A 62-year-old female patient with a non-healing diabetic foot wound is admitted for treatment. Which nursing intervention should be prioritized to promote wound healing and prevent further complications?

C) Monitor blood glucose levels closely and adjust diabetic medications as needed.

A) Initiate wound debridement and apply a topical antibiotic to the affected area.

B) Educate the patient on the importance of foot hygiene and regular podiatry visits.

C) Monitor blood glucose levels closely and adjust diabetic medications as needed.

D) Encourage increased oral fluid intake to maintain hydration status.

A 62-year-old female with a non-healing diabetic foot wound shows signs of infection and compromised circulation. Which of the following nursing interventions is the priority to promote wound healing and prevent complications?

A) Administer prescribed antibiotics and monitor for signs of systemic infection.

B) Educate the patient on proper foot care and the importance of glycemic control.

C) Perform regular wound assessments and document changes in wound characteristics.

D) Encourage adequate nutrition to support tissue repair and immune function.

A patient with a worsening MRSA wound infection and signs of vascular compromise is being reassessed. Which intervention should the nurse prioritize to address the newly identified complications in this patient's condition?

B) Administer vancomycin as ordered to treat the MRSA infection

A) Initiate negative pressure wound therapy to promote healing

B) Administer vancomycin as ordered to treat the MRSA infection

C) Consult with the vascular specialist to evaluate circulation

D) Intensify blood glucose monitoring and management

A patient with a worsening wound infection due to MRSA and poorly controlled diabetes presents with new symptoms including increased erythema, swelling, and escalating pain. Which nursing intervention is most critical to prioritize in managing this patient's condition?

A) Administer prescribed vancomycin intravenously to address the MRSA infection

B) Elevate the affected extremity to reduce swelling and promote circulation

C) Apply a warm compress to alleviate pain and reduce induration

D) Consult with dietary services to adjust the patient's carbohydrate intake for better glycemic control

A patient with peripheral artery disease (PAD) and diabetes is receiving intravenous vancomycin for a wound infection. Despite a reduction in erythema and swelling, the patient's pain remains significant, and Doppler studies reveal reduced arterial flow. Which nursing intervention should be prioritized to address the underlying issues contributing to the patient's condition?

B) Monitor blood glucose levels closely to maintain tight glycemic control.

A) Encourage the patient to ambulate to promote blood circulation.

B) Monitor blood glucose levels closely to maintain tight glycemic control.

C) Educate the patient on the importance of foot care to prevent further complications.

D) Administer pain medication as prescribed to manage the patient's pain.

A patient with peripheral artery disease and diabetes is being treated for a wound infection with intravenous vancomycin. Despite a reduction in erythema and swelling, the patient reports persistent pain. Doppler studies indicate reduced arterial flow, and a basal-bolus insulin regimen has been initiated. What is the most appropriate nursing intervention to address the persistent pain in this patient?

A) Administer prescribed analgesics and reassess pain levels regularly.

B) Increase the frequency of vancomycin dosing to enhance infection control.

C) Encourage the patient to increase physical activity to improve circulation.

D) Advise the patient to reduce fluid intake to prevent edema.

A patient with diabetes and peripheral artery disease (PAD) has been diagnosed with early-stage osteomyelitis in the metatarsals. The interdisciplinary team has adjusted the treatment plan to include intravenous vancomycin and oral rifampin. The patient's pain management plan now includes ketorolac and gabapentin. Which nursing intervention is most critical in preventing further complications in this patient?

C) Schedule regular wound assessments and report any changes in the wound appearance promptly.

A) Monitor the patient's blood glucose levels frequently and adjust insulin therapy as needed.

B) Educate the patient on the importance of completing the full course of antibiotics.

C) Schedule regular wound assessments and report any changes in the wound appearance promptly.

D) Encourage the patient to perform weight-bearing exercises to improve circulation in the affected extremity.

A patient with diabetes and peripheral arterial disease (PAD) has been diagnosed with early-stage osteomyelitis. The current treatment plan includes intravenous vancomycin and oral rifampin for the infection, along with a multimodal pain management strategy. Which nursing intervention is most critical in the ongoing care of this patient?

B) Monitoring renal function and adjusting medications as necessary

A) Administering scheduled ketorolac injections to manage acute pain episodes

B) Monitoring renal function and adjusting medications as necessary

C) Educating the patient on proper foot care to prevent further injury

D) Encouraging increased ambulation to improve circulation in the affected extremity

A patient with a diabetic wound infection is experiencing increased drainage and a foul odor from the wound site. The wound care nurse notes erythematous wound edges and periwound maceration. After a comprehensive wound culture and CBC, the patient's white blood cell count is elevated, and she has a mild fever. The antibiotic regimen is adjusted to include piperacillin-tazobactam, and insulin therapy is optimized. What is the primary nursing action to support wound healing and prevent further infection?

