Case Study case study

 INTRODUCTION

The term cellulitis is commonly used to indicate a non-necrotizing inflammation of the skin and subcutaneous tissues, a process usually related to acute infection that does not involve the fascia or muscles. Cellulitis is characterized by localized pain, swelling, tenderness, erythema, and warmth. Cellulitis has been classically considered to be an infection without formation of abscess (nonpurulent), purulent drainage, or ulceration. At times, cellulitis may overlap with other conditions, so that the macular erythema coexists with nodules, areas of ulceration, and frank abscess formation (purulent cellulitis) (see Presentation). The following images illustrate some of these presentations. Streptococcal species are the most common causes of erysipelas and diffuse cellulitis or nonpurulent cellulitis that is not associated with a defined portal. S aureus is the usual causative organism in purulent cellulitis associated with furuncles, carbuncles, or abscesses. The typical symptoms of cellulitis is an area which is red, hot, and painful. The photos shown here of cellulitis are of mild cases, and are not representative of earlier stages of the condition.

I.

HEALTH HISTORY

A. Demographic (Biographical) Data A. Client’s Name or Initial: M.E B. Gender (Sex) : Male C. Age: 57 years old D. Admission Date: 08/04/2013 E. Time Admitted: 12:53 pm F. Admitting Diagnosis: Cellulitis Right leg, Hypertension Stage 2 Uncontrolled B. Source and Reliability of Information o The sources of information are the patient’s chart, the staff nurses, and the client himself, C. Reason for Seeking Care o The patient experience non-healing wound at his bilateral feet. D. History of Present Illness o Patient M.E. was admitted to St. Dominic Medical Center last August 4 2013 with the chief complaint of non-healing wound at his bilateral feet. E. Past Medical History o 2 months prior to admission the patient has history of non-healing wound at his left lower leg. F. Family History  The mother of the patient was deceased because of heart attack and his father is also deceased. G. Socio-Economic o The client didn’t smoke nor drinks alcohol. o He is a chief in a college institute. H. Developmental History  Erick Erickson’s Psychosocial Development Theory o Stage: Generativity vs. Stagnation(40 to 65 years) The client loves to be in his work. “Gustong-gusto ko ang mag luto” as verbalized by the patient.

I. Review of Systems

System  General

 Integumentary

1. Regional Examination – August 6, 2013 Normal Findings Actual Findings BP: 140/80 mmHg BP: 90-140/60-90mmHg PR: 89 bpm PR: 60-100bpm RR: 20 cpm RR: 12-20cpm T: 36 T: 36-37.5 Dry skin (+) Redness and swelling on the right lower leg (+) scaly lesion on bilateral feet

 Head  Eyes  Nose  Ears  Mouth & Throat:  Neck  Breast & Axillae  Respiratory  Cardiovascular

(+) Hypertension

 Gastrointestinal

 Urinary  Genitalia  Musculoskeletal  Neurologic  Endocrine

(+) increase blood glucose level.

2. Laboratory Studies / Diagnostics

Exam CBG, Hgt, Rbs

CBG Monitoring – August 5, 2013 Time Result 2:15 pm

182 mg/dL

Significance

The patient has elevated blood glucose that indicates hyperglycemia.

Blood Chemistry—August 5, 2013 Exam

FBS

Reference

74.00-106.00 mg/dL

Test

HbA1C

Result

Significance

156.0 mg/dL

The patient has elevated blood sugar. Impaired fasting blood glucose.

HbA1C Test--August 4, 2013 Reference Result

4.8-5.9%

6.26%

Significance The patient has elevated HbA1C which means he is at risk for Diabetes.

J. Functional Assessment * Health Perception and Health Management The client has the awareness that he is going to be okay.

* Nutritional and Metabolic Pattern The client was on the low salt low fat diet, but he loves to eat fatty foods.

* Elimination pattern (while confined) The patient defecates one time a day and be able to urinate regularly with the color of light yellow.

