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History of Present Problem:
Gene Potts is a 78-year-old Caucasian male with diabetes type 2, MRSA cultured in left foot ulcer and dementia who
came to the emergency department because he had increased pain in left foot, chills, fever and feeling weaker the past
two days. His wife noticed an increase in redness and swelling of his chronic left foot ulcer. Initial vital signs: T: 101.5
F/38.6 C P: 98 R: 22 BP: 148/90. O2 sat: 94% room air.
His left great toe is black with an open stage III ulcer 1x1 cm on the top of his left foot. Surrounding tissue is bright
red and extends from his left foot to his lower left leg. His initial WBC: 18.5, lactate: 1.8, and creatinine: 1.7. A CT of
his left foot confirmed osteomyelitis in the left great toe. He is admitted to the med/surg floor and started on
piperacillin/tazobactam IVPB and vancomycin IVPB. He is scheduled to have his left great toe amputated in surgery
tomorrow.
Personal/Social History:
Gene has been married for 55 years and is cared for by his wife, Ruth, who is a retired nurse. They have no children. His
dementia has progressed, and Gene no longer recognizes his wife. He has become more difficult for his wife to manage
at home. Gene is DNR/DNI. Palliative care was consulted to clarify goals of care and communicated that Gene is at high
risk for decline after surgery and may require skilled care after discharge. Ruth is stern and communicates that she knows
her husband best and insistent that he will come home after surgery no matter what.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Diabetes type 2 Diabetes damages the peripheral blood vessels and nerves. Nerve
MRSA left foot ulcer damage makes the patient less aware of ulcers and injuries. The ulcers
may not heal and can easily become infected.
Chills When combined with increased HR, increased RR, the high temp meets
Fever - Temp 101.5 F/38.6 C SIRS criteria for suspected sepsis. Signs of infection include the
R: 22 following: Fever, chills, increased weakness, increased pain, redness
P: 98 and swelling of the infected area.
Chills may occur at the start of an infection. The body’s response to
infection is to raise the temperature because the pathogens thrive best at
a normal body temperature. Chills are caused by rapid contraction and
relaxation of the muscles to increase the body’s temperature. Temp of
above 101 which likely indicates wound infection.
Weakness over the last two days Weakness can indicate localized or systemic infection. Continual or
Increased pain, redness, swelling of the left increasing pain can be a sign of a wound infection. Redness that
foot expands around a wound is a sign of wound infection. You can track this
with a marker by outlining the initial area of redness and observing if it
passes the line. Persistent swelling is a sign of a wound infection.
Left toe is black Foot ulcers occur because of nerve damage and peripheral vascular
Left foot bright red and radiates to left leg damage. Without adequate blood flow, wounds cannot heal, and
gangrene or death of tissue occurs due to lack of blood. A black toe
indicates gangrene. Gangrene symptoms also include skin color changes
including red, blue or black.
WBC: 18.5 WBC elevation indicates an infection is present in the body.
Lactate: 1.8 Lactate of 1.8 is high normal. Lactate is elevated greater than 2 in septic
shock but is also often accompanied by hypotension.
BP: 148/90 The patient’s BP is 148/90. The vigilant nurse should TREND and assess
for signs of shock that would include tachycardia and decreasing BP.
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Diagnosis of Osteomyelitis Osteomyelitis on the CT indicates the infection has progressed into the
bone and sepsis could be a complication.
Creatinine 1.7 An elevated creatinine indicates the kidneys are not working well and
could be elevated for a couple of reasons: Kidney damage secondary to
diabetes, or dehydration due to the temp elevation/lack of hydration
because of dementia.
RELEVANT Data from Social History: Clinical Significance:
Wife is a nurse and caregiver. As a nurse, his wife has correctly assessed his condition change and has
been successful as a caregiver for her husband thus far. At this point,
there is a change in his condition. It is important for the nurse to
recognize that even though his wife is a nurse, she is his wife. There are
no children to support her in caregiving and decision-making, and thus
she is the sole caregiver.
He has become more difficult for his wife to He has become increasingly difficult for her to “manage” at home.
manage at home When a patient becomes 24-hour care, which this patient is likely to
become given that he has dementia, caregivers frequently attempt to
care for their loved ones. It is not realistic for one person to care for a
patient 24/7. Caregivers need permission, support, conversations, social
worker intervention, etc. to allow themselves to let go of caregiving and
consider skilled care after discharge. The wife needs support to work
through this decision, and a social worker can assist.
Palliative care consult At this point, the conversation surrounding palliative (comfort) care and
Surgery is scheduled for tomorrow. whether the surgery should be pursued needs to be opened between the
wife, physician, and palliative care consultant. It is helpful for nurses to
be present during these conversations because nurses are asked
questions later and can be a resource/support to the family
members/patient. One can’t be sure what the wife promised her
husband or what he requested of her regarding his care in the future.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medications treat which conditions? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Ischemic cardiomyopathy • Allopurinol 100 mg PO daily Anti-gout Decreases uric acid
with EF of 35-40% levels
• Atrial fibrillation/flutter
• CVA • Atorvastatin 10 mg PO at HS Antihyperlipidemic To decrease cholesterol
• Obstructive sleep apnea and reduce the risk of MI
• Coronary artery disease and stroke in patients
• Type 2 diabetes-diet with type 2 diabetes.
controlled
• Chronic kidney disease • Docusate 100 mg PO daily Stool softener Regular BM
• Gout
• Fluoxetine 20 mg PO daily SSRI antidepressant Treat depression
• Furosemide 40 mg PO daily Loop Diuretic Diuresis, decrease edema
and antihypertensive
• Losartan 50 mg PO daily ARB Antihypertensive BP normalized
Beta blocker/ BP normalized
• Metoprolol XL 50 mg PO
daily Antihypertensive
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