Osteomyelitis-Surgery- Unfolding Reasoning case study PDF

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Osteomyelitis/Surgery UNFOLDING Reasoning

Gene Potts, 78 years old

Primary Concept Infection Interrelated Concepts (In order of emphasis) • • • • • • • • NCLEX Client Need Categories

Tissue Integrity Perfusion Gas Exchange Pain Clinical Judgment Patient Education Communication Collaboration Percentage of Items from Each Category/Subcategory

Safe and Effective Care Environment ✓ Management of Care ✓ Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity ✓ Basic Care and Comfort ✓ Pharmacological and Parenteral Therapies ✓ Reduction of Risk Potential ✓ Physiological Adaptation Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

✓

6-12% 12-18% 9-15% 11-17%

✓ ✓ ✓ ✓

✓ ✓

History of Present Problem: Gene Potts is a 78-year-old Caucasian male with diabetes type 2, MRSA cultured in left foot ulcer and dementia who came to the emergency department because he had increased pain in left foot, chills, fever and feeling weaker the past two days. His wife noticed an increase in redness and swelling of his chronic left foot ulcer. Initial vital signs: T: 101.5 F/38.6 C P: 98 R: 22 BP: 148/90. O2 sat: 94% room air. His left great toe is black with an open stage III ulcer 1x1 cm on the top of his left foot. Surrounding tissue is bright red and extends from his left foot to his lower left leg. His initial WBC: 18.5, lactate: 1.8, and creatinine: 1.7. A CT of his left foot confirmed osteomyelitis in the left great toe. He is admitted to the med/surg floor and started on piperacillin/tazobactam IVPB and vancomycin IVPB. He is scheduled to have his left great toe amputated in surgery tomorrow.

Personal/Social History: Gene has been married for 55 years and is cared for by his wife, Ruth, who is a retired nurse. They have no children. His dementia has progressed, and Gene no longer recognizes his wife. He has become more difficult for his wife to manage at home. Gene is DNR/DNI. Palliative care was consulted to clarify goals of care and communicated that Gene is at high risk for decline after surgery and may require skilled care after discharge. Ruth is stern and communicates that she knows her husband best and insistent that he will come home after surgery no matter what. 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: - Type 2 DM, MRSA in L foot ulcer, great toe is black with open stage III ulcer 1x1cm; surrounding tissue is bright red extending from L foot to lower L leg. - VS - T:101.5/ RR: 22/ BP: 148/90/ O2 sat: 94% - Labs - WBC: 18.5/ Lactate:1.8/ Crea: 1.7 - vascular access: piperacillin /tazo IVPB & vancomycin IVPB - progressed dementia; no longer recognizes wife -pain in L foot, chills fever and feeling weaker (2days)

RELEVANT Data from Social History: Pt has progressed dementia and he doesnt recognize his wife anymore. The patient's wife, who is a retired nurse, is the patient's primary caretaker. The couple has no children and the wife is having a hard time managing the patient at home. The pt is DNI/DNR and had a consult of palliative care. The patient is found to be at high risk for decline post surgery and will need skilled care after discharge. The wife, Ruth, belieces she can better take care of her husband and insists for him to be sent home after surgery.

Clinical Significance: - injuries to the foot with poorly controlled DM may result to necrotized ulcers-the pt affected foot has a blackened toe that has an open ulcer at stage III which means the tissue has broken down and exposed deeper skin layers. Blackened skin is called an eschar which can be caused by poor tissue perfusion, Elevation in the patient's lactic acid is indicative of poor tissue oxygenation. Decreased healthy blood flow to an extremity such as this patient's foot, makes it susceptible to infetions such as MRSA, which was found in a cultured sample from the foot ulcer. Cellulitis may be present as complication of the foot ulcer as observed by having redness around the affected tissue that extends from the L foot up to the lower L leg. - The patients' VS and labs may be indicative of infection. Elevated WBC indicates increase in leukocyte production to fight off the infection; Elevated creatinine may mean poor perfusion to the kidneys which is common to diabetic patients due to peripheral vascular damage. Elevated temp, RR and BP, increasing pain, chills fever, and weakness are signs of infection. CT revealed osteomyelitis.

