Osteomyelitis/Surgery RAPID Reasoning Gene Potts, 78 years old( Elaborations With Complete Solutions All Graded A)

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: Clinical Significance: Type 2 diabetic MRSA in left foot ulcer (stage III 1x1 cm) with present redness and swelling from left foot to left lower leg Increased pain in left foot, chills, fever, and feeling weaker the past two days T: 101.5 F, P: 98, R: 22, BP: 148/90 Left great toe is black WBC: 18.5, Lactate: 1.8, Creatinine: 1.7 Confirmed osteomyelitis in left great toe that is scheduled to be amputated tomorrow Started on piperacillin/tazobactam IVPB and vancomycin IVPB Higher risk for developing osteomyelitis if foot ulcers develop Infectious bacteria in a deep wound left untreated or treated incorrectly can get into the blood stream and cause systemic infection Indicative of a systemic infection All high, but most relevant is the temperature, because fever is indicative of infection (which will cause other vitals to rise) Necrosis means it has been infected for a while and left untreated All elevated; WBC indicates infection, Lactate indicates potential organ dysfunction, Creatinine indicates kidney dysfunction Most often related to diabetes that has been poorly managed Used to treat systemic infection; Multi-drug therapy indicated for drug resistant bacteria RELEVANT Data from Social History: Clinical Significance: Dementia that has progressed to where he no longer recognizes his wife DNR/DNI Palliative care consulted; stated that Gene at high risk for decline following surgery and may require skilled care after discharge More difficult to entrust that his wife is doing what is best for him because he sees her as a stranger Pt. is not to be resuscitated or intubated if he rapidly declines during surge