A patient with a stage 3 pressure injury and confirmed MRSA infection is experiencing persistent fever and increased pain despite initial treatment with vancomycin. Given these symptoms, what is the most appropriate nursing action to address the patient's condition?

B) Notify the healthcare provider about the persistent symptoms and request a review of the current antibiotic therapy.

A) Administer a higher dose of vancomycin and reassess in 24 hours.

B) Notify the healthcare provider about the persistent symptoms and request a review of the current antibiotic therapy.

C) Increase the frequency of wound dressing changes to every 4 hours.

D) Discontinue vancomycin and switch to a broad-spectrum oral antibiotic.

A patient with a stage 3 pressure injury and a confirmed MRSA infection is being treated with vancomycin. Despite the treatment, the patient develops a persistent fever and increased pain. Which nursing intervention is most appropriate to prioritize in this situation?

C) Notify the healthcare provider of the potential for systemic infection requiring further evaluation.

A) Increase the frequency of wound dressing changes to every 4 hours.

B) Initiate a fluid bolus to help reduce fever and support hydration.

C) Notify the healthcare provider of the potential for systemic infection requiring further evaluation.

D) Administer an additional dose of vancomycin to enhance antimicrobial coverage.

A patient with MRSA bacteremia and poorly controlled diabetes is experiencing worsening symptoms despite being on vancomycin. Which of the following nursing actions is the priority to prevent further complications?

A) Increase the frequency of blood glucose monitoring to ensure tighter glycemic control.

B) Administer additional analgesics to manage the patient's pain more effectively.

C) Prepare for the possible initiation of a broader spectrum antibiotic as per infectious disease recommendations.

D) Initiate contact precautions to prevent the spread of MRSA to other patients.

Based on the patient's current clinical presentation and laboratory findings, which intervention should the nurse prioritize to address the systemic inflammatory response and potential sepsis in this patient?

C) Adjust the antibiotic regimen in collaboration with the infectious disease specialist.

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

B) Initiate a consultation with a dietitian to optimize nutritional support.

C) Adjust the antibiotic regimen in collaboration with the infectious disease specialist.

D) Increase the frequency of blood glucose monitoring to ensure glycemic control.

A patient with suspected sepsis is being monitored after the addition of linezolid to her antibiotic regimen. Which nursing action is most critical to perform in the next 24 hours to ensure early detection and intervention for organ dysfunction?

C) Measure the patient's urine output hourly.

A) Monitor the patient's blood glucose levels every four hours.

B) Assess the patient's mental status every two hours.

C) Measure the patient's urine output hourly.

D) Record the patient's temperature every six hours.

A nurse is caring for a patient with suspected sepsis whose condition has not improved despite a broadened antibiotic regimen. The patient is now exhibiting signs of lethargy, tachycardia, and elevated lactate levels. Which intervention should the nurse prioritize to address the patient's current status?

B) Administer a fluid bolus as prescribed to improve perfusion.

A) Increase the frequency of vital sign monitoring to every 30 minutes.

B) Administer a fluid bolus as prescribed to improve perfusion.

C) Prepare the patient for immediate surgical intervention.

D) Discontinue the current antibiotic regimen and initiate vancomycin.

A patient with confirmed vancomycin-resistant Enterococcus (VRE) and developing pneumonia is experiencing increased confusion and agitation, with oxygen saturation dropping to 89% on room air. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Administer supplemental oxygen to improve tissue perfusion

A) Initiate contact precautions to prevent the spread of VRE

B) Administer supplemental oxygen to improve tissue perfusion

C) Consult with infectious disease specialists to revise the antibiotic regimen

D) Implement pulmonary hygiene measures to clear airway secretions

A patient diagnosed with vancomycin-resistant Enterococcus (VRE) and developing bilateral pneumonia is experiencing fluctuating mental status and oxygen saturation levels. What is the priority nursing intervention to address the patient's respiratory complications?

C) Administer prescribed supplemental oxygen and monitor respiratory status closely

A) Initiate high-dose corticosteroid therapy to reduce inflammation

B) Implement strict isolation precautions to prevent the spread of VRE

C) Administer prescribed supplemental oxygen and monitor respiratory status closely

D) Begin chest physiotherapy to clear pulmonary secretions

A patient with metabolic and respiratory acidosis, significant hypoxemia, and a severe bacterial infection is being evaluated for changes in her care plan. Given the diagnostic findings, what is the most appropriate initial nursing intervention to optimize this patient's respiratory status?

B) Initiate non-invasive ventilation to improve ventilation-perfusion mismatch.

A) Increase the flow rate of supplemental oxygen therapy.

B) Initiate non-invasive ventilation to improve ventilation-perfusion mismatch.

C) Administer a blood transfusion to enhance oxygen-carrying capacity.

D) Start chest physiotherapy to assist with secretion clearance.

