Jared Griffin - Clinical vSim

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS • Methicillin-resistant Staphylococcus aureus (MRSA) is an infection with a mutated strain of Staphylococcus bacteria that has become resistant to methicillin and other antibiotics. It is spread by direct person-to-person contact. • Of the Staphylococcus aureus isolates or strains, 90% are resistant to penicillin and about 27% are also resistant to methicillin, a penicillin derivative. These strains may also resist cephalosporins, aminoglycosides, erythromycin, tetracycline, and clindamycin. When natural defense systems break down (after invasive procedures, trauma, or chemotherapy), these usually benign bacteria can invade tissue, proliferate, and cause infection. Jared Griffin is a 63yo male African American who underwent a TKA surgery on 3/4/2021. Mr. Griffin has a hx of MRSA, diagnosed 3 years ago, and is currently under contact precautions. He also has hx of osteoarthritis and mild hypertension. • Provide emotional support to the patient and family members. Allow the patient and family to verbalize feelings and concerns. Provide an open discussion and answer the patient's and family's questions honestly and clearly in terms that they will understand. • Consider grouping infected patients together and having the same nursing staff care for them. • Use meticulous hand hygiene. • Use appropriate personal protective equipment, as indicated. • Use standard precautions as well as contact precautions, as indicated. • Provide skin and wound care, as indicated; inspect the wound and skin for changes and evidence of healing. • Assist with or provide bathing with chlorhexidine while in the intensive care unit. • Apply antiembolism stockings or sequential compression stockings to prevent DVT. • Administer antibiotics, as prescribed; if the IV route is used, ensure patent IV access, and provide IV site care according to facility protocol. • Obtain cultures of the wound, as ordered. • Assess wound for any bleeding from incision and presence of infection. • Educate patient on plan of care, incentive spirometer, wound care at home, infection control, and PPE. • Coagulation screen test measures the body’s ability to clot / Results: Normal • CBC test counts the cells that make up the blood, it evaluates overall health and is used to check for infection / Results: Low Hb (11) and low HCT (36) • Electrolytes: measures the levels of the body’s main electrolytes (i.e. sodium, chloride, potassium, bicarbonate) / Results: All electrolytes within normal findings except Cl- (low 96-100) • Blood glucose test: measures blood sugar levels are in the healthy range / Results: Normal • Nasal swab tested positive for MRSA. • Erythema • Skin is warm to touch • Bullae that appear honeycrusted