Clinical Significance: The patient cannot remember his wife anymore due to his progressive dementia. This prohibits the patient to perform self care effectively which puts a significant strain in his wife. His wife is insisting for him to be sent home after surgery and denies the patient needs skilled care somewhere else - because she is a former nurse herself. The pt did not have effective care under the wife , hence the development of ulcers and cellulitis. The patient has palliative care initiated and has DNR orders in place.

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medications treat which conditions? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: antigout agents, antihyperuricemics - prevents attack of gouty arthritis by • Ischemic cardiomyopathy • Allopurinol 100 mg PO daily inhibiting production of uric acid in the body. Atorvastatin 10 mg PO at HS

- lipid lowering agent

- prevents cardiovascular disease in patients with multiple risk factors for CHD or type 2 DM.

Docusate 100 mg PO daily

- laxatives

- prevents constipation by incorporating water into stool that produces soft fecal mass

Fluoxetine 20 mg PO daily

- antidepressants (SSRI)

- used to stabilize patient's mood and improve sleep and reduce daytime irritability

Furosemide 40 mg PO daily

- loop diuretics

- promotes diuresis and prevents reabsorption of Na and Cl in pt with impaired renal function.

Losartan 50 mg PO daily

- antihypertensive, angiotensin II receptor antagonist

- lowers BP, slows progression of diabetic nephropathy, decreases risk of stroke in pt with L ventricular hypertrophy

- antianginals, antihypertensive, beta blockers

- decreases BP and HR and prevents MI and decreases mortality in pt with recent MI

- anticoagulants

- prevents thromboembolytic events

Metoprolol XL 50 mg PO daily Warfarin 5 mg PO daily

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology (if applicable), which disease likely developed FIRST that created a “domino effect” in her life? • Circle what PMH problem likely started FIRST • Underline what PMH problem(s) FOLLOWED as domino(s):

Patient Care Begins: Post-Op-Day of Surgery Gene had surgery earlier this morning to remove the left great toe and had no complications. His most recent set of vital signs were: T: 99.8 F/37.7 C P: 78 (irreg) R: 20 BP 142/86 O2 sat 95% 2 liters n/c. The PACU nurse reports that he is awake but is not oriented to person, place, time or location. As he arrives in his room you collect the following clinical data: Current VS: T: 99.5 F/37.5 C (oral) P: 80 (irregular) R: 20 (regular) BP: 132/84 O2 sat: 92% 3 liters n/c

FLACC Pain Assessment Scale: Makes occasional grimace Face: Appears relaxed, normal position Legs: Intermittent periods of restlessness Activity: Quiet Cry: Consolability: Appears relaxed

Score: 1 0 1 0 0/Total:2

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:

- PR: 80 irregular - BP 132/84 - O2 sat: 92% - occasional grimace - intermittent period of restlessness

Clinical Significance:

- patient has irregular PR due to his h/o of atrial fibrillation and ischemic CM, will have to monitor complications such as SOB - BP is slightly elevated maybe due to post op pain or h/o CAD, will have to monitor progression and administer meds as ordered - O2 sat is decreased from normal of >95%, may be due to h/o apnea, will need to administer O2 as ordered - occassional grimace may be a sign of post op pain, will have to follow up with pain meds as ordered - intermittent period of restlessness may cause alterations in pt's vs such as elevations in RR and PR, will need to provide relaxation therapy such as minimizing distractions, turning off bright lights.

