensive treatment. However, acute kidney injury can be reversible. If otherwise healthy, normal, or nearly normal, kidney function may be recovered (Mayo Clinic Staff, 2020).

Page | 7 Basic Adult Health Concept Map Some people have lasting kidney damage after AKI. This is called chronic kidney disease, and it could lead to kidney failure if steps are not taken to prevent the kidney damage from getting worse (American Kidney Fund, 2021). The primary causes of AKI include ischemia, hypoxia, or nephrotoxicity. An underlying feature is a rapid decline in GFR usually associated with decreases in renal blood flow. Because AKI happens suddenly, it can be hard to predict or prevent it. But taking good care of your kidneys can help prevent AKI, chronic kidney disease (CKD), and kidney failure/ESRD. Follow these general rules to keep your kidneys as healthy as possible (American Kidney Fund, 2021): 

Work with your doctor to manage diabetes and high blood pressure.

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Adopt a diet low in salt and fat

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Exercise for 30 minutes at least five days per week

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Limit alcohol intake

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Take all prescription medication as ordered by the medical provider.

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If taking over-the-counter pain medicines, such as aspirin or ibuprofen, do not take more than is recommended on the package. Taking too much of these medicines can hurt your kidneys and can cause AKI.

Clinical Manifestations/signs and symptoms: Some people may not have any signs and symptoms and can only be detected through lab tests that are being done for other reasons. For people who are already quite ill, the problem that's causing the kidney injury may be causing other symptoms as well (Healthwise Staff, 2020). The most common signs and symptoms associated with acute kidney injury are:

Page | 8 Basic Adult Health Concept Map 

Decreased urine output, although occasionally urine output remains normal

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Fluid retention, causing swelling in your legs, ankles, or feet

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Shortness of breath

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Fatigue

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Weakness

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Irregular heartbeat

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Chest pain or pressure

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Decreased appetite

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Nausea and vomiting.

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Feeling confused, anxious, and restless, or sleepy.

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Flank pain.

In cases of severe AKI, the patient may also experience seizures or coma (American Kidney Fund, 2021).

Medical Management: Treatment can vary widely, depending on the cause. For example, doctors may need to restore blood flow to the kidneys, stop any medicines that may be causing the problem, or remove or bypass a blockage in the urinary tract (Healthwise Staff, 2020). Most people need to stay in the hospital during treatment and until their kidneys recover. While being treated for the problem that caused AKI, people may also have medicines to prevent issues that make it harder for kidneys to heal (American Kidney Fund, 2021). At the same time, the doctor will try to:

Page | 9 Basic Adult Health Concept Map 

Stop wastes from building up in the body. Temporary hemodialysis to do the work that the kidneys should be doing until they can recover

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Prevent other problems, initiating antibiotics treatment to prevent or treat infections.

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Other medicines used in the treatment of AKI are diuretics to help get rid of extra fluid and keep patient’s body minerals in balance.

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Medicines to control the amounts of vitamins and minerals in the blood.

Patients can shorten recovery time by taking the medicines a doctor prescribes. They also may need to follow a special diet to keep the kidneys from working too hard. People may need to limit sodium, potassium, and phosphorus. A dietitian can help patients plan meals (Healthwise Staff, 2020).

Page | 10 Basic Adult Health Concept Map List of Medications Medication Name/ Frequency Ceftriaxone 2 g, IVPB inj, q24hr x 7 days

Indication

Osteomyelitis and UTI

Actions

Bactericidal agent that acts by inhibition of bacterial cell wall synthesis. Ceftriaxone has activity in the presence of some beta-lactamases, both penicillinases and cephalosporinase s, of Gramnegative and Grampositive bacteria (Cunha, 2021)

Contraindica tion Ceftriaxone is contraindicated for (Medscape, n.d.): 

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People with cephalospori n& penicillin hypersensitiv ity Corn hypersensitiv ity Diarrhea from a infection with C. diff bacteria A type of blood disorder where the RBC burst called hemolytic anemia. Liver problems Disease of the gallbladder.

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Severe renal impairment.

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Medications containing lidocaine

Side Effects

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Severe stomach pain Watery or bloody diarrhea New signs of infection, such as fever, chills, and sweating Nausea Vomiting Pain in the upper stomach that radiates to the back Pale or yellow skin Dark colored urine New or worsening breathing problems such as wheezing, and feeling short of breath Headache Chest pain Dizziness Weakness Severe tingling or numbness Flank pain Lower back pain spreading to the groin Blood in the urine Painful or difficult urination Little to no urine. Abnormal

Nursing Implication

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Observe for signs of adverse reactions Monitor renal, hepatic, hematopoietic function IV administration: Infusion by syringe pump over 20 minutes Avoid administration of calciumcontaining solution or products within 48 hours of the last administration of ceftriazone.