A patient with pneumonia and VRE infection has an ABG showing pH 7.32, PaCO2 50 mmHg, and PaO2 58 mmHg. Which of the following interventions should the nurse prioritize to address the patient's current condition?

A) Administer an additional dose of antibiotics to target the VRE infection.

C) Increase the flow rate of supplemental oxygen to improve PaO2 levels.

D) Transfuse packed red blood cells to improve hemoglobin levels.

Pressure Injury - Nursing Case Study

Pathophysiology

• Primary mechanism: Prolonged pressure over bony prominences compresses blood vessels, leading to ischemia and tissue necrosis. This results in oxygen and nutrient deprivation, causing cellular death and ulceration.

• Secondary mechanism: Shear forces exacerbate tissue damage by distorting blood vessels and tissues, which further compromises circulation and exacerbates ischemic injury.

• Key complication: An impaired healing process can lead to infection, as necrotic tissue serves as a medium for bacterial growth, increasing the risk of systemic infection and delayed recovery.

Patient Profile

Demographics:

68-year-old female, retired school teacher

History:

• Key past medical history: Type 2 diabetes, hypertension, osteoarthritis

• Current medications: Metformin, Lisinopril, Acetaminophen

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Painful sore on the lower back

• Key symptoms: Redness and swelling at the site, foul-smelling discharge, increased pain, and fever

• Vital signs: Temperature 100.8°F, blood pressure 150/95 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute

Section 1

During the initial assessment, the nursing team noted a stage 3 pressure injury on the patient's sacral region. The ulcer measured approximately 4 cm in diameter with a depth exposing subcutaneous fat. The surrounding skin was erythematous and warm to the touch, and palpation elicited significant tenderness, aligning with the patient's complaint of increased pain. The presence of a foul-smelling, purulent discharge raised concerns for a possible infection. Additionally, the patient's blood glucose levels were elevated at 180 mg/dL, likely exacerbated by the stress of the infection and her underlying diabetes, which could further impair wound healing.

New diagnostic results revealed an elevated white blood cell count of 14,000/mm³, suggesting an ongoing infection. A wound culture confirmed the presence of methicillin-resistant Staphylococcus aureus (MRSA), necessitating the initiation of targeted antibiotic therapy. The patient's renal function remained stable, with a creatinine level of 1.1 mg/dL, but her hemoglobin A1c was recorded at 8.2%, indicating suboptimal long-term glucose control. This finding further emphasized the need for multidisciplinary management, including a review of her diabetic regimen to optimize glycemic control as part of comprehensive wound management.

The patient's condition prompted the healthcare team to initiate a wound care plan, including debridement to remove necrotic tissue and the application of a topical antimicrobial dressing. Given the patient's penicillin allergy, vancomycin was started to target the MRSA. Over the next 48 hours, the patient's fever persisted, and her pain slightly increased, prompting a review of her analgesic regimen. The persistence of systemic symptoms despite initial interventions suggested the development of cellulitis, requiring close monitoring for potential systemic involvement, such as sepsis, and adjustments to her treatment plan.

Section 2

Following the implementation of the initial wound care and antibiotic regimen, the healthcare team closely monitored the patient's condition for signs of improvement or further complications. Despite the initiation of vancomycin and wound debridement, the patient's clinical status began to deteriorate. Her vital signs showed a low-grade fever persisting at 100.8°F, and her heart rate increased to 112 bpm, indicating a possible systemic inflammatory response. Blood pressure remained stable at 128/76 mmHg, but her respiratory rate was slightly elevated at 22 breaths per minute. The patient continued to report significant pain at the wound site, now rated an 8 out of 10 on the pain scale, despite adjustments to her analgesic regimen.

New laboratory results revealed a further increase in the white blood cell count to 16,500/mm³, and blood cultures drawn due to the worsening symptoms returned positive for MRSA bacteremia. This confirmed the systemic spread of the infection, complicating the clinical picture with the potential for sepsis. Given the patient's suboptimal glycemic control and the presence of MRSA bacteremia, the team recognized the need for more aggressive intervention. An infectious disease specialist was consulted to review and potentially broaden the antibiotic therapy, considering the patient's penicillin allergy and persistent fever. Additionally, the endocrinology team was involved to optimize her insulin regimen, aiming for tighter glucose control to enhance wound healing and immune response.

In response to the evolving situation, the healthcare team initiated additional supportive measures. The patient was moved to a higher level of care for closer monitoring, and intravenous fluids were administered to maintain hemodynamic stability. The wound care protocol was reassessed, and more frequent wound assessments were planned to evaluate the effectiveness of debridement and antimicrobial therapy. The multidisciplinary approach underscored the importance of integrating infection control, pain management, and metabolic stabilization in addressing the complex interplay of factors affecting the patient's recovery. This comprehensive strategy aimed to prevent further complications and stabilize the patient's condition, guiding subsequent interventions and adjustments in care.

