Case study
The nurse is performing a shift assessment on Andrea, a 75-year-old woman who is 2 weeks post-coronary artery bypass surgery. Andrea is a patient in a long-term care skilled nursing facility. Upon assessment, the patient's lungs are clear to auscultation but diminished, heart sounds normal with regular rate, and bowel sounds are present. The patient ambulates with the assistance of a walker and is seen limping, only placing half of her weight on the left lower extremity. There is an incision on the left lower extremity where the saphenous vein was removed to use for cardiac graft replacement with redness surrounding the length of the incision. Peripheral pulses are 2+ and the left ankle is hot to the touch with 2+ non-pitting edema. The incisional area is open in two places-one near her ankle and one near her knee. The opening near the ankle is 2 cm long x 1 cm wide x 1/4 cm deep. The opening near her knee is 3 cm long x 1½ cm deep x 3/4 cm wide. Thick, yellow fluid drains from both sites. VS: 127/77, HR- 110, RR -26, T- 101.2, Sa02 94% on room air. The nurse receives the following orders from the physician: Ampicillin 500mg IV q6 hours, CBC with differential, erythrocyte sedimentation rate, wound culture with sensitivity, NPO after midnight, and Tylenol 650mg PO q6 hours as needed for fever.
1. Compare the presentation of inflammation and infection in this patient. Identify and include the cardinal signs of inflammation and the type of immune system process responsible.
2. What order should the nurse follow when completing the prescribed interventions (i.e. first, second, third...)?
3. What laboratory value results (from the labs ordered) should the nurse expect to see?
4. Which ordered test would evaluate the presence of a MDRO?
5. What factors place this patient at risk for infection caused by a multi-drug resistant organism (MDRO)?
6. If the wound cultures were to come back with positive presence of methicillin-resistant staphylococcus bacteria, specify which isolation type may be initiated for this patient & what precautions would be required?