Extremity Cellulitis Case

1. Tell the patients story

 FR is a 67 year old woman with chronic lower extremity edema and right lower extremity cellulitis, who has been managed with ciproflaxin, having failed outpatient treatment. Now is admitted for antibiotics and wound care after presenting to clinic on day of admission. The patient also has been complaining of poor p.o. intake for the last week or so due to poor appetite and some chills. Also notes some falls, 2 times in the last week or so. Several days prior to admit, had a fall while trying to have a bowel movement, which resulted in incontinence. While running to the bathroom, she slipped and fell on a stool, hit her head on the toilet, and passed out as a result. She did not present to medical care at that time, but in the ED during this presentation she had a normal CAT scan of her abdomen. Chest x-ray was also normal. Vitals were unremarkable, without any evidence of SIRS physiology. Prior cultures grew MSSA resistant to clindamycin, levo, penicillin, and pseudomonas pan sensitive.

 The patient has multiple allergies, however mainly to Clindamycin, Doxy, Minocycline, Penicillin, and SULFA.

 The patient denies any chest pain, shortness of breath, any new neurologic complaints. No nausea, no vomiting, no dysuria, no

increased frequency or urgency, but does note decrease in urine output. Denies any diarrhea or constipation. Denies any abdominal pain.

2. Discuss the patient’s pathophysiology.

 Current vital signs - BP: 131/48, HR: 63, RR: 18, T: 36.4
Weight- Unable to assess-no scale on bed

Which concepts are directly involved in your patient’s altered health status?

 This patient with chronic venostatis ulcer on the left presents with worsening right lower extremity cellulitis and chronic acute renal failure stage 2. Patient also presents with hyperkalemia – Acute Kidney Injury (AKI), falls and syncope- syncope likely due to vasovagal event in the setting of loose bm and possible hypovolemia from poor p.o. intake, Gout- may need to decrease dose if Creatinine does not improve, and Hypertension- Acute Kidney Injury (AKI).

Describe the physiologic process and how these concepts inter-relate.

 Cellulitis is a bacterial infection of the skin and tissues beneath the skin.

Cellulitis is an infection that also involves the skin's deeper layers: the dermis and subcutaneous tissue. The main bacteria responsible for cellulitis are Streptococcus and Staphylococcus ("staph"). MRSA (methicillin-resistant Staph aureus) can also cause cellulitis. Sometimes, other bacteria (for example, Haemophilus influenzae, Pneumococcus, and Clostridium species) may cause cellulitis as well. Cellulitis is fairly common and affects people of all races and ages. Men and women appear to be equally affected. Although cellulitis can occur in people of any age, it is most common in middle-aged and elderly

people.

 Acute kidney failure or acute kidney injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate and your blood's chemical makeup may get out of balance. Acute kidney failure develops rapidly over a few hours or a few days. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care. Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal kidney function.

Hyperkalemia is the medical term that describes a potassium level in your blood that's higher than normal. Potassium is a nutrient that is critical to the function of nerve and muscle cells, including those in your heart. Your blood potassium level is normally 3.6 to 5.2 millimoles per liter (mmol/L). Having a blood potassium level higher than 7.0 mmol/L can be dangerous and requires immediate treatment. The most common cause of genuinely high potassium (hyperkalemia) is related to your kidneys, such as:
• Acute kidney failure
• Chronic kidney disease

Gout is characterized by sudden, severe attacks of pain, redness and tenderness in joints, often the joint at the base of the big toe. Gout — a complex form of arthritis — can affect anyone. Men are more likely to get gout, but women become increasingly susceptible to gout after menopause. An acute attack of gout can wake you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable. Fortunately, gout is treatable, and there are ways to reduce the risk that gout will recur. Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood. Your body produces uric acid when it breaks down purines — substances that are found naturally in your body, as well as in certain foods, such as organ meats, anchovies, herring, asparagus and mushrooms. Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes your body either produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Hypertension, also called High blood pressure is a common condition in which the force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure.
Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Kidney problems

Compare signs and symptoms listed in your textbook/website to your patient’s signs and symptoms.

