Osteomyelitis/Surgery UNFOLDING Reasoning Suggested Answer Guidelines

Osteomyelitis/Surgery UNFOLDING Reasoning Suggested Answer Guidelines Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved. Osteomyelitis/Surgery UNFOLDING Reasoning Suggested Answer Guidelines Gene Potts, 78 years old Primary Concept Infection Interrelated Concepts (In order of emphasis) • Tissue Integrity • Perfusion • Gas Exchange • Pain • Clinical Judgment • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study 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. 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 thatGene 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: Clinical Significance: Diabetes type 2 MRSA left foot ulcer Chills Fever - Temp 101.5 F/38.6 C R: 22 P: 98 Weakness over the last two days Increased pain, redness, swelling of the left foot Left toe is black Left foot bright red and radiates to left leg WBC: 18.5 Lactate: 1.8 BP: 148/90 Diabetes damages the peripheral blood vessels and nerves. Nerve damage makes the patient less aware of ulcers and injuries. The ulcers may not heal and can easily become infected. When combined with increased HR, increased RR, the high temp meets SIRS criteria for suspected sepsis. Signs of infection include the following: Fever, chills, increased weakness, increased pain, redness and swelling of the infected area. Chills may occur at the start of an infection. The body’s response to infection is to raise the temperature because the pathogens thrive best at a normal body temperature. Chills are caused by rapid contraction and relaxation of the muscles to increase the body’s temperature. Temp of above 101 which likely indicates wound infection. Weakness can indicate localized or systemic infection. Continual or increasing pain can be a sign of a wound infection. Redness that expands around a wound is a sign of wound infection. You can track this with a marker by outlining the initial area of redness and observing if it passes the line. Persistent swelling is a sign of a wound infection. Foot ulcers occur because of nerve damage and peripheral vascular damage. Without adequate blood flow, wounds cannot heal, and gangrene or death of tissue occurs due to lack of blood. A black toe indicates gangrene. Gangrene symptoms also include skin color changes including red, blue or black. WBC elevation indicates an infection is present in the body. Lactate of 1.8 is high normal. Lactate is elevated greater than 2 in septic shock but is also often accompanied by hypotension. The patient’s BP is 148/90. The vigilant nurse should TREND and assess for signs of shock that would include tachycardia and decreasing BP.