Sample Masters Nursing Coursework

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Nursing Case Study Masters

Introduction

Summary of Case

The case study is about a geriatric client aged 74 years with multiple medical conditions and immense health needs. The patient is a known diabetic client with hypertension, cellulitis, and nephropathy. Such a client’s management requires a broader approach and a multi-dimensional intervention (Rello et al., 2010). I chose the patient as a case study to understand the interplay of the multiple conditions viv-a-vis their impacts on a geriatric patient. The patient is also on several medications, forming a basis for learning regarding poly-pharmacy and nursing care.

The study will also enable me to conduct a comprehensive assessment and manage a geriatric client with multiple health needs. This case study will decipher through the management of Mrs Rogers and formulate two comprehensive priority nursing care plans for the patient. The client also has emotional needs because she lives alone with no relatives around to confide in. Thus the case study will also enhance my nursing management in non-pharmacological instances and psychological wellbeing.

Discussion

Trans-Cultural Nursing

Trans-cultural nursing refers to ways in which professional nurses interact with culture. The concept is a particular cognitive nursing speciality focusing on nursing phenomena, health, global cultures, and comparative cultural caring. The idea helps nurses to provide culturally acceptable and appropriate care to their patients. The concept entails learning about international health issues and cultures of different countries vis-à-vis professional nursing practice. Transcultural nursing objectives are to advance nurses’ cultural competence globally, advance knowledge of the field through scholarship, enhance social change for cultural competence in nursing care, and promote the efficient non-profit financial corporation.

Case Review: Cellulitis

Any form of compromise to the flow of blood caused by microvascular or macrovascular diseases such as diabetes and hypertension is associated with a poor sensation of lack thereof as a result of neuropathy, thus predisposing one to infections, particularly on the distal end of the lower limbs (Peate, 2016). Diabetic foot infections assume four forms: cellulitis, soft-tissue, deep skin infections, and acute and chronic osteomyelitis. Cellulitis is mostly confused for deep venous thrombosis due to the overlying symptoms of skin tenderness and warmth to touch.

Pathophysiology

The bacteria on the skin as normal flora could gain access into the deeper tissues following cuts or skin breaks. Once the bacteria invade the skin, they disseminate rapidly, infecting the skin’s deeper layers to reach the bloodstream and the lymph nodes from where they spread throughout the body (Comer et al., 2015). The dissemination results in flu-like symptoms such as fever or chills. Cellulitis is commonly caused by Streptococcus sp (alpha-hemolytic streptococci), Staphylococcus aureus, and Bacteroides sp of bacteria.

Skin injuries such as surgical incisions, insect bites, and cuts are the common portals of entry for the bacteria (In Acton, 2012). Other common risk factors to the infection are a previous positive history of cellulitis, obesity, poorly controlled diabetes, old age, intravenous drug use, pregnancy, burns, lymphedema, skin conditions that could cause skin breaks such as athlete’s foot and eczema, and a weakened immune status such as is the case in prolonged use of corticosteroids, diseases that affect the flow of blood to the extremities such as varicose veins or chronic venous insufficiency, chemotherapy and HIV and AIDS.

Nursing Assessment

Nursing assessment plays a crucial role in managing patients as it enables the nurse to plan care and evaluate the interventions. The review of Mrs Barbara followed the ABCDE framework of the nursing assessment. The assessment starts by looking into the client’s airway for patency, followed by assessing the breathing pattern and effort (In Acton, 2012).

The latter led to the administration of oxygen to the patient via a face mask. The breath sounds were heard using the stethoscope. The circulatory status was also assessed by assessing the temperature. The disability status was also evaluated by examining the level of hypoxia and hypercapnia and giving oxygen as required. The use of accessory muscles is also assessed. Certain laboratory blood tests also assessed the circulatory status.

Exposure is also considered by observing the dignity of the patient and keeping them warm. A Head and toe assessment was done to determine the health risks. The first sign of cellulitis is usually a painful swollen reddish area tender to touch and feels hot. Other signs of cellulitis include skin ulcerations that grow rapidly, abscess formation, chills, shaking, lethargy, myalgia, and dizziness. Lethargy, drowsiness, red streaks, and blistering signify the disease’s dissemination, usually to the lymph nodes (In Acton, 2012).

Nursing Diagnosis

Some of the nursing diagnoses identified after the assessment were ineffective tissue perfusion related to sepsis, as evidenced by oliguria and acute pain related to cellulitis. The patient also had a self-care deficit and a risk for impaired skin integrity. The diagnosis of cellulitis relies on the history and physical examination of the patient and appropriate laboratory tests.

The clinicians observe the classical signs of warmth, pain, reddening, and swelling coupled with the nearby lymph nodes (Comer et al., 2014). Cellulitis differs from erysipelas as it invades the inner tissues and is often associated with abscesses, carbuncles, and furuncles.

Planning

Planning of nursing care improves the efficiency of nursing practice and enhances continuity of care. The planning should include self-care, educational needs as well as the plan of treatment. Sepsis is a life-threatening condition due to the body’s response to an antigen leading to tissue and organ injury.

The common signs of sepsis are mental changes, hypercapnia, increased heart rate, and body temperature changes. In clients with a weakened immune system and those with extreme ages, such as the very young and the elderly, the body temperature may be low (Brunner & Smeltzer, 2010). Mrs Rogers presented with a low temperature of 350C, an elevated heart rate of 104 beats per minute, and a slightly elevated breathing rate of 23 breaths per minute.

