Cellulisi Case Study

Date of care:_______3/27/14 _______________ Client Initials:___GW___ Sex:___M__ Age:__56__ Rm#__308-1___
Religion:______ Allergies:_______N/K/A __________ Admission date:____3/24/14______ Code status___FULL___
Admitting diagnosis ___Cellulitis and Infected Left Leg Ulcer_____ ________________________________
Social Hx:_____________________________________________________ ___________________________________
PMH:___MRSA NARES, DVT RIGHT FEMORAL, SAD, DEPRESSION, STATUS POST LEFT HIP REPLACEMENT, ULCERS- STASIS, VERICOSE VEIN STRIPPING, ALCOHOL ABUSE, DRUG ABUSE Recent Surgeries ____LEFT HIP REPLACEMENT, VERICOSE VEIN STRIPPING________________________
Chief Complaint
He was complaining of left leg pain of his infected leg and was diagnosed with Cellutitis and infected ulcer wound of the left leg. He is a full code, NKA, and AO x 3. He is on CONTACT precaution. He has a history of MRSA Nares from February, with a present culture still pending. Other past history includes Schizo-affective Disorder, depression, DVT right femoral, hip replacement, stasis ulcer drug abuse, and alcohol abuse. He is NPO, scheduled to go into surgery for wound debridement of the leg left/ankle. He has a 22G right outer forearm IV access, being treated with 0.45 NS at 40CC/HR. He is being treated with Piperacillin/Tazob (Zosyn) 3.375G Q6 IVP, and Vancomycin 1.0MG Q12 IVP. Patient has a tendency to act sexually inappropriate, yell, and is uncooperative at times. Stay calm, and firmly ask to change conversation. He is able to tolerate most activity i.e. sitting up in chair, independent feeding, and uses urinal. Due to decreased movement, pt is on pressure reduction air mattress, and SCD post surgery. He refused AM care, and reused Stress test, stating, “Why do I need a stress test, I am not here for my heart!” Follow up with education on personal hygiene, skin care, and education on circulation problems and how the heart is great affected. Follow nursing care of his wound post surgery: Cleanse with NS, apply Bactroban ointment, apply Vaseline gauze, cover with 4X4, and then wrap with
Accu-check

Foley

NG tube

PEG/PEJ tube

Chest tube

Trach

Suctioning

Drains

Ostomy

Dressing change &/or wound care
Routine dressing care for ulcer/cellulitis
Treatments

Special Equipment
SCD compression
Other

PRO STAT 64 SUPPLEMENT FOR INSUFFICENENT PROTEIN/BID

IV ACCESS
Type: 22G IV

Site: Right outer forearm
Fluid/rate: 0.45 NS 40 ml/hr

Reason(s) for IV access:
Patient is on NPO status, so fluid is needed for supplementation. Also IV antibiotics are needed to treat infected wound.

Abnormal Labs: Please document abnormal labs here. Add more lines if needed.

Pathophysiology Treatments

Risk