C) Monitor blood glucose levels closely to maintain them within the target range.

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

B) Encourage the patient to ambulate every 2 hours to promote circulation.

C) Monitor blood glucose levels closely to maintain them within the target range.

D) Apply a topical antimicrobial ointment as an extra measure against infection.

Diabetic wounds - Nursing Case Study

Pathophysiology

• Impaired Blood Flow: Diabetes leads to macro and microvascular damage, reducing blood flow to extremities. This impairs nutrient and oxygen delivery, critical for wound healing.

• Neuropathy: High blood glucose levels damage peripheral nerves, causing loss of sensation. This can prevent patients from noticing injuries, allowing wounds to worsen before treatment.

• Key Complication - Infection: Reduced blood flow and neuropathy create a perfect environment for infections, as immune cells can't reach the wound site effectively, delaying healing and increasing the risk of severe complications.

Patient Profile

Demographics:

62-year-old female, retired school teacher

History:

• Key past medical history: Type 2 Diabetes Mellitus diagnosed 15 years ago, hypertension, hyperlipidemia

• Current medications: Metformin 1000 mg twice daily, Lisinopril 10 mg daily, Atorvastatin 20 mg daily, Aspirin 81 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Non-healing wound on the left foot

• Key symptoms: Increasing redness and swelling around the wound, mild fever, occasional chills, and pain in the affected area

• Vital signs: Temperature 100.2°F, Blood Pressure 145/90 mmHg, Heart Rate 95 bpm, Respiratory Rate 18 breaths per minute, Blood Glucose 220 mg/dL

Section 1

The initial assessment of the 62-year-old female patient with a non-healing diabetic foot wound reveals several concerning findings. Upon examination, the wound on the left foot is approximately 4 cm in diameter with irregular borders and a necrotic center, surrounded by erythema extending 2 cm beyond the wound margins. There is purulent drainage noted, and the area is warm to the touch, indicating a likely infection. Palpation elicits tenderness, and the patient reports a pain level of 6 out of 10. The pedal pulses are weak, and capillary refill is delayed, suggesting compromised circulation to the affected area. The patient's sensation is diminished in both feet, consistent with peripheral neuropathy, which likely contributed to the unnoticed progression of the wound.

Diagnostic results further elucidate the severity of the situation. Laboratory tests reveal an elevated white blood cell count of 14,000 cells/μL, indicating an active infection. C-reactive protein is significantly raised at 8.5 mg/L, corroborating the presence of inflammation. Blood cultures are pending, but preliminary results from the wound culture suggest the presence of Staphylococcus aureus. An X-ray of the foot shows no signs of osteomyelitis at this stage, but the presence of soft tissue swelling is evident. The patient's blood glucose remains poorly controlled, with a recent HbA1c of 9.2%, underscoring the need for better diabetes management to aid in wound healing.

This clinical scenario necessitates prompt intervention to prevent further deterioration. The healthcare team initiates a comprehensive wound care regimen, including debridement of necrotic tissue and the application of an appropriate antibiotic regimen based on culture sensitivities. Efforts to optimize blood glucose levels are intensified, with a potential consideration for insulin therapy if oral hypoglycemics continue to prove insufficient. The patient is educated on the importance of foot care and regular monitoring to prevent future complications. Close monitoring of the wound and patient's systemic condition is essential to assess response to treatment and adjust the care plan as needed.

Section 2

Several days into the treatment regimen, the patient's condition presents new complexities that necessitate further clinical attention. Despite the initial interventions, the wound shows signs of worsening infection. The erythema now extends 4 cm beyond the wound margins, and the purulent drainage has increased. The patient reports escalating pain, now rated at 8 out of 10, and there is a noticeable increase in swelling. The surrounding tissue is more indurated, and the warmth has intensified, suggesting possible cellulitis. A repeat assessment of peripheral circulation reveals even weaker pedal pulses and a capillary refill time extending beyond 5 seconds. These findings raise concerns about further vascular compromise, potentially exacerbating the healing process.

New laboratory results further complicate the clinical picture. The white blood cell count has risen to 17,000 cells/μL, indicating an unmitigated or worsening infection. Blood cultures confirm the presence of methicillin-resistant Staphylococcus aureus (MRSA), necessitating a change in the antibiotic regimen to include vancomycin. C-reactive protein levels have increased to 10.2 mg/L, reflecting ongoing systemic inflammation. The patient's blood sugar remains poorly controlled, with fasting glucose levels consistently above 180 mg/dL, despite intensified efforts to manage her diabetes.

This development prompts the healthcare team to reassess and modify the treatment plan. The patient is started on intravenous antibiotics to address the MRSA infection, and consultation with a vascular specialist is initiated to evaluate and address the compromised circulation. The team considers advanced wound care options, including negative pressure wound therapy, to facilitate drainage and promote healing. Additionally, the patient's diabetes management plan is critically reviewed, with an endocrinologist brought in to explore the potential initiation of insulin therapy to achieve better glycemic control. This multifaceted approach aims to stabilize the patient's condition, prevent further complications, and ultimately promote wound healing.