* Activities of daily living (ADL) (while confined) The client verbalized that he can eat independently and can dress himself properly without a need of any assistance as well as in bathing. He usually sleeps around 9 o’clock in the evening and wake up at 7am, he also have afternoon nap for two hours. He also loves to cook.

* Activities Tolerance-Exercise pattern (while confined) Patient was able to ambulate around without assistance; he was able to dress and eat on his own. *

Sleep rest pattern (while confined) The client doesn’t have difficulty in sleeping. He normally sleeps at 9 pm and wake up at 7 am, he also sleep during morning and afternoon.

* Cognitive-Perception (while confined) The patient can speak fluently and understand fully in Tagalog. He is oriented with the time, people surround him and place. He can answer the questions that were given to him. He is also aware of his conditions and to his medications.

* Role-Relationship Pattern (while confined) The client is nice and easy to get along with, he also actively participate to the procedures that are given to him.

II.

PATHOPHYSIOLOGY

Predisposing Factors: Age Gender

Precipitating Factor: Open sound of the fight foot. Staphylococcus Aureus enters to the open wound

Infection of connective tissue

Redness of the right lower leg

Inflammation of dermal and subcutaneous layer of the skin

Scaly lesions at the bilateral feet

III.

CONCEPT MAPPING

Problem no.1

Problem no. 2

Unstable Blood Glucose level r/t insulin deficiency.

Impaired Skin Integrity r/t slow wound healing at the bilateral feet.

Key Demographic Data: Clients initial: M.E. Age: 57yo Gender: Male Assessment of Patient: Increased blood sugar level With Hypertension With scaly lesions at bilateral feet. Redness of the right lower leg. Key Assessments: Bp: 140/ 80 RR: 20 PR: 89 Temp: 36 FBS= 156.0 mg/dL CBG=182 mg/dL HbA1C= 6.26%

Problem no. 3 Imbalance Nutrition: More than Body requirements r/t lifestyle.

IV.

PROBLEM LIST

a. ACTUAL or active

Problem No.

Problem

Remarks

1

Unstable Blood glucose level r/t insulin deficiency.

The patient will be able to maintain glucose level in satisfactory range.

Impaired Skin Integrity r/t slow wound healing at the bilateral feet.

The patient will be able to display timely wound healing.

Imbalance Nutrition: More than Body requirements r/t lifestyle.

The patient will identify appropriate foods that are needed by his body.

2

3

V.

NURSING CARE PLAN

Assessment

Diagnosis

S: no verbal Unstable cues. Blood glucose O: level r/t  Vital insulin signs BP: 140/80 deficiency. PR: 89 RR: 20 Temp: 36  CBG of 182 mg/dL  FBS of 156.0 mg/dL  HbA1C of 6.26%

Planning

Intervention

Evaluation

After 8 hours of nursing interventions the patient will be able to maintain glucose level in satisfactory range.

Independent:  Monitored vital signs and recorded.  IandO taken and monitored.  Encouraged low salt low fat diet.  Assessed patient condition.  Kept rested.  Encouraged verbalization of feelings.

After 8 hours of nursing interventions the patient wasn’t able to monitor CBG.

Dependent:  Monitored CBG.

Assessment

Diagnosis

Planning

Intervention

Evaluation

S: “Patuyo na yung sugat, hindi na din siya masakit” as verbalized by the patient.

Impaired Skin Integrity r/t slow wound healing at the bilateral feet.

After 8 hours of nursing interventions the patient will display timely wound healing.

Independent:  Monitored vital signs and recorded.  IandO taken and monitored.  Kept affected leg elevated.  Kept rested  Provide calm and safe environment.  Health teaching on proper hand hygiene. Dependent:  Administered medications as prescribed by the physician.

After 8 hours of nursing interventions the patient displayed timely wound healing.

O:  Vital signs BP:140/80 PR: 89 RR: 20 T: 36  Elevated affected leg.  With scaly lesions at bilateral feet.  With redness at right lower leg.

Assessment

Diagnosis

S: No verbal Imbalance Nutrition: cues More than Body O:  Triceps requiremen ts r/t skin lifestyle. fold  Observ ed dysfunc tional eating pattern.

