Case Study

Pitt CC Nursing 120Clinical Case StudySpring 2010 : 

Pitt CC Nursing 120Clinical Case StudySpring 2010 Mrs. Jones Pitt County Memorial Hospital SIU

Slide 2: 

Hailey Metts, Courtney Herring, Erin Haines, Emily Houston, Samantha Williams, Jessica Cohen, Britney Cooke

admission : 

admission D.F. is a 64 year-old nurse who was admitted to PCMH on February 11 from Onslow Memorial Hospital. Her initial complaint was pain, redness and swelling from a small laceration in her lower left leg. On February 25, Britney was involved in her care.

admission : 

admission After intubation for respiratory failure at OMH, she was transferred to PCMH for sepsis management.

admission : 

admission Upon arrival to PCMH, blood cultures and CT scans found a second diagnosis:

Necrotizing Fasciitis : 

Necrotizing Fasciitis Necrotizing fasciitis destroys the skin and the soft tissues beneath it, including the fat and tissue covering the muscle (fascia). It is extremely painful and is often misdiagnosed.

Necrotizing fasciitis : 

Necrotizing fasciitis Necrotizing fasciitis (some times called the “flesh-eating” bacteria) is usually caused by a group A bacteria such as Streptococcus pyogenes, the same bacteria that causes strep throat.

Necrotizing fasciitis : 

Necrotizing fasciitis Signs and symptoms of necrotizing fasciitis include severe pain (pain that is disproportionate to the injury), redness and edema, and later, the skin appearing purple or black.

Necrotizing fasciitis : 

Necrotizing fasciitis The bacteria must be introduced into the body through a break in the skin. D.F. sustained a cut on her leg; she failed to adequately monitor the cut for infection, eventually resulting in sepsis. The necrotizing fasciitis and its effect encompassed her entire lower left extremity from her groin to her toes. No unaffected skin was visible.

Necrotizing fasciitis : 

Necrotizing fasciitis Necrotizing fasciitis interferes with the flow of blood to infected tissue, which prevents the body from healing the damaged tissue.

History : 

History D.F. has multiple co-morbidities: Obesity—she weighed 119 kg (262 pounds) and her BMI was 38.4 upon admission.

history : 

Gastric Ulcers—managed with Nexium. history

history : 

Chronic obstructive pulmonary disease (COPD)—managed with Atrovent and Levalbuterol inhalers as well as oxygen therapy. history

history : 

Depression—managed with Prozac and Seroquel. history

history : 

Hypertension—managed with Norvasc and Lopressor. history

history : 

Gastric bypass surgery. history

History : 

History Diabetes—managed with regular insulin and blood glucose testing every six hours.

complications : 

complications Because of her respiratory failure, D.F. used a tracheotomy tube with an oxygen flow rate of 6 liters per minute at 28%.

complications : 

complications D.F. also used both a rectal tube and Foley catheter to void.

complications : 

complications Naso-gastric tube for continuous tube feedings.

complications : 

complications D.F. was in an enormous amount of pain and she became detrimental to her own health. She removed her trach, rectal tube and Foley catheter. She was subsequently restrained, both physically and chemically.

Medical management : 

Medical management Immediately after diagnosis, D.F. was started on intravenous penicillin and placed on isolation precautions.

Medical management : 

Medical management Surgical debridement is almost always needed to remove the infected dead tissue. This can also reduce the number of bacteria in the body, remove toxins, and stop the spread of infection.

Medical management : 

Medical management A wound VAC is a device that uses negative pressure to form an airtight seal over the area and "sucking" all the drainage out and pulling new tissue to the top.

Medical management : 

Medical management A short video of wound vac application. (Keep in mind, no unaffected skin was visible on D.F.’s leg. Only the black sponges were visible.)

Medical management : 

Medical management D.F. has undergone two skin grafts “harvests” to obtain enough healthy skin to cover the extensive wound on her leg. The donor sites were on her abdomen.