Current Assessment: GENERAL Thin male with left leg elevated on a pillow. Occasionally tugs at IV site and is APPEARANCE: intermittently restless and attempts to get to the edge of the bed. Calls for his wife and is calmer with someone talking to him in the room. RESP: Breath sounds clear, diminished in bases, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds irregular with no abnormal beats, pulses right leg anterior pedal and posterior post-tibial 2+and brisk cap refill. Left leg popliteal pulse 2+ and lower leg with brisk cap refill. Disoriented x4, follows simple commands to change position. NEURO: Abdomen flat, soft/nontender, bowel sounds hypoactive per auscultation in all four GI: quadrants GU: Incontinent of urine INTEGUMENTARY: ACE wrap around left foot. Small amount of bloody drainage visible. Right foot pale, dusky heel red with blanchable redness, skin turgor elastic, tenting present. Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

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:

- occassionally tugs at IV site and intermittently restless, and attempts to get on edge of bed, calmer when someone is talking to him on room - diminished lung sounds on lung bases - irregular heart sounds - pt is disoriented - pt bowel sounds is hypoactive in all 4 quadrants - incontinent of urine -ACE wrap on L foot with small amount of bloody drainage, R foot pale and dusky heel with blanchable redness, tenting present, slightly diminished pulses

- will need to monitor pt for safety and prevent his IV to be disconnected; will ask wife to stay with him so he will remain calm - diminished sounds on lung bases may indicate fluid or mucus collection; will have to monitor patient for signs of PN, teach patient to use incentive spirometer to prevent complications such as PN, ask for referral of CXR to determine cause - pt has irregular heart sounds due to h/o ischemic CM and Afib, monitor pt cardiac function and administer meds as ordered to maintain cardiac function - pt may be disoriented post op due to anesthesia and h/o dementia, will ensure safety by checking on pt q1h and asking caregiver to remain on bedside - pt bowel sounds hypoactive in all quads as expected in post op patients, will have to keep patient NPO until bowel sounds resume, encourage ambulation as tol - pt is incontinent may be due to age and disease progression (severe dementia), will offer assist in voiding, offering bedpan, insert indwelling foley as ordered. - small amount of drain may be expected post op, need to monitor for purulent discharge, pale foot with dusky heel and blanchable redness means poor perfusion and circulation, will need to elevate extremity or use compression stockings, tenting in skin means dehydration, offer fluids as ordered and ensure pt's receiving fluid via IV

Cardiac Telemetry Strip:

Regular/Irregular:

P wave present?

Irregular rhythm

Interpretation:

non discernible

PR: non discernible

QRS: .

QT :

0.06-0.10sec

Atrial Fibrillation

Clinical Significance: Absence of P wave is characteristic sign for Afib. Atrial fibrillation is when the heart has an irregular beat which can lead pt to have blood clots, stroke and heart complications.

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

Results Cardiomegaly. Pulmonary vasculature prominence is increasing; mild CHF is a possibility.

Radiology: Chest X-Ray Clinical Significance: .Cardiomegaly is present due to h/o ischemic cardiomyopathy which caused the heart to work harder than it should be. As stated in the results of the cxr, the patient may have CHF which may cause cardiomegaly and pulmonary hypertension. Pulmonary vascular prominence may be caused by pulmonary HTN.

Lab Results: Current: Admission:

WBC 20.2 18.5

Complete Blood Count (CBC) HGB PLTs 10.2 285 10.0 296

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

% Neuts 92 87

Bands 2 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:

- WBC: 18.5 and 20.2

- Elevated WBC suggests that the pt has an infection.

- Hgb: 10.0 and 10.2

- Decreased Hgb suggests decreased oxygenation / hypoxia - improved

- %neutrophils: 87 & 92

- elevated neutrophils suggests an active bacterial infection

Basic Metabolic Panel (BMP) K Gluc. 4.0 254 3.9 225

Na 138 137

Current: Admission:

- worsening

- worsening

Creat. 1.8 1.7

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:

- Glucose: 254 and 225 - Creatinine: 1.8 and 1.7

- Pt has elevated glucose in relation to pt's h/o - worsening DM type 2. Pt may need pharmacological intervention. - creatinine is elevated - suggests impaired kidney - worsening function. pt has a h/o chronic kidney disease MISC.Misc.

