History of Present Illness
Jose Crixell, an 85-year-old male, is hospitalized following a fall accident at his residence that inflicted a deep cut and inflammation on the bottom of his right leg. Since his wife passed away two years ago, Jose has been living with his daughter and her family. The client had been pre-diagnosed with hypertension and depends on a cane for stability. Although the departing nurse noted Jose’s physiological parameters as being “within normal norms,” the Unlicensed Assistive Personnel (UAP) interprets his contemporary signs as follows: Blood Pressure 165/94, Pulse 101; Respiratory Rate 28, and Temperature 101.8oF (“Differential diagnosis,” 2013). Moreover, compared to the previous day, the patient reports feeling weak and generally worse due to feelings of pain on a scale of 5/10 and swelling on the lower side of his right leg. Besides the IV antibiotics prescription to contain the infection, Jose is taking an antipyretic for pain. The antipyretic acetaminophen dosage administered to Jose increased from 1200 to 1800. Although Jose’s prescription recommends 650 mg of acetaminophen at four hours intervals, he took his last dose at 0900 and expects the next at 2200.
Pathophysiology of Admitting Diagnosis
Pathophysiology
- Drawing from the UAP reports, Jose presents elevated blood pressure and pulse rate at 165/94 and 101, respectively. Additionally, he has a peak temperature of 101.8F and acute injury on the wound with minimal presiding leakage.
- On the lateral aspect of his right lower thigh, there is an approximately 1 cm round wound. According to Baker et al. (2019), a high pulse is related to blood pressure and is a vital factor in physicians’ judgment during diagnosis. Therefore, the above-average pulse and blood pressure rates recorded by the patient are signs of an infection. The lower right leg of the client has an injury on the lateral side, which is a frequent site for illnesses. Jose’s wound is characterized by an open incision with serosanguinous discharge and a high body temperature which are signs of an infection.
Etiology
- The etiology of the open incision on Jose’s wound is a fall at his home that led to a puncture on his lower right leg that has caused active pain, bleeding, and inflammation on the injured spot. In a study by Patel et al. (2019), patients affected by lower-limb cellulitis with prolonged wound drainage face the most significant rate of contamination and necrosis that derail wound healing. Bleeding wounds host bacteria, such as streptococcus or staphylococcus, and cause cellulitis (Gordon & Phelps, 2020). The patients’ wounds have taken longer to heal and exhibited prolonged pain and bleeding, influencing the adjustment of the preceding acetaminophen dosage. Conclusively, Jose’s slow healing process and unending pain are influenced by bacterial contamination from bleeding.
- Moreover, the patient has exhibited high blood pressure and pulse rates. Notably, Jose has a history of hypertension, characterized by above-normal blood pressure and pulse rates.
Risk factors
- Open wound and hypertension comorbidity are risk factors facing Jose. First, hypertension influences high blood pressure and pulse rates, inhibiting wound healing. The client’s blood pressure is 165/94, moreover, Jose’s pulse rate is 101, above the normal range. Aside from the high blood pressure influencing tenacious wound drainage, hypertension interrupts the injury oxygenation critical to healing.
- Consequently, open and swollen wounds pose hazards to hypertension patients by triggering high blood pressure and subsequent health conditions. Wound infections that are swollen elevate C- reactive protein (CRP) levels that influence atherosclerosis hence unregulated blood pressure (Thomas & Aguh, 2021). Escalated demand for white blood cells following excessive bleeding triggers high blood pressure.
Signs and Symptoms
- The patient’s abnormal vital signs and worsening bleeding and pain symptoms suggest that the cellulitis is progressing. Possibly due to comorbidity infection, the client’s temperature, blood circulation, and heart rates have increased. Correspondingly the patients’ respiratory rates have escalated to match the high blood pressure.
- The priority problems are cellulitis and pain. The patient’s white blood cell count is elevated, suggesting that there is an infection present. Cellulitis is a severe skin infection and underlying tissue infection (Gordon & Phelps, 2020). It most often occurs on the legs but can occur on any body part. Signs and symptoms include redness, warmth, swelling, and pain.
Complications
- The patient reports that he is weak overall and getting worse than before. The patient claims his right lower leg is more painful, rating it a 5 out of 10, and more swollen and red. Hypertension implicates the wound-healing process exposing Jose to risks of necrosis, periwound dermatitis, and edema. Very high blood pressure is influenced by hypertension and potentially exposes the patient to risks of heart attack or stroke (Orgambídez & Almeida., 2020). Jose is also at risk for developing pneumonia due to the increased respiratory rate and difficulty breathing.
Priority Nursing problem #1
Problem #1: A puncture wound is a deep cut or hole in the skin caused by a sharp object influencing cellulitis, a bacterial infection of the skin and underlying tissues.
Patient Goal #1: The patient will manage vital signs, including swelling, oozing, and pain in the wound, within normal limits during the 2200hrs check-up and administration.
