Integumentary - Nursing Case Study

Pathophysiology

• Primary mechanism: The integumentary system, including skin, hair, nails, and exocrine glands, acts as a physical barrier against harmful external agents. A disruption of this barrier, through burns, cuts, or chronic conditions like psoriasis, compromises its protective function, allowing the entry of pathogens, and leading to infections.

• Secondary mechanism: The system also plays a vital role in temperature regulation. Conditions such as hyperhidrosis (excessive sweating) or hypohidrosis (reduced sweating) can disrupt thermoregulation, leading to overheating or hypothermia.

• Key complication: Additionally, the system’s role in vitamin D synthesis, which is crucial for calcium absorption, can be hindered due to conditions like vitiligo or albinism. This can lead to complications like osteoporosis due to reduced calcium absorption.

Patient Profile

Demographics:

52-year-old female, works as a school teacher.

History:

• Key past medical history: Diagnosed with diabetes mellitus type 2, minor skin infections in the past, and a history of psoriasis.

• Current medications: Metformin for diabetes, topical corticosteroids for psoriasis.

• Allergies: Penicillin.

Current Presentation:

• Chief complaint: Severe itching and redness over the body, especially in the lower legs.

• Key symptoms: Skin flaking, dryness, red patches, itching, occasional bleeding from cracks in the skin, and minor swelling in the legs.

• Vital signs: Increased heart rate (110 beats per minute), slightly elevated blood pressure (140/90 mmHg), body temperature of 98.6°F, respiratory rate of 18 breaths per minute, and blood glucose level slightly high at 180 mg/dL.

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorated. She reported an increase in the severity of itching and burning sensations, particularly in her lower extremities. The red patches over her body had grown in size and intensity, becoming warm to the touch. The patient also mentioned feeling increasingly fatigued and complained of mild shortness of breath. On examination, her lower legs appeared to be more swollen with signs of weeping from the cracked skin. Her heart rate had increased to 120 beats per minute, her blood pressure had risen slightly to 150/95 mmHg, and her blood glucose level had also increased to 205 mg/dL.

The worsening of the patient's integumentary symptoms, coupled with her deteriorating vital signs, raised concerns about a possible skin infection. The increased blood glucose levels suggested that her diabetes was not well controlled, potentially compromising her immune system and making her more susceptible to infections. The fatigue and shortness of breath could be indicators of systemic involvement. The healthcare team decided to conduct further diagnostic tests to understand the underlying cause of her deteriorating condition. The critical thinking and clinical reasoning were necessary to connect her integumentary symptoms with her past medical history and current clinical presentation.

Section 2

New Diagnostic Results:

Upon further investigation, the test results revealed a high white blood cell count of 15,000 cells/µL, indicating a possible infection. Furthermore, a wound culture from her lower leg's weeping blisters tested positive for Staphylococcus aureus, confirming the presence of a skin infection. The patient's HbA1c level was 9.6%, suggesting poor glycemic control over the past few months. An arterial blood gas analysis showed a decrease in her PaO2 levels to 75mmHg and an increase in her PaCO2 levels to 45mmHg, which could explain her shortness of breath and fatigue. The chest X-ray, however, did not show any abnormalities, ruling out respiratory infections or anomalies.

The discovery of a staphylococcal skin infection in the context of poorly controlled diabetes provided a possible reason for her worsening integumentary symptoms. The elevated blood glucose levels could have impaired her immune response, allowing the infection to take hold and exacerbate her skin condition. Additionally, the abnormally high PaCO2 and low PaO2 levels suggested a respiratory issue, possibly related to her fatigue and shortness of breath. The healthcare team needed to address these issues promptly, starting with the infection and her blood glucose levels, while further investigating her respiratory symptoms. Clinical reasoning was crucial in interpreting these results, linking her symptoms, and formulating a comprehensive treatment plan.

Section 3

Change in Patient Status:

Over the next few days, the patient's condition continued to deteriorate. Despite administration of antibiotics, her white blood cell count remained elevated at 14,000 cells/µL, suggesting that the infection was persisting. Her blood glucose levels also continued to fluctuate, with readings ranging from 200 to 300 mg/dL, well above the desired range of 70-130 mg/dL. Moreover, her respiratory symptoms worsened. She was now experiencing increased shortness of breath even at rest, and her oxygen saturation dropped to 90% on room air. A repeat arterial blood gas analysis revealed further decrease in PaO2 levels to 70mmHg and increase in PaCO2 levels to 50mmHg, indicating worsening respiratory function.

The persistence of high white blood cell counts despite antibiotic treatment raised concerns about potential antibiotic resistance, requiring a reassessment of her infection management. The poor glycemic control was a significant challenge, potentially exacerbating both the skin infection and the respiratory issues. The deterioration in her respiratory status, signaled by the worsening arterial blood gases and decreased oxygen saturation, hinted at an underlying, yet unidentified, respiratory condition. The healthcare team had to consider these factors in refining her treatment plan, emphasizing the need for a multidisciplinary approach involving infectious disease specialists, endocrinologists, and pulmonologists. This complex case required a high degree of clinical reasoning to manage the interconnected complications and optimize the patient's outcomes.

Section 4

Response to Interventions:

Despite the healthcare team's concerted efforts, the patient's condition did not show significant improvement. Her white blood cell count remained stubbornly high at 15,000 cells/µL, and her glucose levels continued to oscillate between 220 and 320 mg/dL, despite adjustments to her insulin regimen. Her respiratory symptoms persisted, with her oxygen saturation on room air falling further to 88%. The patient was also started on bronchodilators without much effect on her oxygen saturation or arterial blood gas levels, which showed a persistent decrease in PaO2 to 65mmHg and an increase in PaCO2 to 55mmHg.

These stagnant results prompted the healthcare team to investigate the possibility of other underlying conditions that might be hindering her recovery. Considerations included a possible uncontrolled diabetes, a resistant strain of the skin infection, or a co-existing respiratory condition that might be exacerbating her current symptoms. The team decided to conduct a broader set of diagnostic tests, including a sputum culture and sensitivity, a repeat HbA1c test, and a chest CT. They also consulted a pulmonologist for further evaluation of her respiratory condition. This situation demanded a high level of clinical reasoning to correlate the patient's symptoms, lab results, and response to the interventions thus far in order to guide the next steps in her management.

Section 5

New Diagnostic Results:

The repeat HbA1c test returned at 9.2%, confirming poor glycemic control. The sputum culture and sensitivity test revealed the presence of Pseudomonas Aeruginosa, which was resistant to the current antibiotic regimen. The chest CT scan showed patchy infiltrates and ground-glass opacities, suggestive of a possible superimposed pneumonia. The pulmonologist, after reviewing the patient's history and current findings, also suggested the possibility of chronic obstructive pulmonary disease (COPD) exacerbation, given the patient's long history of smoking.

These new diagnostic results provided much-needed insight into the patient's stagnant recovery. The uncontrolled diabetes was making it difficult for the patient's body to fight off the skin infection, and the skin infection itself was resistant to the current antibiotics. Additionally, the presence of a superimposed pneumonia and possibly exacerbated COPD was contributing to her persistent respiratory symptoms. The results necessitated a change in the management plan, including a switch to an antibiotic that would be effective against Pseudomonas, and the initiation of corticosteroids to help manage the potential COPD exacerbation. This situation called for careful monitoring of the patient's response to these changes, and a potential need for further intervention if her respiratory status did not improve.