 Patient experiencing chronic left lower extremity ulcer, admitted with RLE resistant Methicillin-Sensitive Staphylococcus Aureus (MSSA) cellulitis and chronic AKI. Her signs and symptoms are her LLE pressure ulcer and RLE cellulitis- oozing and warm to touch, and her chronic AKI as evidenced by her Hyperkalemia, and hypertension.

Does your patient have other signs and symptoms? How do you explain these other signs and symptoms?

 Patient has had three toes amputated due to gout.

3. Interpret the most recent CHEM 12 and CBC.

 Upon admission and throughout her two week stay, her BUN and Creatinine levels have been both running high indicating kidney disease. Additionally her EGFR (Ca) has been running low again indicating renal failure.

Her white blood cell (WBC) started off very high and has been going down with vancomycin treatment. Her red blood cell/hematocrit/hemoglobin have been running low- possibly due to dehydration as I do not see any fluids on her med list and she came in with poor p.o. intake? However she also has bi-lateral lower extremity edema.

Does the lab data support your answers in question 2?

 Yes

Are there lab results that surprise you or that you can’t explain/understand?

 Yes
• I am not sure that I understand the low levels of Red Blood Cells (RBC)/Hemoglobin/Hematocrit? Could be a sign of dehydration, and she came in to hospital with poor p.o. intake. I do not see any fluids on her medical records chart? She also has LLE edema, which is fluid excess but could go with dehydration due to her age and AKI.

Are there labs that seem unnecessary for this patient?

 No

4. Describe the standard treatment for the patient’s primary problem (use your textbook or a reliable website for best practice or standard treatment)

 Antibiotics are essential for the treatment of cellulitis. Penicillin derivatives are often prescribed to treat cellulitis, but other antibiotics can also be effective. In more advanced cases of cellulitis, hospitalization and administration of intravenous antibiotics may be required. In our patient’s case, she is on IV vancomycin. If not appropriately treated, the bacterial infection can spread throughout the body, resulting in serious illness.

Her other diagnoses are secondary to her chronic AKI and are being managed with oral medications.

Is your patient getting the standard treatment?

 Yes

What is the expected outcome for someone with this illness?

 Most people with cellulitis respond to the antibiotics in 2 to 3 days and begin to improve. In rare cases, the cellulitis may spread through the bloodstream and become serious.

There is no cure for kidney disease, but it may be possible to stop its progress or at least slow down the damage. In many cases, the correct treatment and lifestyle changes can help keep a person and his kidneys healthier longer.

Hyperkalemia and Gout can be resolved with medications.

Most of the time, high blood pressure can be controlled with medicine and lifestyle changes. When blood pressure is not well-controlled, you are at risk for:

• Bleeding from the aorta, the large blood vessel that supplies blood to the abdomen, pelvis, and legs
• Chronic kidney disease
• Heart attack and heart failure
• Poor blood supply to the legs
• Problems with your vision
• Stroke

Will the person likely be discharged to home? Is a full recovery expected?

 The person will be discharged to home. The recovery from her wound is doubtful since she has had this for quite awhile. Her doctors believe that her inability to completely heal of this chronic wound has something to do with allergies.

Her cellulitis should respond to the antibiotics and begin to improve.

There is no cure for kidney disease, but it may be possible to stop its progress or at least slow down the damage. In many cases, the correct treatment and lifestyle changes can help keep a person and his kidneys healthier longer.

Again, the goal of treatment for hypertension is to reduce blood pressure so that there is a lower risk of complications.

5. Are they getting better or worse? How do you know this?

 The patient has resolved many of her acute issues including infection, hypokalemia, hypovolemia, and gout.