Nursing diagnosis : 

Nursing diagnosis Key Problem: ineffective airway clearance related to artificial airway (trach) Supporting Data: history of COPD, morbid obesity and respiratory failure; oxygen therapy via trach at 6L/min at 28%; decreased mobility; medications: Haldol, Atrovent, Levalbuterol, methadone, morphine, oxycodone; pain; right and left upper lobe wheezing

Nursing diagnosis : 

Nursing diagnosis Key Problem: actual/risk for infection related to current infection (sepsis), wounds and medical management Supporting Data: history of sepsis and diabetes; wounds— left leg (surgical debridement), abdomen (skin graft), IV sites; Foley catheter; rectal catheter; WBC 13.3 and 13.1; gastric tube; contact isolation status; tracheotomy; IV penicillin; decreased mobility, self-care deficit; prealbumin 10.8

Nursing diagnosis : 

Nursing diagnosis Key Problem: decreased tissue perfusion related to morbid obesity, infection and limited mobility Supporting Data: SCD; TEDs; Lovenox; surgical wounds and infection of left leg; activity limitations; decreased oxygen-carrying capacity (RBC 2.9 , HGB 7, HCT 21.4); diabetes

Nursing diagnosis : 

Nursing diagnosis Key Problem: acute pain related to wounds Supporting Data: extensive wounds on left leg from surgical debridement; abdominal wounds from skin graft; rectal tube; Foley catheter; gastric tube; medications: methadone, morphine, oxycodone; physical and chemical restraints

pause : 

pause We know this is bland—bear with us! 

Nursing interventions : 

Nursing interventions Problem: actual/risk for infection Goal: the patient will show no new signs or symptoms of increasing or new infection—redness, swelling, purulent drainage or elevated WBC count Assess wounds, IV site, Foley catheter and rectal tube for purulent drainage. Goal met; no additional signs of infection noted. Reposition every two hours. Goal met; patient moved and repositioned no less than every two hours. Adhere to isolation precautions and wash hands upon entering and leaving the patient’s room. Goal met. Monitor WBC count. Goal met—WBC 13.3 and 13.1.

Nursing interventions : 

Nursing interventions Problem: impaired gas exchange Goal: the patient will maintain optimal gas exchange as evidenced by alert responsive mentation or no reduction in mental status; skin pallor; and quality of respirations. Assess respirations, noting quality, rate, pattern, depth, and breathing effort. Goal met—respirations 16-17 per minute; wheezing noted in upper R&L lobes. Position with proper body alignment for optimal respiratory excursion (head of bed at 45°). Goal met—HOB at 45°. Assess for changes in orientation and behavior. Goal not met due to chemical restraints and pain medications. Assess skin color for development of cyanosis. Goal met—oral mucosa pink and moist; extremities acyanotic and dry x3.

Nursing interventions : 

Nursing interventions Problem: decreased tissue perfusion Goal: the patient will maintain optimal tissue perfusion to vital organs, as evidenced by strong and equal peripheral pulses, cap refill < 3s, and alert LOC. Assess cap refill on all four extremities. Goal met—cap refill <3s x4. Administer anticoagulation therapy (Lovenox) as prescribed. Goal met—40mg administered at 1000. Facilitate peripheral circulation (elevating lower extremities, SCDs, passive ROM exercises). Goal partially met—lower extremities elevated, SCD to right leg, passive ROM not completed due to patient’s restraints. Assess peripheral pulses. Goal met—pedal and radial pulses equal and moderate x4.

prognosis : 

prognosis Necrotizing fasciitis is a life-threatening condition with a reported mortality rate around 12-25%. Early diagnosis and aggressive treatment of necrotizing fasciitis is the most important factor in determining outcome. Certain risk factors with a negative impact on the prognosis have been identified, including age of over 50 years, diabetes mellitus, malnutrition, hypertension and intravenous drug abuse. Premorbid diabetes mellitus alone, and the presence of three or more of these risk factors have been reported to be predictive of a significantly higher mortality rate. Death is usually caused by sepsis, multisystem organ failure or invasion of major vessels.

prognosis : 

prognosis Though D.F. presents with several complicating factors, her prognosis is improving. She is successfully fighting the infection and showing significant signs of improvement. At best, she will have significant disfigurement/scarring and decreased use of her left leg.

prognosis : 

prognosis At worst, her body will not be able to fight off the infection, and her leg could be amputated. She would require both physical and occupational therapy.

discharge : 

discharge After discharge, D.F. will likely return to her home in Topsail Island as an outpatient rehabilitation patient. Living in her home as an amputee will require that a wheelchair-accessible ramp be added to her house.

discharge : 

discharge D.F. will have very few resources available to her after discharge. The nearest outpatient rehabilitation facility to her home is in Jacksonville, which is a 30 minute drive.

discharge : 

discharge D.F. is divorced with no children; her closest relative, a sister, lives many hours away. She was living alone with several dogs as companions. She is at a high risk for persistent depression and social isolation.

discharge : 

discharge Though D.F. is a nurse, education is the primary method to prevent readmission. She needs education related to wound care, infection prevention and nutritional management.

closing : 

closing Thanks for your time! Are there any questions?