Question

Case Study

A student nurse is caring for a 62 year-old client who underwent a great toe amputation related to Type 2 diabetes mellitus 3 weeks ago. The client is admitted with a suspected infection of the wound. Upon initial assessment the student nurse observes that the client’s right foot is swollen, warm, and tender to touch, with red streaks extending upward approximately 1 inch above the ankle and has an oral temperature of102.6° F. The wound has yellow, odorous drainage that the patient reports started 4 days ago. The patient reports a pain level of 7 out of 10 on a visual analog scale with an acceptable pain level of 3.   The client lives alone and has been disabled for the last 3 years.

Allergies:   Penicillin (hives), seasonal environmental allergies

Diagnostic tests results: White blood cell (WBC) count: 17,500 / mm3 Sed rate: elevated at 92% Blood glucose: 280 mg/dL Blood culture is positive for Staphylococcus aeruginosa

Based on the assessment and diagnostic results, the client has been diagnosed with osteomyelitis of the right foot and the treatment plan includes: Bed rest with elevation of right lower extremity. After a short hospitalization, the client will receive IV antibiotics at home for 6 weeks.

Medication orders:

Vitamin C 500 mg PO BID oxycodone 20 mg Q 4 hrs prn moderate pain morphine sulfate 2-4 mg IV Q 2 hrs for severe pain

Acetaminophen 1,000 mg (2 tabs) Q 4 hours prn headache Heparin sodium 5,000 units Subcutaneously q 8 hrs Vancomycin* 1 gram q 12 hours; Trough after 3rd dose. Metformin (Glucophage) 250 mg BID

1. List your top 3 Nursing Actions and Assessments in order of PRIORITY

2. What Personal Protective Equipment (PPE’s) will be required to care for the client?

3. What safety concerns relate to the ordered medications?

4. What education would be required for the client prior to discharge?

Answer 1

Question no. 1 :

The specified patient has osteomyelitis of right foot with features of Sepsis (fever, leukocytosis and blood culture positivity for Staphylococcus).
Top 3 Nursing actions and assessments regarding this patient:
- Assessment for signs and symptoms of acute organ dysfunction. Monitor for hypotension, tachycardia, respiratory failure, oliguria, coagulopathy and jaundice.
- Assessment of hemodynamic status, nutritional status and fluid intake output ratio.
- Evaluation for the presence of bedsore, Peripheral pulses , deep vein thrombosis and Prophylactic measures to prevent bedsore and DVT.

Question no.2 :

PPE is required for the care of the patient. Since the patient has suspected MRSA infection adequate precautions are essential to prevent spread of infection to the caregiver.
- Ensure hand hygiene.
- Gloves: wear gloves on entering into the room, touching patient’s skin or articles near the patient.
- Use Masks and protective eye wear or face shield to protect from splashes of blood or other body fluids.
- Impervious gowns to protect from splashes of blood.
- Remove PPE and observe hand hygiene immediately after leaving patient’s environment.
- Appropriate handling of patient care equipments: Use disposable medical equipments or clean and disinfect equipments regularly.

Question no.3 :

Safety concerns related to the medications:
- Heparin sodium is an anticoagulant.It can lead to oozing and bleeding from the wound as well as from oral and gastrointestinal mucosal surfaces.
- Vancomycin is an antibiotic which can cause hearing loss, Renal failure and Redman syndrome related to infusion rate.
- Metformin is an Oral hypoglycemic agent which can cause hypoglycemia, weight loss, unpleasant metallic taste and stomach discomfort as side effects.
- Acetaminophen Overdosage can lead to severe hepatic impairment.
- Oxycodone and Morphine are opioids which can lead to drowsiness, Constipation, addiction and dizziness. Overdose can lead to respiratory failure.
- Vitamin C overdosage can lead to gastrointestinal disturbances.

Question 4:
Patient education prior to discharge
- Patient should be advised about regular Cleaning and dressing of the infected wound and avoid contamination of wound.

- Tight control of blood sugars.
- Possible infusion reactions like Redman syndrome associated with Vancomycin.
- Risks of addiction with Morphine use and possibility of withdrawal symptoms on abrupt discontinuation.
- Early ambulation to prevent bedsore and DVT.
- Identification of early signs of infection and report to treating physician.
- Elevation of lower extremity to prevent venous pooling and edema.