Her chronic issues will need to be closely managed, including diet, exercise, medication compliance, hygiene, getting to the doctor when necessary, etc.

6. Describe two major complications to watch out for. What are the symptoms of these risks? What can be done to prevent them? How will you treat them if they occur?

 One complication (symptoms, prevention, risks) for FR will be recurrent episodes of cellulitis due to her chronic wound.

Possible signs and symptoms of cellulitis include Redness, Swelling, Tenderness, Pain, Warmth, and Fever. The changes in your skin may be accompanied by a fever. Over time, the area of redness tends to expand. Small red spots may appear on top of the reddened skin, and less commonly, small blisters may form and burst.

Those who experience recurrent episodes of cellulitis may benefit from efforts to keep skin hydrated, control of chronic dermatoses, or, in some cases, antibiotic prophylaxis.

Recurrent disease is common especially in those with persistent risk factors (e.g., lymphedema, venous insufficiency, tinea pedis). Usually beta-hemolytic streptococci are the cause. Prophylaxis with penicillin’s or macrolides has been beneficial in some patients and can be considered if frequent relapses (>3 times yearly) occur.

Chronic cellulitis is rare, usually occurs only in immunocompromised patients, and is restricted to indolent organisms.

 Another complication (symptoms, prevention, risks) is her acute kidney failure stage 2. Here are some symptoms to watch out for:

• Changes in Urination
• Swelling
• Skin Rash / Itching
• Leg, Back or Side Pain
• Metallic Taste in Mouth/Ammonia Breath
• Nausea and Vomiting
• Feeling Cold
• Shortness of Breath
• Dizziness and Trouble Concentrating
• Fatigue
Three primary ways to prevent AKD are:
• Know if you are at risk
• Keep your blood pressure under control
• Monitor your blood sugar if you are diabetic

We already know she has AKD, but other risk factors include those with diabetes, hypertension and a family history of kidney disease. African Americans, Hispanics, Pacific Islanders, Native Americans and seniors are also at increased risk.

7. Describe the biggest safety risk for your patient and how you will prevent it.

 The biggest safety risk for my patient going home is a fall risk. She had two falls the week prior to her admission to the hospital. Should she not take proper care of herself, as described above, she could have poor p.o. intake again resulting in nutrition deficit and hypovolemia, resulting in a fall (or falls).

8. Patient centered care is providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Describe how you provided patient centered care according to the above definition.

 Patient is a very pleasant unmarried lady without immediate family, but is supported by her many friends and church family around her. She seems happy to discuss her many friends wanting to pick her up and take her home. I asked her how she was supported at home, get to doctors’ appointments, medications, groceries, any help she needed and she said that she had so many friends in and out all the time all more than willing to take her wherever she needed to go. She seems very upbeat and is ready to go home.

I discussed with her plans to take care of her wound and she insisted that she has always taken very good care of it and was very clean and her house was very clean. We discussed importance of good diet and fluid intake to help the wound heal as much as possible. And to keep appointments with her home nurse and follow up doctor appointments.

Due to her falls we discussed ways to be prepared for ways to call for help should she have another fall, and that she shouldn’t necessarily wait for a second or third fall to visit the doctor with her history of this chronic wound and cellulitis.

She is a happy and social lady, so this conversation flowed well and she was very receptive and open to discussing these needs upon returning home. For the most part, it seemed her needs from us and from the hospital had been met, and that she was happily independent with her church and support system.

