cellulitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Infection - Cellulitis is primarily caused by bacteria (most often Streptococcus and Staphylococcus) entering the body through a break in the skin. This invasion triggers an inflammatory response, leading to redness, swelling, and pain.

• Secondary mechanism: Inflammation - The body's immune response to the bacterial invasion results in inflammation. The release of chemicals like histamines increases blood flow to the area, causing warmth and redness. Other inflammatory cells migrate to the area causing swelling and potentially pus formation.

• Key complication: Abscess formation - If not treated promptly, cellulitis can lead to the formation of an abscess. Here, the body encapsulates the bacteria and pus in a cavity, which can lead to more severe infections if not treated properly.

Patient Profile

Demographics:

57-year-old male, warehouse worker

History:

• Key past medical history: Diabetes mellitus type 2, hypertension, previous episode of cellulitis

• Current medications: Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing pain, redness and swelling in the left lower leg

• Key symptoms: Fever, chills, red and swollen left lower leg, difficulty in walking due to pain

• Vital signs: Blood pressure 145/95 mmHg, pulse 105 bpm, temperature 38.5 C (101.3 F), respiratory rate 20 breaths per minute, oxygen saturation 94% on room air

Section 1

New Diagnostic Results:

Laboratory tests were ordered to assess the severity of the infection and evaluate the patient's overall health status. The complete blood count (CBC) revealed an elevated white blood cell count of 15,000 cells/uL indicative of an ongoing infection. The blood glucose level was also high at 220 mg/dL, suggesting poor control of his diabetes, which can contribute to impaired wound healing and increased susceptibility to infections. Blood cultures were positive for Staphylococcus aureus, confirming the source of the cellulitis.

Further imaging was conducted due to the patient's history of a previous cellulitis episode and the persistent severe pain. An ultrasound of the left lower leg showed a hypoechoic area consistent with an abscess formation. This indicates that the infection has advanced, leading to a localized collection of pus. The patient's elevated blood pressure and heart rate could be attributed to both the pain and systemic inflammatory response due to the infection. This necessitates the need for immediate intervention to prevent septicemia and other potential complications.

Given these findings, the patient's case has become more complex, requiring careful consideration of his diabetes, hypertension, and allergy to penicillin in managing his cellulitis. The development of an abscess also presents an additional challenge, as it may require surgical drainage along with antibiotic therapy. The choice of antibiotics would need to be effective against Staphylococcus aureus and suitable for a patient with a penicillin allergy.

Section 2

Change in Patient Status:

Over the next 24 hours, the patient's condition declined. He started to exhibit signs of increased restlessness and disorientation. His temperature spiked to 39.2°C (102.5°F), and his blood pressure dropped to 90/55 mmHg, suggesting potential septic shock. His respiratory rate also increased to 24 breaths per minute, and oxygen saturation decreased to 92% on room air, indicating possible respiratory distress. The increased heart rate of 120 beats per minute could be due to the body's attempt to compensate for the low blood pressure and increased metabolic demands.

The patient's blood glucose level remained elevated at 230 mg/dL despite administration of sliding scale insulin, indicating ongoing poor glycemic control. Repeat lab tests showed an increased white blood cell count of 18,000 cells/uL, confirming the worsening infection. The patient's worsening status, along with the persistent high blood glucose levels, complicated the cellulitis management and required adjustments in the treatment plan. The team needed to balance the immediate need to control the infection and manage septic shock, with the need for long-term diabetes management and prevention of further cellulitis episodes.

Section 3

Change in Patient Status:

Following the next 48 hours, the patient's condition continued to spiral downwards. He became increasingly confused and lethargic, showing clear signs of altered mental status. His temperature rose further to 40°C (104°F) and blood pressure dipped to 85/50 mmHg, indicating worsening septic shock. His respiration rate escalated to 28 breaths per minute and oxygen saturation fell to 88% on room air, a clear indication of increasing respiratory distress. His heart rate rose to 130 beats per minute, further demonstrating the body's attempt to compensate for the low blood pressure and increased metabolic demands.

The patient's blood glucose level spiked to 275 mg/dL even after the administration of aggressive insulin therapy, suggesting an uncontrolled hyperglycemic state. Lab results revealed a further increase in white blood cell count to 22,000 cells/uL, indicating the exacerbation of the infection. The patient's deteriorating condition and persistent hyperglycemia further complicated the cellulitis management and necessitated urgent reassessment of the treatment plan. The team was now faced with a critical situation where they had to manage the escalating septic shock, worsening respiratory distress, and uncontrolled diabetes, while simultaneously preventing further cellulitis episodes.

Section 4

Change in Patient Status:

Despite aggressive insulin therapy and fluid resuscitation, the patient's condition failed to stabilize. His mental status continued to decline, with increased episodes of confusion and disorientation. His temperature remained elevated at 40.2°C (104.4°F), and blood pressure further dropped to 80/45 mmHg, reflecting a deepening septic shock. Respiration rate soared to 30 breaths per minute, and oxygen saturation continued to drop, reaching 85% on room air. His heart rate remained at an alarming 135 beats per minute. Blood glucose levels, despite continuous insulin infusion, remained critically high at 280 mg/dL, suggesting a severe, uncontrolled hyperglycemic state.

Lab results showed a significant increase in procalcitonin levels to 4.5 ng/mL, consistent with a severe bacterial infection. Blood cultures revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA), further complicating the treatment plan. The combination of septic shock, worsening respiratory distress, uncontrolled hyperglycemia, and now confirmed MRSA infection presented a critical situation that required immediate and aggressive intervention. The medical team had to adapt their approach to manage these multiple complex conditions and prevent further deterioration of the patient's condition.

Section 5

New Complications:

Further complications arose when the patient began to complain of severe abdominal pain, which was diffuse and crampy in nature. His abdomen was distended and tender to touch. Bowel sounds were hypoactive. Re-assessment of the patient's lab results showed an elevation in lactate to 5 mmol/L, indicating possible bowel ischemia. The patient's white blood cell count had also risen to 18,000/mm3, suggestive of an ongoing systemic inflammatory response.

An urgent CT scan of the abdomen was ordered, which confirmed the diagnosis of bowel ischemia. The medical team recognized that this complication added another layer of complexity to the patient's already critical condition. Bowel ischemia, if not promptly and properly managed, could lead to bowel necrosis and perforation, which would result in life-threatening peritonitis and further exacerbate the patient's septic state. The team needed to quickly decide between conservative management with bowel rest and parenteral nutrition versus surgical intervention. They also needed to continue managing the patient's hyperglycemia, respiratory distress, and MRSA infection, all while keeping in mind the patient's overall frail condition and the risks associated with any intervention.