Week 8 Case Study Osteomyelitis Surgery Rapid Reasoning PDF

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Osteomyelitis/Surgery RAPID Reasoning

Gene Potts, 78 years old

Primary Concept Infection Interrelated Concepts (In order of emphasis) · Tissue Integrity · Perfusion · Gas Exchange · Pain · Clinical Judgment · Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Safe and Effective Care Environment ✓ Management of Care 17-23% ✓ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity ✓ Basic Care and Comfort 6-12% ✓ Pharmacological and Parenteral Therapies 12-18% ✓ Reduction of Risk Potential 9-15% ✓ Physiological Adaptation 11-17%

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

Covered in Case Study ✓ ✓ ✓ ✓ ✓ ✓ ✓

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)

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RELEVANT Data from Present Problem: Hx of Type 2 Diabetes, MRSA cultured in left foot ulcer and dementia had increased pain in left foot, chills, fever and feeling weaker the past two days, 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 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 patient scheduled to have his left great toe amputated in surgery tomorrow.

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Clinical Significance: Foot ulcers are a common complication of poorly controlled diabetes. They form as a result of skin tissue breaking down and expose the layers underneath. The patient is having the most visible sign of a serious foot ulcer and there is a black area, also called eschar, surrounding the ulcer. which forms in the absence of healthy blood flow to the area around the ulcer. Partial or complete gangrene, which refers to tissue death due to infections, can appear around the ulcer. Infection was confirmed by VS such as elevated temp, resp, and BP. In this case, odorous discharge, pain, and numbness can occur. The fever chills the patient is experiencing may be due to sepsis formation. Him feeling weak may be a sign of motor neuropathy which is known to cause muscle weakness, atrophy, and paresis. Autonomic dysfunction causes vasodilation and decreased sweating resulting in a loss of skin integrity, providing a site vulnerable to microbial infection, such as MRSA. The patient is in a chronic stage. Cellulitis is already leading towards sepsis and an infection which is evident by the bright red color of associate tissue. The patient is leading towards gangrene partial or complete which is associated by cellulitis and infection caused by MRSA. The elevated WBC of 18.5 usually indicates an increased production of white blood cells to fight an infection. An elevated lactate level of more than 1.5 usually indicated the patient is leaning towards sepsis. An elevated creatinine level is common in diabetic patients. Impaired renal function increases creatinine level and decreases GFR. These tests confirmed the osteomyelitis hence patient has chronic sepsis leading to gangrene due to MRSA and also osteomyelitis which can lead the surgeons to make the decision for amputation.

RELEVANT Data from Social History: Clinical Significance: - Gene has very severe cognitive dementia as he no longer recognizes His is married for 55 years with no kids, his wife, and due to his situation, is impaired to do most activities His dementia has progressed, and Gene no longer recognizes his wife. He has become make things difficult to his wife who is former nurse. Palliative care is already in mind due to the severity of his condition. He has a DNR in more difficult for his wife to manage at home. Gene is DNR/DNI. Palliative care place so CPR will not be allowed if his heart stops beating. was consulted to clarify goals of care and communicated that Gene is at high risk for decline after surgery, may require skilled care after discharge

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: Appears relaxed Consolability:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

Score: 1 0 1 0 0/Total:2

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RELEVANT VS Data: BP: 132/84 Temp: 99.5 P: 80 (irregular)

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC:

NEURO: GI: GU: INTEGUMENTARY:

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Clinical Significance: His BP is slightly elevated which may be due to his pain. His temp has decreased since admission but should still be monitored. This should be discussed with the physician to ensure that arrythmias do not occur.

Thin male with left leg elevated on a pillow. Occasionally tugs at IV site and is 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. Breath sounds clear, diminished in bases, nonlabored respiratory effort on room air. 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. Abdomen flat, soft/nontender, bowel sounds hypoactive per auscultation in all four quadrants Incontinent of urine 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)

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RELEVANT Assessment Data: Clinical Significance: General appearance: Occasionally tugs- Patient should be monitored to ensure that he does not injure himself. at IV site and is intermittently restless Have wife stay in the room with him to keep him calm, if possible. 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.

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Resp: Diminished in bases

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Neuro: Disoriented x4, follows simple commands to change positions.

Post-operative delirium is common in older people. Gene also has severe cognitive dementia.

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Cardiac: Pulses right leg anterior pedal and posterior post-tibial 2+

Cardiac output should be monitored. This is a little more diminished than normal pulses on leg landmarks.

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GI: bowel sounds hypoactive

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Hypoactive bowel sounds are normal during sleep. The patient may be constipated due to some of the medications he is on. This should be monitored.

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GU: Incontinent of urine

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There are two main causes for urinary retention: mechanical obstruction of the urinary outflow tract and altered neural control of the bladder and detrusor mechanism (most commonly due to analgesic drugs). The nurse needs to consult doctor as soon as possible

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Integumentary: Right foot pale, dusky heel red with blanchable redness, skin turgor elastic, tenting present.

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Even though this is not uncommon in the elderly, this should be monitored.

Poor circulation is indicated by the pale, dusky heel. The patient may also be dehydrated which is indicated by the tenting.

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Cardiac Telemetry Strip:

P wave present?

Regular/Irregular:

PR:

QRS: .