9. Print ALL the medications the patient is on (not just the ones on your shift).

Medication Action Side Effects Nursing Precaution Reason for Taking Working?
acetaminophen (Tylenol) tablet 325-650 mg
Oral
Every 4 hrs PRN for mild pain
Mild pain or fever Jaundice, skin rash, urticaria Contraindicated in patients hypersensitive to drug. Use cautiously in patients w/history of alcohol abuse; hepatotoxicity may occur Pain Yes. As needed.
allopurinol (Zyloprim) tablet 150 mg oral daily Decreases level of uric acid/gout

Hives, difficult breathing, swelling of your face, lips, tongue, or throat, fever, rash, headache, pain/bleeding when urinating Increase acute attacks of gout reported during the early stages, take prophylactically, drink adequate fluid, decreased renal function require lower doses Gout Yes, when taken as ordered.
bisacodyl (Dulcolax) suppository 10mg
Dose 10 mg
Daily as needed for constipation
Chronic constipation Nausea/vomiting, ab cramps, diarrhea, protein-losing enteropathy, lax dependence, alkalosis, hypokalemia, fluid & electrolyte imbalance, tetany Patients sensitive to drug, rectal bleeding, gastroenteritis, intestinal obstruction, acute surgical abdomen, ab pain, nausea/vomit Constipation Yes. As needed
Diltiazem (Cardizem CD) 24 hour capsule 300 mg Oral nightly High Blood Pressure (Calcium Channel Blocker) Hives, difficult breathing; swelling of your face, lips, tongue, or throat, skin rash, trouble breathing, stomach pain, brady/tachycardia Take exactly as prescribed, take with full glass of water, do not crush, do not stop immediately. High Blood Pressure Yes
Gabapentin (Neurontin) capsule 300 mg oral BID Nerve Pain Hives, fever, swollen glands; sores in/around eyes/mouth, diff breathing, swelling of your face, lips, tongue, or throat, report mood or behavior changes, hyperactivity, suicidal thoughts Take as prescribed, causes sedation, can be taken with or without food, if break in half, take other half next dose, do not stop immediately. Nerve Pain Yes
heparin (porcine) injection 7500 units Subcutaneous TID Anticoagulant
Helps prevent blood clots Bleeding, nausea, vomiting, sweating, hives, itching, trouble breathing, swelling of your face, lips, tongue, or throat, light-headedness, chest pain, weakness, tachycardia, SOB Do not administer unless solution is clear and container is intact. Discard unused portion, watch out for heparin resistance, higher incidence of bleeding in older women Blood clot prevention Yes
Hydralazine (apresoline) injection 10 mg IV Q6H PRN High blood pressure, systolic Headache, pounding/fast heartrate, anorexia, nausea/vomit, diarrhea, dizziness This product may cause allergic reactions, do not use with certain heart conditions, this drug can cause dizziness, tell MD before surgery HBP Yes. As needed
Hydromorphone (dilaudid) tablet 2-4 mg oral Q2H PRN Severe Pain (8-10) Respiratory depression, apnea, dizziness, sedation, nausea/vomit, sweating, flushing, dysphoria/euphoria, dry mouth, pruritis Causes respiratory depression, use with caution in patients with respiratory problems, high risk for abuse, added effects with alcohol, do not use with head injury, hypotensive effect Pain Yes. As needed
Lactobacillus rhamnosus (GG) (Culturelle) capsule 1 capsule oral BID Reseeding stomach (on vancomycin) flatulence might cause pathological infection, particularly in critically ill or severely immunocompromised patients, may cause bacteremia in patients with short-bowel syndrome, caution to people with central venous catheters, contraindicated in and persons with a hypersensitivity to lactose or milk Yes
Oxycodone SR (Oxycontin) tablet 10 mg Oral Q12H scheduled Pain Signs of allergic reactions shallow breathing, slow heartbeat, Seizure, cold, clammy skin,
Confusion, weakness or dizziness, nausea, vomiting, constipation, loss of appetite, dizziness, headache,
dry mouth, sweating; or itching. Addiction and abuse , life-threatening respiratory depression, neonatal opioid withdraw syndrome, interaction with other CNS depressants, use in elderly/debilitated, use with COPD, hypotensive effects, patients with head injury, gastro conditions, seizure disorders Yes
Pantoprazole (Protonix) EC tablet 40 mg Oral every am on empty stomach Proton pump inhibitor. Reduces acid in stomach Stomach pain, blurred vision, dry mouth, flushed skin, fruit-like breath, increased hunger/thirst/urination, nausea/vomit, sweat, trouble breathing, weight loss, vomit Concurrent gastric malignancy, atrophic gastritis, b-12 deficiency, c.diff associated diarrhea, increased risk bone fracture, hypomagnesmia Reduces acid in stomach Yes
Vancomycin 1500 mg in sodium chloride 0.9% 500 mL IVPB 300 mL/hr IV Q24H Antibiotic Bladder pain, bloating, convulsions, decreased/bloody urine, dry mouth, fever, thirst, anorexia, back pain, irregular heartbeat, mood change, weight gain, SOB may result in overgrowth of nonsusceptible microorganisms, nephrotoxicity, ototoxicity, reversible neutropenia, irritating to tissue, frequency of infusion-related concomitant administration of anesthetic agents
Cellulitis Yes
zolpidem (Ambien) tablet 5 mg as needed
Oral
Nightly
Short-term management of insomnia Sleep-related behaviors, drowsiness, amnesia, headache, depression, palpitations, sinusitis, nausea/vomit, ab pain, constipation, back or chest pain, rash Use cautiously in patients with conditions that could affect metabolism, compromised respiratory status, depression, history of drug/alcohol Insomnia Yes. As needed

