NRS 490 Class# 9 Pathophysiology and Nursing Management of Clients.

NRS 490 Class# 9 Pathophysiology and Nursing Management of Clients. The case scenario provided will be used to answer the discussion questions that follow. Case Scenario Ms. G., a 23-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She has been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling. Subjective Data  Complains of pain and heaviness in her leg.  States she cannot bear weight on her leg and has been in bed for 3 days.  Lives alone and has not had anyone to help her with meals. Objective Data  Round, yellow-red, 2 cm diameter, 1 cm deep, open wound above medial malleolus with moderate amount of thick yellow drainage  Left leg red from knee to ankle  Calf measurement on left 3 in than right  Temperature: 38.9 degrees C  Height: 160 cm; Weight: 83.7 kg Laboratory Results  WBC 18.3 x 10¹² / L; 80% neutrophils, 12% bands  Wound culture: Staphylococcus aureus Critical Thinking Questions 1. What clinical manifestations are present in Ms. G and what recommendations would you make for continued treatment? Provide rationale for your recommendations. 2. Identify the muscle groups likely to be affected by Ms. G's condition by referring to "ARC: Anatomy Resource Center." 3. What is the significance of the subjective and objective data provided with regard to follow-up diagnostic/laboratory testing, education, and future preventative care? Provide rationale for your answer. 4. What factors are present in this situation that could delay wound healing, and what precautions are required to prevent delayed wound healing? Explain. Ms G. presents with a left lower extremity (LLE) wound that is round, measuring 2 cm in diameter and 1 cm deep that is draining a moderate amount of thick yellow drainage. Her LLE is also red and swollen with a three inch difference in diameter when measured at the location of the calf. Ms G. is also febrile and complains of a painful heavy leg. Ms G. has a wound that has become infected based on her clinical manifestations; fever of 102.02 accompanied by chills and elevated white blood cell count. Her laboratory results also show elevated neutrophils with an increase in immature neutrophils (bands) indicated a more severe infection (Copstead-Kirkhorn, 2010). I would first obtain blood cultures prior to any antibiotic therapy, this allows for a more specific antibiotic therapy to be initiated and has also been associated with a decrease in mortality rates related to infection (Institute of Healthcare Improvement, 2017). Following a sepsis protocol if other objective data warrants may be initiated by ordering a procalcitonin and lactic acid level. Sepsis is a concern with serious infections. The wound culture shows staph aureus which is a gram-positive bacteria and can be treated with common cephalosporin’s, naficillin and their counterparts as well as sulfa drugs, but increased resistance to these drugs have required the more frequent use of vancomycin to treat more serious infections (Staph infections Treatments and drugs, 2014). The cause of Ms G. ulcer should be looked into further since she has risk factors for both venous and arterial disease. Both of these types of ulcers require a different course of treatment (Grey, Harding & Enoch, 2017). An initial assessment of surrounding pulses, skin and capillary refill would assist in meriting further testing of arterial flow to the extremity. Obtaining a Venous Doppler study to rule out a deep vein thrombosis (DVT) is necessary since this could be contributing to the ulcer and because the affected leg is three inches larger which is characteristic of a DVT. It is recommended to debride the ulcer to remove the dead (yellow portion) skin to see the wound better and to allow for the wound to heal. Applying medications and or dressings that also facilitate the healing process is recommended. Offloading the extremity and not allowing any pressure to be placed on the affected leg can also promote wound healing. (Grey, Harding & Enoch, 2017). Elevating the leg to alleviate pain from pressure and edema as well as administering antipyretics help to keep the patient comfortable. The muscle that could be very likely affected by the infection are the flexor digitorium longus muscle since it lies posterior to the medial malleolus. The subjective and objective data show that Ms G. is not in control of her diabetes and general health. She is a young female who is considered obese with a body mass index of 33. An individual’s BMI is a close indicator of how much body fat one is carrying (How Much Should I Weigh?(nd). Obesity is the most prominent risk factor for type 2 diabetes with a large midsection being a bigger risk factor than lower body fat (CopsteadKirkhorn, 2010). She should be given immediate diabetic teaching as it pertains to diet, exercise and medications. Her hemoglobin AIC should be drawn so that there is a baseline of how she has been managing her glucose levels over the past two to three months. This will be a useful indicator of her glucose control for further follow up appointments. Monitoring her CBC will also ensure her white count is trending down showing that the prescribed antibiotics are working. It is also important to teach Ms G. that she should be extremely cautious of her lower extremities since persistent high glucose levels lead to peripheral vascular disease, neuropathy and ulcerations as she is currently experiencing (Copstead-Kirkhorn, 2010). Informing her that wounds can develop and can quickly spiral out of control without proper foot care and monitoring. Keeping a tight glucose level and teaching glucose monitoring will also facilitate further vascular damage and future ulcerations. The factors that can delay wound healing in this situation are Ms G. lack of knowledge in managing her diabetes and how to effectively manage any symptoms. She was trying to treat her wound herself instead of seeking medical attention immediately. High glucose levels, infection, inadequate circulation, a compromised immune system and neuropathy are all factors that can make it difficult for a wound to heal quickly (Wound Care Centers, 2017). Precautions for Mrs G. would include careful inspection of her skin, looking for possible sign of infection or wounds that she may not feel due to neuropathy. Careful meal planning so that all the nutrients needed for wound healing are incorporated and so that caloric intake is monitored so that weight reduction can occur. Following up with a podiatrist and wound care are imperative to ensure professional assessment of skin (Wound Care Centers, 2017). Institute for Healthcare Improvement. (2017). Timing of Blood Cultures. Retrieved from How Much Should I Weigh? (n.d.). Retrieved from Copstead-Kirkhorn. (2010). Pathophysiology, 4th Edition. [Pageburstl]. Retrieved from Staph infections Treatments and drugs. (2014). Retrieved from Grey, J. E., Harding, K. G., & Enoch, S. (2006, February 11). Venous and arterial leg ulcers. Retrieved from Wound Care Centers. (2017). How Diabetes Affects Wound Healing. Retrieved from