A 46-year-old female patient with cellulitis and a positive blood culture for MRSA is experiencing systemic signs of infection, including fever, tachycardia, and dizziness. Her current antibiotic regimen needs adjustment due to her penicillin allergy. Which of the following interventions should the nurse prioritize to address both the local and systemic aspects of her condition?

A) Administer vancomycin and initiate IV fluid resuscitation.

B) Apply topical antibiotics to the affected limb and monitor vital signs every 4 hours.

C) Increase oral fluid intake and administer acetaminophen for fever.

D) Initiate contact precautions and schedule a follow-up blood culture.

A 46-year-old female patient with cellulitis and a penicillin allergy has been diagnosed with MRSA. Her current symptoms include fever, tachycardia, and slight hypotension, suggesting systemic involvement. Which nursing intervention should be prioritized to address her condition effectively?

A) Initiate vancomycin therapy as ordered and monitor trough levels.

B) Administer acetaminophen to reduce fever and manage pain.

C) Prepare for immediate surgical debridement of the affected area.

D) Encourage increased oral fluid intake to prevent dehydration.

A patient with MRSA infection on intravenous vancomycin therapy is showing signs of potential sepsis with mild confusion, increased respiratory rate, and a downward trend in blood pressure. What should be the nurse's priority intervention at this stage?

B) Increase the rate of isotonic saline infusion to improve perfusion.

A) Administer antipyretics to manage the patient's fever.

B) Increase the rate of isotonic saline infusion to improve perfusion.

C) Request an immediate evaluation for potential septic shock.

D) Prepare for intubation due to the increased respiratory rate.

A patient with a MRSA infection, on intravenous vancomycin, is showing signs of possible sepsis, including mild confusion, increased respiratory rate, and persistent tachycardia. Which of the following nursing interventions is most critical to implement immediately to address her deteriorating condition?

B) Administer supplemental oxygen via nasal cannula.

A) Increase the rate of isotonic saline infusion.

B) Administer supplemental oxygen via nasal cannula.

C) Initiate a broad-spectrum antibiotic in addition to vancomycin.

D) Prepare the patient for immediate transfer to the ICU.

A patient with suspected severe sepsis shows an elevated lactic acid level and a decline in mental status despite initial interventions. Which of the following nursing actions is most appropriate to prioritize given her current condition?

B) Administer a fluid bolus as prescribed to address potential hypoperfusion.

A) Increase the rate of supplemental oxygen to ensure adequate oxygenation.

B) Administer a fluid bolus as prescribed to address potential hypoperfusion.

C) Initiate vasopressor therapy immediately to stabilize blood pressure.

D) Request an urgent repeat blood culture to confirm the presence of infection.

A patient with suspected severe sepsis exhibits signs of confusion, increased respiratory rate, and decreased oxygen saturation. Despite supplemental oxygen, her mental status remains altered. Which of the following interventions should the nurse prioritize to address tissue hypoperfusion?

B) Administer an IV fluid bolus as ordered

A) Increase supplemental oxygen to 4 liters per minute

B) Administer an IV fluid bolus as ordered

C) Request an immediate repeat chest X-ray

D) Prepare for intubation and mechanical ventilation

A patient with a history of penicillin allergy is being treated for a secondary bloodstream infection with ceftriaxone due to gram-negative bacilli growth. Her condition includes respiratory distress, bilateral infiltrates on chest X-ray, and hypotension. Which nursing intervention is most critical to prioritize in this scenario?

A) Administering the prescribed ceftriaxone infusion while monitoring for allergic reactions

B) Educating the patient about the importance of completing the full course of antibiotics

C) Encouraging the patient to increase oral fluid intake to prevent dehydration

D) Assisting the patient with deep breathing exercises to improve lung function

A patient with a known penicillin allergy has been diagnosed with a secondary bloodstream infection due to gram-negative bacilli. The healthcare team has decided to use ceftriaxone as part of her antibiotic regimen. As the nurse, what is the most important action to take before administering the first dose of ceftriaxone?

A) Review the patient's allergy history to confirm the severity of the penicillin allergy.

B) Check the patient's renal function to determine appropriate dosing of ceftriaxone.

C) Prepare to administer epinephrine in case of an anaphylactic reaction.

D) Educate the patient on the potential side effects of ceftriaxone.

A patient in the ICU with suspected pneumonia is experiencing hypotension despite norepinephrine infusion, tachycardia, increased respiratory rate, elevated white blood cell count, and rising serum lactate levels. Which nursing intervention is most appropriate to prioritize at this time to stabilize the patient's condition?

