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Question: 75-year-old who had right knee arthroplasty

24 Sep 2024,7:34 PM

 

Situation: Admission of 75-year-old client s/p right knee arthroplasty with cellulitis
Background: L.A. is a 75-year-old who had right knee arthroplasty 1 week ago, discharged on day 3. She returned to the emergency department with 1 day of fever and surgical site appears “angry”. L.A. is being readmitted for intravenous antibiotics. Her daughter reports that she has not been doing physical therapy and seems depressed. L.A. told her daughter that she should just “give up”. L.A. has been taking her pain medications as prescribed but also started to drink wine because she was having trouble sleeping. Last set of vital signs were T.101.7. HR 120, BP. 140/88, RR. 20, spO2 95% on room air, and pain at surgical site 5/10.


1. When obtaining the client history, what are 3 priority areas you will inquire about based on the background provided?
2. Based on the information provided by L.A.’s daughter, which screening tools would be appropriate to apply when interviewing the client (e.g. substance use)? Suggest 2 appropriate tools to use during assessment.
3. Which vital sign parameters would be abnormal in a client with cellulitis? What would be abnormal about each vital sign parameter you identified (e.g. heart rate – low or high)?
4. When examining the surgical site, you see the following (see image attached)
Use the patients background information above and the picture of the wound to describe your assessment using the ISBAR template.

 

DRAFT/STUDY TIPS

Introduction

The case of L.A., a 75-year-old patient readmitted post-right knee arthroplasty, presents a complex clinical scenario. She exhibits signs of both physical and emotional distress, with complications including cellulitis, fever, and a decline in mental health. This case requires a comprehensive assessment and tailored intervention, considering L.A.'s age, medical history, and psychosocial challenges. The objective of this essay is to critically analyze L.A.’s situation through key inquiries into her medical history, screening tools for her condition, abnormal vital signs linked to cellulitis, and an assessment of her surgical site using the ISBAR (Identify, Situation, Background, Assessment, and Recommendation) template.

Priority Areas for Client History

When obtaining L.A.’s client history, three priority areas demand focused inquiry: physical health, mental health, and lifestyle factors.

1. Physical Health
Given the context of her recent knee surgery and current cellulitis, the first area of inquiry should address L.A.'s surgical recovery process and associated symptoms. The nurse should ask specific questions related to her pain levels, mobility, signs of infection such as redness, warmth, and swelling around the surgical site, and any changes in her ability to perform daily activities. It is also essential to ask about her compliance with post-surgical rehabilitation exercises, as her daughter’s report suggests a lack of engagement in physical therapy. Non-compliance could be contributing to her worsened condition.

2. Mental Health
L.A.'s daughter has reported signs of depression, which should be investigated further. The nurse should ask about her mood, emotional state, and thoughts of hopelessness or self-worth. L.A.'s statement that she should “give up” is concerning and warrants exploration to determine whether she is experiencing clinical depression. Additionally, sleep patterns should be inquired about, as her sleep issues have led her to consume wine, potentially exacerbating her condition.

3. Substance Use
The third priority area is her use of alcohol as a coping mechanism for sleep disturbances. L.A.’s consumption of wine, in combination with prescribed medications, could have adverse effects on her health. The nurse should inquire about the quantity and frequency of wine consumption and whether L.A. has previously used alcohol or other substances to manage stress or symptoms.

These areas will help guide clinical decisions regarding L.A.'s treatment plan, addressing both her physical recovery and psychosocial well-being.

Appropriate Screening Tools

Given L.A.'s reported issues, two screening tools are recommended: the Geriatric Depression Scale (GDS) and the AUDIT (Alcohol Use Disorders Identification Test).

1. Geriatric Depression Scale (GDS)
The GDS is an effective screening tool designed to assess depression in older adults. It uses a series of yes/no questions tailored to the unique experiences and challenges faced by elderly patients, such as feelings of hopelessness, changes in sleep patterns, and loss of interest in usual activities. Administering this tool will help determine the severity of L.A.'s depressive symptoms and guide mental health intervention strategies.

2. AUDIT (Alcohol Use Disorders Identification Test)
The AUDIT is a comprehensive screening tool that evaluates alcohol consumption, drinking behaviors, and alcohol-related problems. Since L.A. has begun using wine to manage sleep issues, it is essential to assess whether her alcohol consumption is within safe limits or if it poses a risk of dependence or interaction with her medication. The AUDIT will help in identifying whether L.A. requires intervention for substance use in addition to addressing her physical and mental health concerns.

Abnormal Vital Signs in Cellulitis

L.A.'s vital signs suggest abnormalities that are consistent with cellulitis, a bacterial skin infection that can cause systemic inflammatory responses.

1. Elevated Temperature (Fever)
L.A.'s fever of 101.7°F is a typical sign of an infectious process, likely related to cellulitis at the surgical site. Fever is the body’s natural response to infection, indicating that her immune system is fighting the bacteria causing the cellulitis.

2. Increased Heart Rate (Tachycardia)
Her heart rate of 120 beats per minute (bpm) is abnormally high, indicative of tachycardia. This could be a result of the fever, pain, and systemic inflammation associated with cellulitis. The increased heart rate can also be a compensatory mechanism as the body attempts to deliver more oxygen and nutrients to the tissues to combat the infection.

3. Normal Respiratory Rate and Oxygen Saturation
While L.A.'s respiratory rate of 20 breaths per minute and oxygen saturation of 95% are within normal ranges, it is crucial to monitor these values closely. In cases of severe cellulitis, respiratory complications can arise, particularly if the infection spreads or if the patient develops systemic sepsis.

ISBAR Assessment of Surgical Site

Using the ISBAR template to assess L.A.’s condition, the following critical points emerge:

  • Identify:
    L.A., a 75-year-old woman, is being readmitted for intravenous antibiotics following a right knee arthroplasty, complicated by cellulitis.

  • Situation:
    The patient presents with a fever, tachycardia, and an “angry” surgical site appearance, as described by her daughter. Her pain at the surgical site is rated as 5/10, and she has been non-compliant with physical therapy, likely contributing to her current condition.

  • Background:
    L.A. had knee arthroplasty one week ago and was discharged on day 3. She has since developed fever and cellulitis around the surgical site. Her daughter reports signs of depression and that L.A. has been using wine to help with sleep. She has been taking her prescribed pain medication.

  • Assessment:
    On examination, the surgical site shows signs of infection, including erythema, warmth, and swelling. L.A. is febrile with a temperature of 101.7°F, and her heart rate is elevated at 120 bpm. Pain at the surgical site is moderately high, indicating ongoing inflammation or infection. There is concern about the potential spread of the infection if not managed promptly.

  • Recommendation:
    Immediate intervention is required, including the administration of intravenous antibiotics, wound care, and possible adjustment of pain management strategies. A mental health evaluation is also recommended to assess for depression, and a referral to a substance use counselor may be appropriate if alcohol use continues.

Conclusion

L.A.’s case underscores the complexity of managing post-surgical complications in older adults. Her readmission for cellulitis, compounded by symptoms of depression and substance use, requires a holistic approach that addresses both her physical and mental health needs. By prioritizing key areas in her history, applying appropriate screening tools, monitoring abnormal vital signs, and using structured assessments like ISBAR, healthcare providers can develop a comprehensive and patient-centered care plan. Immediate action is essential to manage her infection and prevent further complications, while long-term interventions may be necessary to support her emotional well-being and recovery.

 

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