Planning

Intervention

Evaluation

After 6 hours of nursing interventions the patient will identify appropriate foods that are needed by his body.

Independent:  Assist clients understanding.  Discussed necessity for decreased caloric intake and limited intake of fats, salt and sugar as indicated.  Encouraged the client to maintain a daily dietary food intake.  Discussed the client about the appropriate food selection.  Encouraged on low salt low fat diet. Dependent:  Refer to dietician.

After 6 hours of nursing interventions the patient identified appropriate foods that are needed by his body.

VI.

PHARMACOTHERAPEUTICS/MEDECINES

Generic Name(Brand Name) Losartan Potassium (Cozaar) Classification: Angiotensin II Antagonist

Indication Dosage & Frequency

Mechanism of Action

Side Effects

 For patient with hypertension. Reduction in the risk for cardiovascular morbidity and mortality in hypertensive patients.  50 mg/tab, 1 tab PO OD

blocks  Generally vasoconstrictor well and aldosterone tolerated producing  Dizziness effects of angiotensin II atreceptor sites, including vascular smooth muscle and the adrenal glands

Nursing Responsibilities  Monitor for blood pressure  Monitor for intake and output ratios and daily weight.  Assess for signs and symptoms of Hypotension  Instruct patient to have a low fat low sodium diet regimen  Monitor BUN and serum creatinine levels  Monitor for signs of hyperkalemia

Generic Name(Brand Name) Sulbactam+Am picillin (Unasyn) Classification: Antiinfectives

Indication Dosage & Frequency  For skin and soft tissue infections.  750 mg, IV Q8

Mechanism of Action

Side Effects

Nursing Responsibilities

Binds to bacterial cell wall, resulting in cell death. Addition of sulbactam increases resistance to Betalactamases, enzymes produced by bacteria that may inactivate ampicillin.

 GI disturbances  Skin rashes  itching

 Assess patient for infection at beginning and throughout course of therapy.  Obtain a history before initiating therapy to determine previous use and reactions to penicillins or cephalosporin  Observe patient for signs and toms of Anaphylaxis. Discontinue the drug and notify the physician immediately if these occur.

Generic Name(Brand Name)

Indication Dosage & Frequency

Mechanism of Action

Side Effects

Celecoxib (Celebrex) Classification: Analgesics

 For acute pain  400mg 1 cap PO OD

Celebrex is a non steroidal antiinflammatory drug (NSAID) that exhibits antiinflammatory, analgesic and antipyretic activities in animal models. It inhibits the prostaglandin synthesis, primarily via the inhibition of cyclooxygenas e-2 (COX-2).

 Dry mouth  Dysphagia  Skin exfoliation

Nursing Responsibilities  Take drug with food or meals if GI upset occurs.  Take only the prescribed dosage; do not increase dosage.  You may experience these side effects: Dizziness, drowsiness

VII.

ONGOING APPRIASAL

A 57 years old male patient was admitted last August 4, 2013 with a chief complaint of non-healing wound at his bilateral feet. He was diagnosed with Cellulitis Right leg, Hypertension Stage 2 Uncontrolled. He underwent several test like CBG monitoring, Blood Chemistry, Fasting blood sugar, and HbA1C test. His attending physician prescribed Unasyn as his antibiotic, Losartan, to manage his hypertension and Celecoxib as his analgesics. As a student nurse, I monitored his vital signs and Intake and output, I also administered his medications. The client has adequate knowledge about his condition; he also actively participates in the procedures that are given to him.

BIBLIOGRAPGHY

Online Recourses http://labtestsonline.org/understanding/analytes/glucose/tab/test#what http://medweb.bham.ac.uk/easdec/prevention/what_is_the_hba1c.htm http://www.scribd.com/doc/13325843/Common-Lab-ValuesABG-CBG-Urinalysis-Mechanical-Testing

Book Resources Marilyn E. Doenges, Mary Frances Moorhouse, Alice C. Murr Nursing Care Plans 8th Edition Davi's Nursing Resource Center Philippine Pharmaceutical Directory 11th Edition