Scabies - Nursing Case Study

Pathophysiology

• Primary mechanism: Scabies is caused by the infestation of Sarcoptes scabiei var. hominis, a microscopic mite. The female mite burrows into the stratum corneum layer of the skin and lays eggs, leading to an infestation.

• Secondary mechanism: An allergic reaction to the mite, its eggs, and feces causes intense itching and inflammation. This leads to the formation of burrows, papules, and vesicles on the skin surface.

• Key complication: Persistent scratching can lead to secondary bacterial infection, commonly caused by Staphylococcus aureus or Streptococcus pyogenes. This can result in impetigo, cellulitis, or post-streptococcal glomerulonephritis.

Patient Profile

Demographics:

45-year-old, Male, Construction worker

History:

• Key past medical history: Diabetes type II, previously managed with oral medications

• Current medications: Metformin, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Intense itchiness, especially at night; secondary skin changes

• Key symptoms: Rash, sores from scratching, small red bumps and blisters, secondary skin infection presenting as redness, warmth, and pus

• Vital signs: Temperature 100.4°F, Pulse 88 bpm, Respiratory rate 18 breaths per minute, Blood pressure 140/90 mmHg, Blood glucose level 220 mg/dL

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorates. He continues to experience intense itching, especially at night, despite the application of topical permethrin and oral antihistamines. His temperature spikes to 102.3°F, and his blood glucose levels rise to 250 mg/dL. His blood pressure also increases to 150/95 mmHg. He complains of increased pain and warmth over the areas of skin changes, which now appear to be more erythematous and are oozing pus. He also reports malaise and fatigue.

These changes in the patient's status could suggest worsening of the secondary bacterial infection, possibly cellulitis or even systemic infection. The increase in blood glucose levels could be due to the stress of the infection or possibly poor diabetes control. The elevated blood pressure could be a result of pain or stress. This deterioration in the patient's condition necessitates immediate intervention and further diagnostic testing to identify the cause and treat appropriately. A blood culture and skin swab for culture and sensitivity should be obtained and antibiotics started promptly as guided by the culture results. The patient's diabetes and hypertension management also need to be reassessed.

Section 2

New Diagnostic Results:

The blood culture and skin swab results arrive 48 hours later. The culture reveals a methicillin-resistant Staphylococcus aureus (MRSA) infection. This is a type of bacteria that is resistant to many antibiotics and can lead to severe skin infections. In addition, the patient's HbA1c level is 8.5%, indicating poor control of his diabetes over the past three months. A chest X-ray is also done, which shows no signs of pneumonia or other lung infection, ruling out a potential source of the fever.

The diagnosis of MRSA raises the complexity of the case, as treatment options are limited due to antibiotic resistance. The high HbA1c level suggests that the patient's diabetes has not been well-managed, which could be contributing to the severity of the infection and poor wound healing. The medical team must now consider a change in the antibiotic regimen to target MRSA and reassess the patient's diabetes management plan. This might include adjusting his insulin dosage or changing his oral hypoglycemic medications. In addition, the team should consider consulting a dietician to review the patient's diet and an endocrinologist to opt for the best approach in managing his diabetes. The patient's blood pressure also needs to be monitored closely and medications adjusted as necessary.

Section 3

Change in Patient Status:

Over the next couple of days, the patient’s condition deteriorates. His fever continues to spike intermittently with temperatures reaching up to 39.5°C, and his blood pressure readings fluctuate, with systolic pressure ranging from 130 to 160mmHg. His skin lesions worsen, with increased redness and swelling, and a purulent discharge is noted. The patient also complains of increased itching, especially at night, which is affecting his sleep. His blood sugar levels remain elevated, with random blood glucose readings consistently above 200mg/dL, suggesting that his diabetes is still poorly controlled.

These findings suggest that the current antibiotic regimen is not effectively managing the MRSA infection, and the patient's poorly controlled diabetes may be contributing to his deteriorating condition. The team must consider escalating the antibiotic therapy to a more potent agent active against MRSA, such as vancomycin or daptomycin, while monitoring for potential side effects. They should also consider involving a wound care specialist to help manage the patient's skin lesions. The patient's diabetes management plan needs to be urgently reviewed and adjusted, as poor control can further complicate the patient's condition and delay healing. These changes will require careful clinical reasoning, taking into account the patient's overall health status and potential risks.

Section 4

New Diagnostic Results:

Laboratory findings reveal a marked increase in white blood cell count, indicating an escalating infection. The patient's fasting blood glucose levels remain high, averaging around 250mg/dL, despite increased insulin administration. An MRSA wound culture taken from the purulent discharge confirms resistance to the current antibiotic regimen. Additionally, the patient's HbA1c level is at an alarming 9.5%, which is significantly above the target range for diabetes management.

These diagnostic results indicate an urgent need for a change in the patient's treatment plan. The elevated white blood cell count suggests that the MRSA infection is not being effectively controlled, necessitating an upgrade in the antibiotic therapy. The persistently high blood glucose levels, combined with the elevated HbA1c, indicate that the patient's diabetes is poorly controlled and this could be exacerbating his infection and hindering wound healing. The team must therefore consider a more aggressive approach to managing the patient's diabetes. They also need to deliberate on the potential risks and benefits of switching to a stronger antibiotic, while keeping in mind the patient's overall health status. This requires advanced clinical reasoning and careful decision-making.

Section 5

Change in Patient Status:

The patient’s condition continues to deteriorate despite the escalated antibiotic regimen and increased insulin administration. He exhibits signs of increased discomfort, with persistent itching and erythema extending beyond the initial lesion sites, suggesting a possible worsening of the scabies infestation. The patient is also showing signs of increasing fatigue, reduced appetite, and unexplained weight loss. His current vital signs are slightly concerning: temperature is 38.6 degrees Celsius, heart rate is 110 beats per minute, respiratory rate is 22 breaths per minute, and blood pressure is 135/85 mmHg. Additionally, the patient's oxygen saturation has dropped to 92%, lower than the desired range of 94-99%.

The patient's overall mood appears to be affected as well; he seems more irritable and anxious, which could be a response to the persistent discomfort and the uncertainty about his treatment. Furthermore, he complains of blurred vision, a symptom often associated with poorly controlled diabetes, and an indication that his current diabetes management plan is inadequate. This new development underscores the need for an urgent reassessment of the patient's treatment regimen and the possible inclusion of a multidisciplinary team to address the multifaceted challenges faced by the patient. It also necessitates the need for increased patient education on the importance of glucose control in his overall health and recovery.