Section 3

In the days following the escalation of care, the healthcare team observed concerning changes in the patient's status, indicating new complications. Despite the broadened antibiotic regimen, her fever persisted, now fluctuating between 101°F and 102°F, and her heart rate showed no significant improvement, remaining tachycardic at 115 bpm. Her respiratory rate increased to 24 breaths per minute, and although her blood pressure remained stable, there was a noticeable change in her mental status. The patient appeared more lethargic and disoriented at times, which raised concerns about possible sepsis progression and organ dysfunction.

Further diagnostic testing was conducted, including a comprehensive metabolic panel, which revealed a slight elevation in creatinine levels at 1.4 mg/dL, indicating potential early renal involvement. The lactate level was elevated at 3.0 mmol/L, supporting the clinical suspicion of sepsis. These findings necessitated immediate adjustments to her treatment plan to address the evolving situation. The infectious disease specialist recommended the addition of linezolid to the antibiotic regimen, given its efficacy against MRSA and the patient's penicillin allergy, while the endocrinology team worked to achieve tighter glucose control, monitoring her blood glucose levels every four hours to avoid further complications.

The multidisciplinary team emphasized the importance of frequent reassessment and timely intervention. Nurse practitioners conducted regular evaluations to monitor for any further decline in the patient's condition, adjusting the care plan as necessary. This dynamic approach aimed to stabilize the patient's status, manage her current complications, and prevent further deterioration. These clinical decisions paved the way for the next steps in her management, focusing on detailed monitoring and potential adjustments in therapeutic strategies to address the underlying sepsis and support organ function.

Section 4

As the healthcare team continued to monitor the patient closely, new diagnostic results emerged that shed further light on her condition. A follow-up blood culture revealed the presence of vancomycin-resistant Enterococcus (VRE), complicating the infection control strategy. This finding necessitated a rapid reassessment of her antibiotic regimen to ensure appropriate coverage while minimizing side effects and the risk of further resistance. Additionally, a chest X-ray was performed due to her increasing respiratory rate, which showed new bilateral infiltrates suggestive of developing pneumonia. This raised concerns about secondary respiratory complications, likely exacerbating her current sepsis picture.

The patient's change in status further underscored the urgency of the situation. Despite the inclusion of linezolid and ongoing glucose monitoring, her clinical condition did not significantly improve. Her mental status fluctuated, with episodes of increased confusion and agitation, likely reflecting worsening systemic inflammation and potential hypoxia due to the pulmonary involvement. Her oxygen saturation dropped to 89% on room air, prompting the initiation of supplemental oxygen therapy to maintain adequate tissue perfusion and prevent further organ compromise.

These developments required the healthcare team to integrate their clinical reasoning skills to prioritize interventions effectively. They focused on optimizing respiratory function through pulmonary hygiene measures and titrating oxygen support to stabilize her oxygen levels. Furthermore, the team considered alternative antimicrobial strategies to address the VRE, consulting with infectious disease specialists to tailor her treatment precisely. This comprehensive approach aimed to halt the progression of her sepsis, manage the newly identified pneumonia, and support her overall recovery process, setting the stage for the next phase of her clinical management.

Section 5

New Diagnostic Results:

As the healthcare team continued to assess the patient's evolving condition, additional diagnostic results provided further insight into her complex clinical picture. An arterial blood gas (ABG) analysis was conducted to evaluate her respiratory status more precisely. The results revealed a pH of 7.32, indicating metabolic acidosis, and a PaCO2 of 50 mmHg, suggestive of a concomitant respiratory acidosis component. Her PaO2 was measured at 58 mmHg, confirming significant hypoxemia despite the supplemental oxygen therapy. These findings highlighted the need for enhanced respiratory support and a review of her ventilatory strategy to optimize gas exchange and address her acid-base imbalance.

Concurrently, a repeat complete blood count (CBC) showed a white blood cell count of 18,000/µL with a left shift, indicating a persistent and potentially worsening inflammatory response. Her hemoglobin level dropped to 9.5 g/dL, raising concerns about her overall oxygen-carrying capacity and the potential need for transfusion to maintain adequate tissue oxygenation. The team also received results from a procalcitonin test that showed elevated levels at 4 ng/mL, supporting the diagnosis of a severe bacterial infection and reinforcing the urgency of adjusting her antimicrobial therapy to effectively target the VRE and manage her pneumonia.

These diagnostic revelations guided the healthcare team's clinical reasoning to enhance her respiratory support by considering the initiation of non-invasive ventilation to improve her ventilation-perfusion mismatch and correct her acid-base disturbances. Additionally, the team engaged in discussions with the infectious disease specialists to refine her antibiotic regimen further, aiming to optimize her treatment response and mitigate the risk of additional complications. This multi-faceted approach was crucial in addressing her immediate needs and preparing for the next phase of her recovery journey.