B) Prepare for intubation and mechanical ventilation

A) Initiate a fluid bolus to address potential hypovolemia

B) Prepare for intubation and mechanical ventilation

C) Increase the dose of norepinephrine infusion

D) Administer antipyretics to reduce fever

A nurse is caring for a patient with suspected septic shock who is showing signs of worsening hemodynamics despite being on norepinephrine infusion. The patient's heart rate is 128 beats per minute, blood pressure is low with a mean arterial pressure of 60 mmHg, and serum lactate is 3.5 mmol/L. Which intervention should the nurse anticipate next in collaboration with the healthcare team to improve the patient's condition?

B) Add vasopressin to the treatment regimen

A) Increase the dose of norepinephrine

B) Add vasopressin to the treatment regimen

C) Initiate a rapid infusion of normal saline

D) Administer a high-dose corticosteroid

Cellulitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Cellulitis is primarily caused by a breach in the skin barrier allowing bacteria, most commonly Streptococcus pyogenes or Staphylococcus aureus, to enter and proliferate in the dermis and subcutaneous tissues. This triggers an acute inflammatory response characterized by redness, warmth, swelling, and pain at the affected site.

• Secondary mechanism: The inflammatory response leads to increased vascular permeability, resulting in the leakage of plasma proteins and immune cells into the tissue. This contributes to the edema and further propagation of inflammation, which can exacerbate tissue damage if not appropriately managed.

• Key complication: If the infection spreads beyond local tissues, it may lead to systemic involvement such as sepsis, particularly in immunocompromised individuals, necessitating prompt medical intervention to prevent severe outcomes.

Patient Profile

Demographics:

46-year-old female, office worker

History:

• Key past medical history: Type 2 Diabetes Mellitus, Hypertension

• Current medications: Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing swelling and redness of the left lower leg

• Key symptoms: Pain, warmth, and tenderness in the affected area; fever; fatigue

• Vital signs: Temperature 101.3°F, Heart Rate 110 bpm, Blood Pressure 138/88 mmHg, Respiratory Rate 22 breaths per minute

Section 1

As the healthcare team continues to monitor the 46-year-old female patient with cellulitis, new diagnostic results reveal a concerning shift in her condition. Laboratory tests indicate an elevated white blood cell count of 14,500/mm³, suggesting a heightened systemic inflammatory response. Additionally, blood cultures return positive for methicillin-resistant Staphylococcus aureus (MRSA), necessitating a review and adjustment of her antibiotic regimen, given her penicillin allergy. Her renal function tests, including serum creatinine, remain within normal limits, but there is a slight elevation in C-reactive protein (CRP) at 65 mg/L, further supporting the presence of significant inflammation.

Clinically, the patient exhibits increasing signs of systemic involvement. Her fever persists despite initial interventions, with her temperature spiking to 102.1°F. She reports escalating pain and tenderness in the affected limb, and the erythema now extends beyond the originally demarcated area. Her heart rate remains elevated at 115 bpm, and she experiences occasional episodes of dizziness, raising concerns about potential dehydration or early signs of sepsis. The patient's blood pressure has dropped slightly to 130/85 mmHg, which, combined with her tachycardia and altered mental state, prompts consideration of fluid resuscitation to support her hemodynamic status.

Given these developments, the healthcare team must engage in clinical reasoning to prioritize interventions that address both the local and systemic aspects of her condition. The shift to an alternative antibiotic effective against MRSA is critical, as is close monitoring for any further signs of sepsis. The team must also ensure adequate hydration and supportive care to stabilize her vitals. This stage of the patient's journey underscores the importance of timely intervention and vigilance to prevent further complications such as septic shock, which could significantly impact her recovery.

Section 2

The healthcare team initiates a revised treatment plan to address the MRSA infection, opting for intravenous vancomycin, given the patient's penicillin allergy. After 24 hours on the new antibiotic regimen, the patient's clinical presentation requires close evaluation to ascertain the effectiveness of the treatment. Although her fever shows slight improvement, with a temperature now fluctuating between 101°F and 101.5°F, her tachycardia persists with a heart rate of 110 bpm. The erythema on her affected limb appears slightly reduced, but the area remains tender, and the patient continues to report moderate pain.

Further laboratory tests reveal an increase in her white blood cell count to 15,200/mm³, indicating ongoing systemic inflammation. Her CRP level has risen to 72 mg/L, suggesting that while the antibiotic intervention may be beginning to take effect locally, the systemic inflammatory response is yet unabated. The patient's blood pressure continues to trend downward, recorded at 125/80 mmHg, raising concerns about her overall hemodynamic stability. The team prioritizes fluid resuscitation to counter potential dehydration and enhance perfusion, administering isotonic saline intravenously.

Despite these efforts, the patient exhibits new symptoms, including mild confusion and increased respiratory rate of 24 breaths per minute, hinting at the progression towards sepsis. This new complication demands swift clinical reasoning to adjust the treatment plan, ensuring that all potential sources of infection are addressed, and supportive measures are optimized. The healthcare team must remain vigilant, closely monitoring for any signs of organ dysfunction that could herald the onset of septic shock, thereby necessitating more aggressive interventions to safeguard her recovery trajectory.

