Case Study: 42-Year-Old Female Patient Admitted

Case Study 1ld Is A 42 Year Old Female Patient Who Was Admitted Dir

Case Study #1 involves a 42-year-old female patient admitted due to an infected wound on her left foot, originating from a cat bite. She has a medical history including hypertension (HTN), a recent hysterectomy due to cancer, and completed chemotherapy and radiation over a year ago. She is allergic to sulfa drugs, iodine, shellfish, avocados, papaya, and walnuts. The assessment should prioritize managing her infected wound, considering her medical history, allergies, and recent surgical status.

Paper For Above instruction

Introduction

The management of infected wounds requires careful assessment and planning, especially in patients with complex medical histories such as recent cancer treatment, hypertension, and multiple allergies. Applying the ADPIE process—Assessment, Diagnosis, Planning, Implementation, and Evaluation—guides comprehensive care to optimize healing and prevent complications.

Assessment

The primary assessment focus should be on the wound characteristics—size, depth, odor, surrounding tissue condition, and signs of systemic infection (fever, malaise). Due to the malodorous nature, suspicion of bacterial infection is high, necessitating prompt wound evaluation. The patient's medical history, including hypertension and past cancer, may influence immune response and healing capacity. Allergies to specific drugs and foods should be documented to inform medication choices. Vital signs, particularly temperature and blood pressure, are essential to monitor systemic infection and stability. The patient's recent surgical history and current functional status are also vital assessments.

Additional priorities include evaluating for signs of sepsis, such as tachycardia, hypotension, and mental status changes, given the infected wound. Monitoring for signs of allergic reactions and ensuring patient safety during interventions are also critical.

Diagnosis

The priority nursing diagnosis is likely "Impaired Skin Integrity related to infection and trauma secondary to a cat bite." This diagnosis addresses the wound’s infected state. Other diagnoses include "Risk for Sepsis" due to the infected wound progressing if untreated, and "Impaired Comfort" related to pain and discomfort. Allergic responses and potential for delayed healing due to patient's comorbidities are additional considerations.

Rationale:

The primary focus on skin integrity stems from the infected wound, which, if not properly managed, can lead to systemic infection. The presence of malodor suggests bacterial colonization or infection requiring immediate attention. Risk for sepsis is high in infected wounds, especially in immunocompromised or recently treated cancer patients.

Planning

The plan involves immediate wound management, infection control, and addressing the patient's allergies and medical history. Key components include:

- Initiate wound cleaning and appropriate dressing changes with sterile technique.

- Administer prescribed antibiotics, selecting agents safe considering allergies.

- Monitor vital signs closely to detect early signs of systemic infection.

- Educate the patient on wound care, signs of worsening infection, and when to seek help.

- Coordinate care with interdisciplinary team members:

- Wound care specialist or surgeon for wound assessment and care planning.

- Pharmacist for medication management, ensuring allergy considerations.

- Dietitian if nutritional support is needed for wound healing.

- Primary care provider or infectious disease specialist if systemic antibiotics or further testing are required.

- The significance of allergies requires selecting medications that do not contain sulfa or iodine derivatives, avoiding shellfish and related foods.

Consultation with the provider might include requesting wound culture and sensitivity testing, and possibly blood work to assess systemic infection or sepsis markers.

Implementation

Implementation entails executing the wound care plan, including sterile dressing changes, administering medications as prescribed, and monitoring patient's response—vital signs, wound appearance, symptoms of systemic infection. Patient education on wound hygiene, avoiding allergens, and recognizing infection signs is critical.

Additional involvement includes:

- Family members or caregivers for assistance with wound care post-discharge.

- Infection control team to ensure proper handling and isolation if needed.

- Nursing colleagues for consistent wound assessment and documentation.

Effective communication among team members ensures coordinated care and swift response to complications.

Evaluation

The plan's effectiveness is evaluated by observing:

- Resolution or improvement in wound appearance (reduced size, decreased odor, healthy granulation tissue).

- Stabilization of vital signs within normal ranges.

- Absence of systemic infection signs: no fever, hypotension, or mental status changes.

- Patient's reported pain levels and comfort.

- Patient education adherence and understanding regarding wound care and allergy management.

SMART goals for evaluation may include:

- The wound will show signs of healing (reduction in size, decreased odor) within 72 hours.

- The patient's temperature remains below 100.4°F (38°C) during hospitalization.

- Patient demonstrates understanding of wound care procedures before discharge.

Consistent documentation and regular assessments facilitate monitoring progress and adjusting care plans accordingly.

Conclusion

Managing a patient with an infected wound requires a comprehensive, multidisciplinary approach that emphasizes early assessment, targeted interventions, and continuous evaluation. Recognizing the patient's allergies and medical history guides safe and effective treatment, reducing risks of allergic reactions and systemic infections. Applying the ADPIE framework ensures a structured, patient-centered pathway toward healing and improved health outcomes.

References

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• Bradley, S. (2020). Infection control in wound management. Infection Control & Hospital Epidemiology, 41(2), 134-140.
• Cameron, J. S., & Rees, L. (2018). Allergies and drug reactions. British Medical Journal, 336(7639), 638-643.
• Gould, D., & O’Connell, C. (2021). The importance of multidisciplinary teams in wound care. Wound Practice & Research, 29(1), 3-10.
• Hutchinson, A. (2017). Wound healing: principles and practices. Wound Management, 17(6), 34-38.
• Johnson, M. (2020). Managing infections in surgical patients. Surgical Infections, 21(3), 283-290.
• Kumar, S., & Clark, M. (2017). Clinical Medicine (9th ed.). Elsevier.
• Lewis, R., et al. (2019). Allergic reactions and treatment considerations. Journal of Allergy and Clinical Immunology, 143(6), 2103-2111.
• Smith, G. B., & Wall, R. (2018). Patient-centered wound care. Nursing Standard, 32(12), 45-52.
• Walker, P., & Smith, E. (2022). Systematic approach to wound management. The Nursing Clinics of North America, 57(2), 145-158.