#1
Ms. G is a 23 year-old female with a history of diabetes that presented to the hospital with cellulitis of the left lower leg. Lab results revealed elevated white blood cell count, elevated neutrophils, and bands. These results along with the wound culture that is positive for Staphylococcus aureus indicate the presence of infection. Antibiotics would be the recommended treatment for a Staphylococcus aureus infections with cephalosporins, sulfa drugs or vancomycin being the most common antibiotics used (Mayo Clinic, 2017).
Ms. G’s wound in located above the medial malleolus. The flexor digitorum longus muscle is located posteriorly to the medial malleolus and could be affected by the wound (Grand Canyon University, n.d.). The soleus muscle left also has the potential to be impacted if wound reaches the muscle.
Subjective and objective data can help clinicians make determinations about the cause of the patient’s condition and the best way to proceed. In Ms. G’s case the subjective data is the complaint of left leg pain and heaviness, reports of being unable to bear weight on the leg, and inability to get her own meals for three days while she was not able to get out of bed because she lives alone. Objective data in her case includes the laboratory results, assessment of left lower extremity color, difference in size between bilateral lower extremities, elevated temperature, and wound properties. With this information providers can make treatment recommendations and determine what additional tests are needed. Given Ms. G’s history of diabetes the provider may determine that a HgbA1c test is needed to assess how well she is doing at controlling her diabetes. Ms. G needs reeducation on her diabetes and a consult should be placed to a diabetes educator to see her while she is admitted to reinforce teaching on such topics as importance of diet, compliance with medication regimen, and monitoring of blood glucose levels. Ms. G should also be evaluated by case management to determine if she will be able to perform her wound care, be able to afford her medications, and determine if she needs either home health or rehab placement on discharge. Before being discharged from the hospital Me. G needs to have an appointment set to follow up with her doctor or clinic.
Elevated blood glucose levels can delay wound healing (American Diabetes Association, 2018). It is important that Ms. G understand how her glucose levels can impact the ability of her wound to heal. Another issue that can impact wound healing is proper wound care. Prior to discharge the nurse needs to make sure that Ms. G understands how to clean her wound and complete her dressing changes.
References:
American Diabetes Association (2018). Foot complications. Retrieved January 30, 2019 from http://www.diabetes.org
Grand Canyon University (n.d.). Anatomy resource center. Retrieved January 30, 2019 from https://lc.gcumedia.com
Mayo Clinic (2017). Staph infections. Retrieved January 30, 2019 from https://www.mayoclinic.org
#2
Ms. G., has been admitted for cellulitis left lower leg, with comorbidities of diabetes and obesity. Assuming antibiotics have not begun, blood cultures should be drawn immediately, as she is showing early signs of sepsis, high fever and chills along with a positive would culture.
Unfortunately Ms. G. is at risk for cellulitis given she is diabetic and obese. Consults for wound care, diabetes and nutrition should be ordered. Ms. G. labs should be ordered to monitor her blood sugar, given the infection and that she was bedridden and likely not eating proper meals given she had no help at home. POC blood glucose as well as A1C, as high levels may delay would healing. Other labs in addition to blood cultures are BUN and creatinine to monitor kidney function as long as she is showing signs of early sepsis. All of the muscles in her lower leg have the potential to be affected by the cellulitis, although it is not common. This would include fibularis longus, extensor digitorum longus, gastrocnemius, soleus, extensor halluces longus (Grand Canyon University, n.d.). The wound on her malleolus is not specified which leg, this may be a stage III pressure ulcer (Hughes, 2008), or an abscess from the cellulitis (Mayo Clinic, n.d). Ultra sound of left lower leg should be ordered to rule out DVT, given the history of bed ridden for 3 days.
Discharge education should begin now, as this is key for Ms. G. This must include wound care, and continued ongoing skin care including using lotion and doing skin checks regularly, and to not use heat on cellulitis, but cool compress (Mayo Clinic, n.d.). This should also include nutrition and diabetes education both of these can greatly influence her would healing. Ms. G may need to rely on home care for dressing changes given she does not appear to have a large support system. She may also require some physical therapy while IP and outpatient if she has deconditioned while bed ridden.
References:
Grand Canyon University (n.d.). Anatomy resource center. Retrieved January 30, 2019 from https://lc.gcumedia.com
Hughes, R. (2008). Pressure ulcers: A patient safety issue. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved from: https://www.ncbi.nlm.nih.gov
Mayo clinic (n.d.). Cellulitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/cellulitis/diagnosis-treatment/drc-20370766
#3
Clinical manifestations present are: 102.02degree temperature (febrile), calf size is greater in left leg, pain, redness, open wound with thick yellow drainage, culture positive for Staph with elevated WBCs
Recommendations: elevate left leg to reduce the swelling, start on antibiotic therapy to treat Staph infection, refer to wound care for treatment of open wound to minimize further complications, such as an amputation, have an ultrasound to rule out a DVT, and involve the social worker to assist with discharge planning.
The muscle groups affected are gastrocnemius and soleus muscles, longus and brevis muscles; all these muscle groups provide active stability. Patient stated that she could not bear weight on the leg.
The significance of the data is that member is overweight and needs to be referred to a dietician to assist with proper diabetic meal planning to control blood sugar levels, refer to home health for continued monitoring at home, and refer for provider services to assist with activities of daily living at home (which includes meal preparation), can also involve Meals on Wheels to assist with meals, and contact PCP to schedule a follow up upon discharge. Proper nutrition, glucose control, and mobility can assist in minimizing chronic wounds and cellulitis.
Patient is diabetic, overweight, poor nutrition, poor circulation, immobility, and has no available caregiver or resources to assist her. Member must maintain and control her glucose levels by proper medications, glucose monitoring and proper diet. Nutrition is very important in healing and patient must receive proper education in nutrition and have proper meals. Patient needs to be mobile to get the circulation and blood flowing to assist with wound healing. A clean environment is also very important for proper wound healing.
When I read this case scenario, it was like I was reading one of my patient’s charts. Majority of my patients are diabetic, overweight, and live alone. They were in and out of the hospital with cellulitis and other complications. Once the proper referrals were made and resources obtained, these patients went on to live better lives, with little to no hospitalizations. Preventative care and follow up is crucial to managing and stabilizing diabetes and its long-term effects so that patients can have an improved quality of life.
References
Copstead, L., Banasik.J. (2012). Pathophysiology (5th ed.). St. Louis, MO: Saunders Elsevier.
ARC: Anatomy Resources Center. Retrieved from http://lc.gcumedia.com/bio155l/anatomy-resource-center/v2.1/