Interventions

The Sepsis 6 bundle was used to manage the sepsis developed by Mrs Barbara. The framework was developed to help reduce patients’ mortality rate with sepsis, reduce hospital stay duration, and improve their management. Sepsis Six bundles contain three therapeutic and three diagnostic criteria that should be observed within the first hour of sepsis management.

The first step was to administer oxygen to the patient to reach a target of oxygen saturation above 94%, followed by blood samples collection for culture (Peate, 2014).

Depending on the results of the blood culture, appropriate antibiotics are administered intravenously. The fourth step involves measuring lactate levels and performing a complete blood count.

The fifth step of the Sepsis Six Bundle included the commencement of intravenous fluid resuscitation followed by the final step that involved the accurate measurement of urine output. Nursing interventions should be based on prior assessment, diagnosis, and planning. Antibiotics are usually prescribed for sepsis and cellulitis based on the isolated microbe and the presence of purulence.

The most effective antibiotics for the infection are penicillins, macrolides, fluoroquinolones, and cephalosporin (Hamilton, 2015). Surgical management is usually the management of choice in cases where purulence is present. The latter is usually followed by antibiotic therapy for prophylaxis. Analgesic is also prescribed for pain. However, pain should be assessed as extreme pain may point towards necrotizing fasciitis.

The microbes that cause cellulitis are normal skin flora but could cause infection when accessing the deeper tissues’ usually sterile areas. The bacteria invade the inner tissues when the skin’s integrity has been altered by an insect bite, a gaze, cut, tattoos, animal or human bite, puncture wound, or leg ulcers. Skin aspirations and blood culture may not be helpful for non-purulent cellulitis.

Ultrasound is used to identify abscesses in case of antibiotic failure. A Doppler scan on the right leg ruled out deep venous thrombosis, confirming cellulitis type 4 with sepsis. Other tests include blood samples for Erythrocyte Sedimentation Rate (ESR), C – reactive protein (CRP), Full Blood Count (FBC), and blood culture. A swab is taken from the infected leg ulcer for culture to identify the offending microbe.

Conclusion

Critical Analysis of the Case Study

Impacts of Uncontrolled Diabetes

Uncontrolled diabetes mellitus type 2 can lead to many complications such as nephropathy, neuropathy, retinopathy, foot damage, poorly healing wounds, cardiovascular diseases, and skin conditions. Neuropathy is caused by the damage to the blood vessels supplying the nerves by the high blood glucose levels (Brill, 2012).

This can lead to a gradual loss of sensation in the affected area. Nephropathy caused by diabetes can lead to a decreased urine output, as is seen in Mrs Rogers’ case. If left untreated, severe kidney damage can lead to end-stage renal failure.

Geriatric clients are at a higher risk of contracting cellulitis. Patients with uncontrolled diabetes are also at risk due to the disease’s detrimental impacts on the immune system.

The blood supply to the lower extremities is compromised, leading to foot ulcers or diabetic foot (Brill, 2012). If the blood glucose is poorly controlled, bacteria can multiply rapidly in the affected area and gain access into the bloodstream, causing sepsis. Neuropathy causes the ulcers not to be painful; therefore, they frequently become infected, resulting in sepsis.

Impacts of Sepsis

Severe sepsis leads to insufficient blood flow and poor organ function of vital organs such as the kidney. Decreased tissue perfusion is seen in reduced urine output, high blood lactate, and low blood pressure.

The hypotension results from the higher cardiac output and decreasing systemic vascular resistance (Rello et al., 2010). The common locations for sepsis are primarily the abdominal organs, the skin, brain, urinary system, and lungs. The above result is related to nausea and abdominal pain, difficulty breathing, and decreased urine output.

Comprehensive Nursing Care Plans

Acute pain related to cellulitis as evidence by self-report of pain intensity of 2/3 by using a numeric rating pain intensity scale.

Please click here to see the full Comprehensive Nursing Care Plans.

References

Brill, M. T. (2012). Diabetes. Minneapolis, MN: Twenty-First Century Books.

Brunner, L. S., & Smeltzer, S. C. O. C. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Comer, S., Jaffe, M. S., Teton Data Systems (Firm), & STAT!Ref (Online service). (2015). Delmar’s geriatric nursing care plans. Australia: Thomson/Delmar Learning.

Gulick, M., & Myers, Judith L. (2014). Nursing care plans. St. Louis, Mo: Mosby Elsevier.

Hamilton, P. D. J. D. P. E. A. (2015). Therapeutics and pharmacology for medical students. Place of publication not identified: Pastest.

In Acton, Q. A. (2012). Cellulitis: New insights for the healthcare professional: scholarly paper.

Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative care. St. Louis: Elsevier Saunders.

Johnson, M. (2012). NANDA, NOC and NIC linkages: Nursing diagnoses, outcomes, & interventions. St. Louis, Mo: Mosby/Elsevier.

Lippincott Williams & Wilkins. (2009). Handbook of medical-surgical nursing. Ambler, Pa: Lippincott Williams & Wilkins.
Peate, I. (2016). Medical-surgical nursing at a glance.

Rello, J., & Restrepo, M. I. (2010). Sepsis: New strategies for management. Berlin: Springer.