QT :

Interpretation: Clinical Significance:

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

Radiology: Chest X-Ray Clinical Significance: - Cardiomegaly causes he heart to work harder than usual. Pulmonary vasculature prominence indicates pulmonary vascular disease which is associated with pulmonary HTN doe to conditions like CHF which is indicated in the results.

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

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

WBC 20.2 18.5

Current: Admission:

% 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): -

WBC: 20.2

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Hgb: 10.2 Neutrophils: 92

Current: Admission:

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Na 138 137

TREND: Improve/Worsening/Stable: Elevated WBC indicates an infection. Leukocyte count is - Worsening usually increased in patients with chronic osteomyelitis. This is indicative of low oxygen levels. This is a sign that there is an infection in the body. - Improving - Worsening

Clinical Significance:

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

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

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):

TREND: Improve/Worsening/Stable: - Worsening

Clinical Significance:

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Glucose: 254

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Creatinine: 1.8

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This is may be due to the infection worsening. Higher levels of insulin may be required to address infectioninduced hyperglycemia. Higher creatinine levels are common in diabetic patients because renal function is affected.

Worsening

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MISC.Misc. Lactate Current: Admission:

PT/INR

1.2 1.7

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:

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Lactate: 1.2

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PT/INR: 2.6

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Indicates that the infection is improving but sepsis is still a possibility until this get WNL Indicates that there is a risk for bleeding because the patient’s prothrombin time is increased meaning clotting is happening at a slower rate.

TREND: Improve/Worsening/Stable: - Improving -

Improving

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: Pathophysiology of Problem in OWN Words: Primary Concept:

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Sepsis

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This is the body’s response to an infection. During an infection, the body releases chemicals into the bloodstream to fight the infection. Sepsis occurs when the body’s response to the chemicals is out of balance which triggers changers to occur that can damage multiple organ systems.

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

Septic shock

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

Rationale: To stop any spread of infection and to maintain sterility.

Piperacillin-tazobactam 3.375 g over 4 hours IVPB

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Useful in treating infection due to its bactericidal properties.

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Decrease infection

Blood glucose every 4 hours w/sliding scale

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To maintain blood glucose log

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Maintaining glucose level log

Insulin glargine 40 units every HS

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For glycemic control

- Maintain blood glucose level

Hydromorphone 0.3-0.5 mg every 2 hours PRN pain

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Used to reduce body pain.

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Decrease pain level

Haloperidol 2.5 mg IV every 8 hours PRN-agitation

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To help calm the patient down.

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Control depression

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

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Treatment of nausea and vomiting

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Decreased nausea level

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To maintain body oxygen level

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Increased O2 capacity

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

Expected Outcome: - No cross contamination

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 glucose every 4 hours w/sliding scale · Insulin glargine 40 units every HS · Hydromorphone 0.3-0.5 mg every 2 hours PRN pain

Order of Priority: Rationale: 1. Infection is most important for sepsis patients. 1. Contact precautions 2. Piperacillin-tazobactam 3.375 2. Treating infection due to its bactericidal properties. 3. Possible reduction in agitation which in turn will g over 4 hours IVPB reduce fall risk and injury. 3. Hydromorphone 0.3-0.5 mg 4. 5. Diabetic patients should always maintain a log. every 2 hours PRN pain Management of DM can prevent the ulcer from 4. Blood glucose every 4 hours worsening and possibly prevent the need for w/sliding scale amputation. 5. Haloperidol 2.5 mg IV every 6. This is a PRN order, so I listed it last. The reduction of pain may help feel VS WNL and decrease the patient’s 8 hours PRN-agitation agitation as well. 6. Insulin glargine 40 units every HS

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

Collaborative Care: Nursing 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Impaired physical mobility r/t pain and limitation of the weight load AEB great toe amputation Risk for injury r/t confusion AEB patient continuously asking for wife and trying to get out of bed without assistance

PRIORITY Nursing Interventions: -

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Rationale:

Provide a safe environment: bed rails up, bed in down position, necessary items close by. Evaluate the need for home assistance.-

Assess the patient’s or caregiver’s knowledge of immobility and its implications.

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Expected Outcome: -

Patient will not acquire any injuries.

Obtaining appropriate assistance for the patient can ensure safe and proper progression of activity. Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression.

Reduce the workload of his wife.

These measures promote a safe, secure environment and may reduce risk for falls.

Patient’s wife will understand his need for a mobility device to ambulate.

3. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: -

4.

PRIORITY Nursing Assessments:

Cardiac Integumentary Immune systems

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Heart sounds since pulses were slightly diminished. Assessment of his ulcer To ensure the infection does not get worse

What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (Reduction of Risk Potential/Physiologic Adaptation)

Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication: - Administer medications as ordered. - Monitor all lab results.

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Septic Shock

Assessments to Identify Problem Nursing Interventions to Rescue: EARLY: - BP monitoring to prevent sudden drop - Be ready to perform CPR if leading to HF or organ failure. necessary. - Temp, respirations and pulse - Push IV fluids as ordered.

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5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

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Rationale:

PRIORITY Nursing Interventions: CARE/COMFORT: Caring/compassion as a nurse -

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Chronic confusion r/t severe cognitive dementia AEB disorientation and inability to recognize his wife.

Sit and talk with the patient when wife is not available to be there with him -

Expected Outcome:

Patient’s anxiety decreased if there is someone in the room with him.

Decrease in the patient’s anxiety.