10. Describe your goal for caring for this patient. It must be specific and realistic and something that can be completed by the end of your shift.

 My patient is ready for discharge so my goal is to be sure I keep her safe and free from falls. I would be sure her wound has been cleaned and dressed and also take any opportunities to provide as much patient education (or education reminders) as possible. I want to be sure she is going to be able to get all her medications filled, a safe ride home, create a safe environment for herself, and follow-up wound care scheduled with her home health nurse.

Describe the patient’s or family’s response when you discussed this goal with them.

 This patient was very receptive to goals and seemed very confident in her abilities to stay safe, and follow discharge instructions closely.

Three things I would do to achieve discharge goals would be:

 The patient has bathroom privileges so I would remind her to get up slowly since she has been in bed, make sure bed in low position, that she has her no-skid socks on, and to call if she needs any assistance to get up to the bathroom.
 I would be sure she has contact information for the home health nurse for her continued wound care and even offer to help make her first appointment.
 I would discuss the discharge instructions with the friend who comes to pick her up and make sure she has access to her medications, groceries, follow up doctor’s appointments, etc.

11. Consider why the patient is still on the unit. What needs to happen for discharge? What could potentially happen to cause them to be transferred to PCU or ICU?

 The patient is discharging today

12. List two people on the interdisciplinary healthcare team that are important to your patient having a good outcome and/or preventing complications

 One of the interdisciplinary team that is important to the client is the home health nurse. She will be instrumental in taking care of this chronic wound and hopefully getting it cleared- at minimum to a place where another infection does not set in.
 The dietician is an important resource to be sure she is getting good and proper nutrition for the healing of her wound, and hydration to avoid additional bouts of hypovolemia.
 A more obvious member of the disciplinary team important to the client will be her regular doctor. It will be important for her to manage her hypertension well in order to keep risks for exacerbation of chronic AKI, gout, hyperkalemia low. Also to keep an eye on her chronic wound and new infections.

13. Suppose your patient was healthy enough to be discharged right now. State a learning goal that would help keep him/her from returning to the hospital with the same problem?

 The patient will go home today. It will be important for her to follow discharge instructions. She must know (be compliant) with her medications, know when to call doctor’s office, understand safety risks, and how to care for her wound.
 The patient will have to understand and maintain hydration and good nutrition.
 The patient must understand the importance of the home health nurse and taking care of her wound until care handed back over to patient.

How will you address this learning need? How will you tell if your patient has learned?

 To be sure that my patient understands this information, I will ask him to repeat it to me. Hopefully we will not see her back at the hospital for a long time.