Implementation/Intervention #1:
- Evaluate signs such as the inflammation and hygiene of the wound.
Rationale: Drawing from Patel et al. (2019), open wounds with scant drainage influence bacteria, causing cellulitis. The client’s wound is swollen and painful due to a blood clot caused by cellulitis (Patel et al., 2019). Therefore, Jose’s wound is infected by cellulitis influenced by poor hygiene of the wound.
- Start Wound Care Bacterial treatment.
Rationale: Proper wound care measures such as regular cleaning, disinfection, inspection, and re-dressing are elemental to enhanced healing and limited bacterial infection. Moreover, facilitating appropriate bed rest for minimal wound disturbance is a necessary wound care procedure. Continuous oral administration of intravenous IV antibiotics will prevent further bacterial infection and enable the patient to combat cellulitis.
Evaluation #1: GOAL MET: Facilitate an improved healing process to reduce wound size, pain, and inflammation by improving bruise care and cellulitis management.
Priority Nursing problem #2
Problem #2: John was previously diagnosed with hypertension, a risk factor for high blood pressure, fever, and elevated respiration rates.
Patient Goal #2: The patient will reduce his blood pressure to less than 120/80mmHg from 165/94 mmHg.
Implementation/Intervention #2:
- Start blood pressure treatment with Angiotensin-converting enzyme (ACE) inhibitors.
Rationale: According to Gabel et al. (2021), medical treatment of hypertension with critical threats is necessary. ACE inhibitors cause vasodilation of blood vessels to regulate pressure. Considering Jose’s hypertension is developing, ACE inhibitors will help relax veins and arteries to lower blood pressure.
- Educate the patient on non-pharmacological measures for inhibiting hypertension.
Rationale: Another critical intervention for Jose’s education about cellulitis. He should be taught the importance of seeking medical attention immediately if he experiences worsening symptoms. Non-pharmacological treatments for hypertension, such as limited alcohol consumption, cigarette smoking, and salt intake, will help Jose navigate his high blood pressure. Moreover, he should also be instructed on the importance of taking his antibiotic as prescribed and completing the entire course of therapy.
Evaluation #2: GOAL MET: The patient lowers his blood pressure to recommended levels of less than 120/80mmHg after implementing medical and non-pharmacological approaches to controlling hypertension.
Priority Nursing Risk for Problem #1
Risk of allergic reaction to the antibiotics.
Implementation/Intervention for Risk #1:
- Terminate the intravenous IV antibiotics after diagnosing an allergic reaction
Rationale: According to Barker et al. (2019), antibiotic prescriptions are subjective to allergic reactions, and nurses ought to monitor and terminate antibiotic medications that trigger allergic reactions in patients. Even after intravenous IV treatment, advancing patients’ inflammation could be influenced by an allergic reaction.
- Administer antihistamines and epinephrine to manage allergic reactions
Rationale: HI antihistamines and Epinephrine medication seems to be the most effective treatment for anaphylaxis influenced by an allergic reaction. Pharmacological treatment of allergic reactions prevents progression to life-threatening respiratory, inflammatory, and cardiovascular symptoms.
Evaluation Risk for #1: GOAL MET: John will recover from an allergic response to intravenous IV antibiotics and prevent adverse effects.
Nursing Application Assessment
Basic Care
- Regular patient inspection
- Assist with therapeutic methods of mitigating pain
Safety and Infection Control
- Wound hygiene procedures
- Environmental checks for the patient
- Education on non-pharmacological methods of hypertension treatment
- Patient positioning to minimize injury
References
Barker, J. H., Kane, R., & Linsley, P. (2019). Evidence-based practice for nurses and healthcare professionals. Evidence-based Practice for Nurses and Healthcare Professionals, pp. 1–264. Web.
“Differential diagnosis” (2013) Practice Nursing, 24(9), pp. 447–447. Web.
Gabel, C., Ko, L. N., Dobry, A. S., Garza-Mayers, A. C., Milne, L. W., Nguyen, E., & Kroshinsky, D. (2021). Patient preference for cellulitis treatment: At-home care is preferred to hospital-based treatment. Journal of the American Academy of Dermatology, 85(3), 767–768. Web.
Gordon, A. A., & Phelps, P. O. (2020). Management of preseptal and orbital cellulitis for the primary care physician. Disease-a-month, 66(10), 101044. Web.
Orgambídez, A., & Almeida, H. (2020). Social support, role clarity, and job satisfaction: a successful combination for nurses. International Nursing Review, 67(3), 380-386. Web.
Patel, M., Lee, S. I., Thomas, K. S., & Kai, J. (2019). The red leg dilemma: a scoping review of the challenges of diagnosing lower‐limb cellulitis. British Journal of Dermatology, 180(5), 993-1000. Web.
Thomas, J., & Aguh, C. (2021). Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review. Journal of Dermatological Treatment, 32(2), 144-149. Web.