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62 y.o. M Dx with Cellulitis BLE (Secondary Dx: Unstageable Pressure ulcer…
62 y.o. M Dx with Cellulitis BLE
SXS
BLE Pain rated 10/10
Nursing Dx:
Acute pain r/t inflammatory changes in tissues from infection
Prevent pain by administering analgesia before wound debridement
identify comfort function goal that will all the pt to perform necessary activities
Maggots/Roaches within LE wounds per report
Pathophysiology of Cellulitis
Entry of pathogen into the dermis through skim impairment. Pathogen overwhelms WBC
progression occurs as pathogens spreads to surrounding tissue
Neurovascular Impairment
Risk for sepsis
RIsk for Gangrene
Risk for Osteomyelitis
Secondary Dx: Unstageable Pressure ulcer to coccyx Eschar/slough
Pathophysiology
Pressure exerted over bony prominences
Decreased blood flow to area
ischemia and hypoxia leads to collapsed capillaries, edema to tissues and necrosis of tissue
waste product builds up that further breaks down tissue
Injury to the skin and underlying tissue
Secondary infection
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Treatment: Triad cream TID, adequate fluid intake, reposition every 2 hours with pillows to support
Risk for Friction/ sheering
Risk factor: wheelchair bound
Braden scale= 12
History
polysubstance abuse
Chronic alcohol abuse
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IV Heroin abuse
Inaccessible veins
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SXS:
Skin popping
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Introducing dangerous substance and microorganism into body
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Homelessness
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Nursing Dx:
Self Neglect r/t functional impairment and substance abuse
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Client will Exhibit improved personal hygiene by discharge
Poor nutrition and Hydration
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Hepatitis C
Pathophysiology
Damage to hepatocytes by body's immune response
altered cellular function and changes in the endoplasmic reticulum responsible for protein and steroid synthesis and detoxification
alteration of liver function
Liver inflammation
#
Liver Cirrhosis
Wheelchair Bound
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RX
Neurontin 800mg
Norco 10 Q4hrs
Zosyn 2.25g Q6hours
Vancomycin 1g in D5W Q24hrs
Treatment
Wound Debridement BID
Labs
Hep CAB = positive
HCV=negative
Mg= 1.1 :red_flag:
Cr= 1.46 :red_flag:
BUN=45 :red_flag:
Hgb= 7.9 :red_flag:
Plt=214
WBC= 13.2 :red_flag:
bilirubin= 0.2
HCT= 24.4 :red_flag:
Na=135
Ca= 6.9 :red_flag:
Treatment
Magnesium Sulfate
iron supplements
Continuous lactated ringer PICC IV R femoral
References
:
https://oceanhillsrecovery.com/blog/california-drug-users-cellulitis-intravenous-iv-drugs/
http://www.nsgmed.com/gastro-intestinal/hepatitis-pathophysiology-sign-and-symptoms-diagnosis-medical-management/
Lewis, Bucher, Heitkemper, Harding, Kwong, & Roberts. (2017). Medical-Surgical Nursing (10th ed.). Elsevier.
Jaclyn Spinner