Post-op Breast reconstruction - Nursing Case Study
Pathophysiology
• Primary mechanism: Surgical trauma - Breast reconstruction surgery involves the manipulation of tissues to create a new breast mound. This results in surgical trauma, causing inflammation and pain. The body responds by releasing cytokines and chemokines, initiating the inflammatory response. This can lead to swelling, redness, and warmth in the affected area.
• Secondary mechanism: Tissue necrosis - The intrusive nature of the surgery can disrupt blood supply to the tissues, leading to tissue necrosis. This is characterized by the death of cells in the tissues due to insufficient blood supply. Necrosis can lead to wound dehiscence, a potential complication where the surgical wound reopens.
• Key complication: Infection - Post-operative infection can occur due to the introduction of bacteria during surgery or compromised immunity during recovery. It can lead to increased pain, fever, and further complications if not treated promptly. Proper sterile technique during surgery and vigilan
Patient Profile
Demographics:
52 years old, Female, Office Administrator
History:
• Key past medical history: Type 2 Diabetes, Hypertension, Breast Cancer (had mastectomy on the right breast six months ago)
• Current medications: Metformin, Lisinopril, Tamoxifen
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Excessive redness, swelling, and pain at the site of surgery, fever
• Key symptoms: Increased tenderness in the breast area, pus-like discharge from the wound, chills
• Vital signs: Blood Pressure 145/90 mmHg, Pulse 110 bpm, Temperature 101.5°F, Respiratory Rate 22 breaths per minute.
Section 1
Change in patient status:
The patient's condition has worsened over the past 24 hours. Her temperature has risen to 102.8°F, and she’s developed a rapid pulse rate of 120 bpm. She describes her pain as a constant 8 out of 10, despite being on regular analgesics. On physical examination, the wound site appears more inflamed, with an increase in the pus-like discharge. The surrounding skin has taken on a shiny, tight appearance, and she reports significant pain on palpation, suggesting a possible abscess formation. Her blood pressure is also elevated at 155/95 mmHg, likely due to the pain and stress of the situation.
In addition to her physical symptoms, she seems increasingly anxious and tearful, expressing concern about the possible implications of these complications on her overall recovery and prognosis. She has also mentioned feeling overwhelmed and fatigued, indicating that her current situation is having a significant impact on her emotional well-being. This change in status necessitates further urgent investigation to identify the cause of the ongoing infection and to plan appropriate interventions. It's also essential to address her emotional concerns and provide the necessary support to help her cope with this challenging situation.
Section 2
New Diagnostic Results:
The physician orders a complete blood count (CBC), wound culture, and C-reactive protein (CRP) to better understand the nature of the infection and the body's immune response. The CBC results reveal a significant leukocytosis, with a white blood cell count (WBC) of 18,000 cells/uL, indicative of an ongoing infection. The wound culture grows Staphylococcus aureus, confirming the presence of a bacterial infection at the surgical site. The CRP level is also elevated at 35 mg/L, suggesting systemic inflammation in response to the infection.
The patient is also sent for an ultrasound of the surgical site to rule out any deep abscess formation. The ultrasound reveals a fluid collection measuring 3 cm x 4 cm beneath the inflamed area, consistent with a subcutaneous abscess. The patient's elevated blood pressure, increased heart rate, and ongoing pain are likely related to this untreated infection and abscess. The results of these investigations will guide the next steps in managing this patient's condition, which will likely include antibiotic therapy and possible surgical intervention to drain the abscess. The healthcare team must also continue to address the patient's emotional distress and provide support as she navigates this challenging situation.
Section 3
Change in Patient Status:
Over the next few days, the patient's symptoms continue to worsen despite the initiation of antibiotic therapy. She reports increasing pain at the surgical site and her temperature spikes to 38.5°C (101.3°F). Her blood pressure is measured at 150/90 mmHg and her pulse rate is elevated at 110 beats per minute. The area around the surgical site becomes more red, swollen, and tender, and she begins to experience chills and malaise. These signs and symptoms indicate that the infection is not being adequately controlled and may be spreading.
The patient's worsening condition causes her significant anxiety and emotional distress. She expresses concern about the potential need for additional surgery and the impact that this might have on her recovery and overall health. This emotional distress could be amplifying her perception of pain and contributing to her elevated blood pressure. The healthcare team will need to reassess the effectiveness of the current treatment plan, consider alternative strategies, and provide ongoing emotional support to the patient.
Section 4
New Diagnostic Results:
Laboratory tests were ordered due to the patient's deteriorating condition. Her WBC count came back elevated at 14,000/mm3, indicating a systemic response to infection. The wound culture revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA), a bacterial strain known for its resistance to common antibiotics, which could explain why the initial antibiotic treatment was ineffective.
Furthermore, her blood glucose levels were found to be elevated at 200 mg/dL, suggesting that the patient may be experiencing stress hyperglycemia or undiagnosed diabetes. Both conditions can impair the immune response, potentially complicating the infection and the overall recovery process. This new information necessitates a change in the patient's treatment plan, requiring the healthcare team to consider alternative antibiotics effective against MRSA and the management of her elevated blood glucose levels.
Section 5
Change in Patient Status:
The patient's condition continues to deteriorate, despite the change in antibiotic treatment to Vancomycin which is effective against MRSA. The patient has now developed a fever of 101.3°F (38.5°C), with increased heart rate of 105 beats per minute and respiratory rate of 22 breaths per minute. On physical examination, the surgical site is red, warm and tender to touch, with purulent drainage; likely indicating worsening infection. The patient also reports new onset of pain at the surgical site, rating it as 7 out of 10 on the pain scale.
Given the elevated blood glucose levels, an endocrinology consult was requested. The endocrinologist suspects that the patient might have latent autoimmune diabetes in adults (LADA), a condition that develops slowly over time and can initially be misdiagnosed as type 2 diabetes. This could explain the patient's elevated blood glucose levels and the impaired immune response, making her more susceptible to infections. Further tests, including GAD65 autoantibodies, are being ordered to confirm the diagnosis. The patient's condition and the new findings necessitate a multidisciplinary approach, involving the surgical team, infectious disease specialists, endocrinologists, and diabetes educators.