Section 3

As the healthcare team continues to monitor the patient closely, they observe a notable change in her status. Over the next few hours, the patient's confusion intensifies, and her respiratory rate increases further to 30 breaths per minute. Her oxygen saturation begins to drop, recorded at 92% on room air, prompting the team to initiate supplemental oxygen therapy via nasal cannula at 2 liters per minute. Despite these measures, her mental status remains altered, with intermittent episodes of disorientation. This escalation in symptoms suggests a progression towards more severe sepsis, necessitating immediate adjustments in the treatment strategy.

In response to these developments, a more comprehensive diagnostic workup is ordered to identify any additional sources of infection or complications. A repeat set of blood cultures is drawn, along with a lactic acid level to assess for tissue hypoperfusion. The results indicate a lactic acid level of 3.2 mmol/L, which is elevated and indicative of anaerobic metabolism due to inadequate oxygen delivery to tissues. The team also orders a chest X-ray and abdominal ultrasound to rule out any secondary infections or abscess formations that could be contributing to her deteriorating condition.

Given the patient's declining status, the healthcare team intensifies the intervention plan by escalating her fluid resuscitation efforts and considering the initiation of vasopressor support if her blood pressure continues to trend downward. They also evaluate the potential need for broadening antibiotic coverage, taking into account her penicillin allergy and ensuring the chosen regimen addresses both gram-positive and gram-negative organisms effectively. The team's proactive approach and continuous reassessment of the patient's clinical presentation are crucial in preventing the onset of septic shock and supporting her recovery.

Section 4

As the healthcare team continues to monitor the patient's condition, they receive new diagnostic results that provide further insight into her deteriorating status. The chest X-ray reveals bilateral infiltrates, raising concerns for possible pneumonia, which could be exacerbating her respiratory distress and contributing to the systemic inflammatory response. Meanwhile, the abdominal ultrasound is unremarkable, ruling out abscess formation in the abdominal cavity. The repeat blood cultures, however, grow gram-negative bacilli, confirming a secondary bloodstream infection that likely stems from the initial cellulitis site. This finding necessitates an immediate adjustment to her antibiotic regimen.

In response to these diagnostic findings, the team decides to broaden the antibiotic coverage to include ceftriaxone, a third-generation cephalosporin, which is effective against both the identified gram-negative organisms and potential atypical pathogens in the respiratory tract. Given the patient's penicillin allergy, careful consideration is made to avoid cross-reactivity, and the choice is deemed appropriate based on her current clinical picture. Simultaneously, the team continues aggressive fluid resuscitation and initiates norepinephrine infusion to support her blood pressure, which has shown a concerning trend towards hypotension with a mean arterial pressure dropping to 58 mmHg.

As these interventions are implemented, the healthcare team closely monitors the patient's response. They focus on her vital signs and mental status, noting any improvements or further deterioration. Despite the escalation in care, her oxygen saturation remains at 94% with supplemental oxygen, and her confusion persists, though slightly improved. These subtle changes suggest a cautious optimism, but the team remains vigilant, aware that the patient is still at significant risk for progressing into septic shock. Continuous reassessment and timely adjustments to the treatment plan are crucial as they strive to stabilize her condition and prevent further complications.

Section 5

As the healthcare team continues to closely monitor the patient's condition, a change in her status becomes evident. Over the next 12 hours, her vital signs show a concerning shift. Her heart rate has increased to 128 beats per minute, indicating a possible compensatory response to the hypotension, while her blood pressure remains low despite the norepinephrine infusion, with a mean arterial pressure now struggling to maintain 60 mmHg. Her respiratory rate has also risen to 28 breaths per minute, reflecting her increased work of breathing and ongoing respiratory distress, further complicated by the suspected pneumonia.

Despite the broadened antibiotic regimen, the patient's white blood cell count has escalated to 18,000/mm³, suggesting a persistent or worsening infection. Her serum lactate level has risen to 3.5 mmol/L, a marker of tissue hypoperfusion and a potential indicator of progression towards septic shock. Neurologically, she remains confused, although intermittently able to follow simple commands, which shows slight improvement but still indicates significant central nervous system involvement in her systemic inflammatory response.

These clinical findings prompt the healthcare team to reassess their treatment strategy. They consider escalating her care to include additional vasopressor support, such as adding vasopressin, to stabilize her hemodynamics. The team also contemplates the need for mechanical ventilation support if her respiratory effort continues to deteriorate. The continuous reassessment highlights the complexity of managing a patient with multifaceted complications, emphasizing the importance of integrating clinical reasoning with timely interventions to prevent further progression of her condition.