Lactate Current: Admission:

1.2 1.7

PT/INR 2.6 2.8

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:

- lactate: 1.2 and 1.7 - PT: 2.6 and 2.8

- elevated lactate may indicate poor oxygenation on body organs or active infection. will need to monitor pt's oxygenation status and s/s of infection (fever, tachypnea, tachycardia, elev. wbc)

- improving - improving

- PT/INR indicates the pt's capacity to form clots. elevation may mean an increase in risk for bleeding and we may need to provide protection to prevent pt. from bleeding

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)

Lab:

Normal Value:

WBC

Value: 20.2

Clinical Significance:

Elevated WBC indicates infection. Critical Value:

Critical Value: 30,000/mm3

Nursing Assessments/Interventions Required: Assessment: The patient has osteomyelitis in the L foot L great toe. There is chronic ulceration in the L foot which tested (+) for MRSA and surrouding tissue is red and swollen extending to the L lower leg. L great toe on the L foot has an open stage III ulcer and is black. Interventions: The pt had an amputation of the L great toe to prevent spread of infection. Pt needs antibiotics as ordered to treat infection. Monitor VS to ensure pt is well oxygenated and fever is managed (fever, tachycardia and tachypnea may occur secondary to infection), monitor S/S of complications regarding post op such as severe pain, swelling and purulent discharge on surgical site.

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Lab:

Normal Value:

Lactate Value:

1.2

Critical Value:

Clinical Significance: Elevated lactate suggests poor oxygenation/ perfusion to body organs or an active infection. Critical Value: >4.0 mmol/L

Nursing Assessments/Interventions Required: assessments: pt has an active infection (osteomyelitis) and has decreased Hgb (indicative of hypoxia). Pt's blackened toe suggests tissue had no perfusion. Pt's R foot is pale and dusky, which may be a sign of poor circulation. Intervention: The pt had an amputation of the L great toe to prevent spread of infection. Will need to monitor the pt's O2 Sat to ensure pt is well ventilated, and antibiotics are administered as ordered. Monitor for s/s of post op complications or possibility of sepsis.

Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)

Problem: Risk for Sepsis

Pathophysiology of Problem in OWN Words:

Primary Concept:

Sepsis is a severe systemic reaction to an infection. It presents as Septic Shock alterations in vital signs such as increased respiratory rate, increased heart rate, fever and confusion. It may cause damage to body organs if left untreated.

Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Contact Precautions

Piperacillin-tazobactam 3.375 g over 4 hours IVPB

Blood glucose every 4 hours w/sliding scale

Insulin glargine 40 units every HS Hydromorphone 0.3-0.5 mg every 2 hours PRN pain

Rationale:

Expected Outcome:

- To prevent spread of infection.

- Maintain sterility and prevent cross contamination.

- Broad spectrum antibiotic that treats infection from many organisms (gram positive and negative).

- Decrease infection after therapy.

- To monitor glucose level and ascertain the need for appropriate intervention (meds, dietary restrictions etc).

- To gather and maintain information on pt's glucose levels.

- To control patient's glucose levels. - To help reduce patient's pain levels.

- Glucose levels will be decreased/ maintained. - Pt. will report reduction in pain.

Haloperidol 2.5 mg IV every - To help the patient relax and prevent agitation. 8 hours PRN-agitation

- Pt will be free from agitation and will have a calm affect.

Ondansetron 4 mg ODT on the tongue every 6 hours PRN-nausea

- To prevent and treat N/V.

- Pt. will be free from n/v.

- To promote better oxygenation.

- Pt will maintain O2 sat over 92%.

Titrate O2 per n/c to maintain O2 sat >92%

Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved.

PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: • Contact precautions • Piperacillin-tazobactam 3.375 g over 4 hours IVPB • Haloperidol 2.5 mg IV every 8 hours PRN-agitation • Blood gluco...