Section 3

The response to the newly implemented interventions is closely monitored over the following days. The patient begins her course of intravenous vancomycin, with serum trough levels regularly assessed to ensure therapeutic efficacy and avoid nephrotoxicity. Initial observations reveal a slight reduction in erythema and swelling around the wound, suggesting a positive response to the antibiotic regimen. However, the patient's pain remains significant, with ratings fluctuating between 6 to 7 out of 10, indicating that while the infection may be stabilizing, the inflammatory response persists. The vascular specialist's evaluation highlights critical findings: Doppler studies reveal reduced arterial flow to the affected extremity, confirming significant peripheral artery disease (PAD) as a contributing factor to impaired wound healing.

In response to the vascular findings, the team initiates a tailored plan that includes antiplatelet therapy to improve blood flow and potentially a revascularization procedure, depending on the patient's response to medical management. Meanwhile, the endocrinologist adjusts the diabetes management strategy, starting the patient on a basal-bolus insulin regimen to achieve tighter glycemic control. This adjustment results in improved fasting glucose levels, now averaging 140 mg/dL, indicating a more stable glucose profile that could enhance the wound healing process.

The patient's clinical picture, while showing some signs of stabilization, remains complex due to the underlying PAD and the need for continued aggressive management of her diabetes. The healthcare team remains vigilant, ready to address any further complications, such as potential osteomyelitis, which could be suggested by persistent pain and delayed healing. Regular interdisciplinary meetings ensure that all aspects of the patient's care are cohesively managed, emphasizing the need for continuous clinical reasoning to navigate the multifaceted challenges presented by her condition.

Section 4

As the interdisciplinary team continues to monitor the patient's progress, new diagnostic results bring additional insights into her condition. A follow-up MRI of the affected extremity is conducted due to the persistent pain and concerns of potential osteomyelitis. The imaging reveals evidence of early-stage osteomyelitis, characterized by marrow edema and cortical irregularities in the metatarsals. This finding necessitates a prompt adjustment in the treatment strategy, as the presence of bone infection poses a significant risk for further complications. The infectious disease specialist recommends extending the course of intravenous vancomycin and adding oral rifampin to enhance the antibiotic regimen's bone penetration.

In light of the new diagnosis, the healthcare team also revisits the patient's pain management plan. They decide to incorporate a multimodal approach, including the addition of periodic ketorolac injections to address acute pain episodes and the introduction of gabapentin to manage neuropathic pain components. The patient's pain scores begin to show a modest improvement, now ranging between 4 to 5 out of 10, suggesting that the revised pain management strategy is beginning to take effect.

Despite these developments, the patient's condition remains precarious. The need for ongoing close monitoring and frequent reassessment is emphasized, particularly given the potential for further vascular compromise or worsening infection. The team continues to hold regular interdisciplinary meetings to ensure comprehensive care, with a focus on integrating the new findings into the overall management plan. The current trajectory underscores the importance of vigilant clinical reasoning and adaptability in addressing the complex interplay of diabetes, PAD, and infection in this patient’s care journey.

Section 5

New Complications

As the interdisciplinary team continues to manage the patient's care, a new complication arises. During a routine dressing change, the wound care nurse notes increased drainage and a distinct foul odor emanating from the wound. The wound edges appear more erythematous, and there is a notable increase in periwound maceration. Concerned about the potential for a superimposed infection, the team orders a comprehensive wound culture and a complete blood count (CBC) to assess for systemic signs of infection. The patient's white blood cell count has risen to 14,000/mm³, indicating a possible infectious process, alongside a mild fever of 38.1°C (100.6°F).

In response to these findings, the team promptly revises the antibiotic regimen to include broader coverage, adding piperacillin-tazobactam to target potential anaerobic and gram-negative organisms. The patient's glucose levels are also closely monitored, as hyperglycemia can impair wound healing and exacerbate infection. Adjustments are made to her insulin regimen to maintain blood glucose levels within a target range of 100-180 mg/dL. The dietitian collaborates to ensure the patient's nutritional intake supports optimal wound healing, emphasizing increased protein and caloric intake.

This development underscores the need for heightened vigilance and adaptability in the patient's care plan. The team remains focused on preempting further deterioration by maintaining strict glycemic control and optimizing antibiotic therapy. Regular reassessment of the wound is scheduled, alongside continued interdisciplinary discussions, to evaluate the efficacy of interventions and adjust the plan as necessary. The patient's journey illustrates the complexities of managing diabetic wounds with concurrent infections, highlighting the critical role of dynamic clinical reasoning in achieving positive outcomes.