Page | 11 Basic Adult Health Concept Map

Vancomycin 750 mg IVPB inj, once. Infused over 1 hr. Rate 250 mL/hr

Staphylococcus aureus positive blood culture

According to Patel et al. (2021), “Vancomycin is a glycopeptide antibiotic that exerts its bactericidal effect by inhibiting the polymerization of peptidoglycans in the bacterial cell wall”.

The following are contraindications or administration considerations (Patel et al., 2021):  Vancomycin should be used with caution in geriatric patients.  People with renal impairment  People who have use vancomycin for a prolonged time or have used it inappropriate ly, as it can lead to bacterial resistance.  Aminoglyco sides  Amphoterici n products  IV contrast

liver function test (Multum, 2021)  Ototoxicity  Nephrotoxici ty leading to uremia  Hypersensiti vity reactions such as chills, fever, skin rash, urticaria, and shock-like state  Anaphylacto id reaction with vascular collapse  Superinfecti ons  Severe pain  Thrombophl ebitis at injections site  Generalized tingling following rapid IV infusion  Transient leukopenia  Eosinophilia  Nausea  Warmth  Hypotension accompanied by flushing and erythema rash on the face and upper body following rapid IV infusion.

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Monitor BP and heart rate continuously through period of drug administration Lab tests: Monitor urinalysis, kidney and liver functions, and hematologic studies periodically. Monitor serial test of vancomycin blood levels in patient with border line kidney function. Assess hearing. This drug may cause damage to auditory branch of eight cranial nerve, with consequent deafness, which may be permanent. Be aware of the serum levels of 6080 mcg/mL are associated with ototoxicity. Tinnitus and high tone hearing loss may precede deafness, which may progress ever after drug is with-

Page | 12 Basic Adult Health Concept Map

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Risperidone 0.5 mg = 1 tablet by mouth once a day

Clinical depression

The primary action of risperidone is to decrease dopaminergic and serotonergic pathway activity in the brain, therefore reducing symptoms of schizophrenia and other mood disorders. Risperidone has a high binding affinity for serotonergic 5HT2A receptors when compared to dopaminergic D2 receptors in the brain (McNeil et al., 2021)

Risperidone should not be given if known allergy/hypersens itivity to risperidone or paliperidone, a metabolite of risperidone, is present. Hallucinogen persisting perception disorder or HPPD may be a relative contraindication for risperidone because some people treated with risperidone for their HPPD reported that panic and visual symptoms intensified (Janssen Pharmaceutical, 2018)

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Increased mortality in elderly with dementiarelated psychosis Cerebrovasc ular adverse events, including stroke, in elderly patients with dementiarelated psychosis. Neuroleptic malignant syndrome Tardive dyskinesia Metabolic changes: Hyperglyce mia and diabetes mellitus, Dyslipidemi a, and Weight Gain Hyperprolact inemia Orthostatic hypotension Falls

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drawn. Older adults and those on high doses are especially susceptible. Monitor I&O: Report changes in I&O ratio and pattern. Oliguria or cloudy or pink urine may be a sign of nephrotoxicity. Monitor diabetics for loss of glycemic control Reassess patients periodically and maintain on the lowest effective drug dose. Monitor closely neurologic status of older adults Monitor cardiovascular status closely; assess for orthostatic hypotension, especially during initial dosage titration Monitor closely those at risk for seizures Assess degree of cognitive and motor im-

Page | 13 Basic Adult Health Concept Map 

Insulin detemir 8 units = 0.08 mL subcutaneous injection twice a day

Diabetes mellitus

The primary activity of insulin detemir is the regulation of glucose metabolism. Insulins, including insulin detemir, exert their specific action through binding to insulin receptors. Receptor-bound insulin lowers blood glucose by facilitating cellular uptake of glucose into skeletal muscle and fat and by inhibiting the output of glucose from the liver. Insulin inhibits lipolysis in the adipocyte, inhibits proteolysis, and enhances protein synthesis (FDA, n.d.)

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Contraindica ted during episodes of hypoglycemi a. In patients with hypersensitiv ity to Insulin detemir/LEV EMIR or any of its excipients.

(Medscape, n.d.)

Leukopenia, neutropenia, and agranulocyto sis  Potential for cognitive and motor impairment  Seizures  Dysphagia  Priapism  Disruption of body temperature regulation  Hypoglycem ia  Headache  Flu-like symptoms  Pallor  Palpitations  Tachycardia  Mental confusion  Redness  Urticaria  Weakness  Blurred vision  Itching  Hunger  Nausea  Lipodystrop hy  Lipohypertro phy  Local allergic reaction  Hypokalemi a  Localized cutaneous amyloidosis (Medscape, n.d.)

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pairment and assess for environmental hazards. Lab test: Monitor periodically blood glucose, serum electrolytes, liver function, and complete blood counts. Assess for contraindicat ions or cautions so that the appropriate monitoring and dose adjustments can be completed Perform a physical assessment to establish a baseline before beginning therapy Asses...