Week 8 Case Study Osteomyelitis Surgery Rapid Reasoning
Advanced Adult Health Care (Keiser
... [Show More] University)
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 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% ✓
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:
- 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. - 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:
- His is married for 55 years with no kids, 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, may require skilled care after discharge. - Gene has very severe cognitive dementia as he no longer recognizes his wife, and due to his situation, is impaired to do most activities 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 place so CPR will not be allowed if his heart stops beating.
) [Show Less]