Topic : Mandatory Discussion Question

Ms G. presents to the ED with cellulitis of the LLL. She reports no improvement since applying heat for several days. Miss G. also reports increased pain and has developed chills suggesting that she has a fever. Assessment findings show an open wound on her LLL with drainage present and swelling of >3 cm in comparison to her RLL. She has a temperature of 102.2 F and wound cultures are positive for Staph aureus. Lab values show an elevated WBC with > 10% bands and 80% L shift in neutrophils.

My recommendation would be IVF, Abx, A1C, CMP, complete set of VS, head to toe assessment, CBG ac/hs (insulin if needed). Miss G. would also benefit from evaluation by OT and PT as well as meeting with a Diabetic Educator. Social work would also be beneficial as she lives alone and may have greater needs than we are aware of. Imaging of the LLL can tell us if she is experiencing DVT or if there is damage beyond what we can see.

It is essential that we treat the existing infection so that she can return to baseline, and it is equally important that we assess her knowledge of Diabetes as uncontrolled diabetes can have a serious impact on wound healing.

Muscle groups that are likely to be affected by Miss G.'s infection include gastrocnemius, soleus, extensor hallucis longus, extensor digitorum longus, fibularis longus, vastus medialis, rectus femoris, and extensor hallucis brevis (ARC Resource Center, nd).

The data presented paints a picture of where Miss G may need assistance and/or education. She needs to be evaluated on her understanding of Diabetes and management of the disease. Many complications come from diabetes including delayed wound healing. She will need labs drawn over the course of her stay to evaluate the effectiveness of the abx. An A1C will tell us if Miss G manages her Diabetes well over time. Evaluation by PT and OT are important for safe discharge home as she lives alone and was not able to perform ADLs independently upon admission. She will need to follow up with her PCP after discharge to have the wound on her leg looked at.

As mentioned above, delayed wound healing can be caused by diabetes and also poor nutrition. Miss G may also suffer from depression as she is managing a chronic condition and living alone; depression has also been linked to delayed wound healing.

"The moment a person with diabetes suffers a break in the skin of their foot, they become at danger for amputation. Most commonly, patients have neuropathy, which could be causative. When coupled with an impaired ability to fight infection, these patients become largely unable to mount an adequate inflammatory response. Thus, the DFU that may look like a healing wound becomes a portal for infection that can lead to sepsis and require limb amputation" (Journal of Investigation, 2007).