Case Intro!
F, 74, full code status, allergic to neomycin and codein. Came into ED 2/10 complaining of swelling in her right knee. What is a potential first diagnosis?
R TKA Infection. Later found abscess in R shoulder.
Pt. reports nausea, thinks the infection began due to steroid injection in shoulder, and feels tired. What kind of information is this?
Subjective!
What is the outcome we want for my pt?
By the end of the shift on 2/21, pt will be discharged with proper education provided to both her and her family.
When transferring care to a night shift nurse, what assessment data would you include?
VS (specifically BP bc pt has HTN); last dressing change; integumentary assessment.
What do you think her treatment consisted of?
D & I of R knee and shoulder. Antibiotics.
Pt is allergic to neomycin and codeine. What are some potential rxns she reported? How does this impact her care?
Skin irritation, itching, persistent redness of skin for neomycin. Headache w/ codeine. Had to discontinue vancomycin to treat infection and switch to cefazolin.
BP is 127/84; 6/10 for pain in RLE; afebrile; A&O x3. Wound dressing is dry and intact. What kind of information is this?
Objective!
Tell me one nursing intervention we could do to accomplish this, given the information I have provided.
Ensure that the orders are in for patient to be transferred to skilled nursing facility and that the facility is ready for her.
What lab values should you mention?
WBC; PT (her antibiotic lowers these levels).
The antibiotic was ceFAZolin (Ancef). What drug class do you think this is in?
Semi-synthetic first-gen cephalosporin antibacterial agent.
What are some initial assessments and diagnostics to complete?
VS (febrile or not); integumentary assessment; MRI of R knee and shoulder to look for fluid; x-ray to confirm previous knee replacement hardware in place; WBC count; cultures of body fluid, urine, and blood (positive for staph aureus).
Later had x-ray to confirm PICC line placement.
WBC count on 2/10 was 15.6. On 2/15 it was 11.9. Why this this important?
Showing signs of improvement in infection.
Tell me another nursing intervention to accomplish the goal.
Educate pt and family on proper wound care (how to do a dressing change, change every other day, wash skin around dressing with CHG wipes).
What diagnostics/results should you include?
Primarily MRI's; D & I's; PICC line. Mention that she is WBAT but needs assistance.
What do you think are some indications for its use?
Basically any infection! (Resp, UTI, skin, bone and joint, endocarditis, septicemia, spreading odontogenic infections, strep. diseases)
What are the common s/s of an infection?
Joint pain, swelling, erythema, warm to the touch, fever.
After hearing the pts lab values and progression, and after being in the hospital for 11 days now, do you think she is ready to go home?
Kind of! After proper education and discharge planning has been complete ;)
Tell me one final intervention.
Educate pt and family on IV antibiotic use (use for full 6 weeks, tie in PICC line care and removal).
What recommendations would you give to the nurse?
Prepare for discharge; educate; review ROM activities; administer pain medication still
What is some education you would provide for the pt?
Avoid missing doses; complete entire course of therapy; call provider if allergic rxn occurs
Can be caused by bacterial, fungal, or viral infections. Commonly staph aureus. Infection spreads through blood to joint. Can be caused by an injection near a joint. Lining of joints are not good at protecting themselves from infection. Having an artificial joint is a big risk factor.
Discharge planning
Were the interventions implemented? How did the pt respond?
Hopefully it went well!
What is one last important thing to double check with the nurse (especially if she is leaving soon)?
That she has pooped! (Last bowel movement)
Reflection time!
Woop woop