MRSA bacteremia patho help please

xtxrn, ASN, RN · Nov 1, 2011

What a mess!!! (not you- the patient ) Gotta spend some time reading through this- but with prioritizing, use ABCs as your initial guide :)

xtxrn, ASN, RN · Nov 1, 2011

Also- outcomes are what the PATIENT will do.... not you :)

xtxrn, ASN, RN · Nov 1, 2011

hey y'all,
patient is a 45 yo female placed on contact isolation.
medical hx : ht, esrd(on hd), hx atrial fib with rvr, hx of brady-tachy syndrome, no pacemaker put in b/c of recurrent infections, multiple failed av grafts and fistulas on all 4 extremities, recurrent pc and graft infections with mrsa bacteremia, previous mi with icm, tte ef 40%, moderate tr, no valvular stenosis, hx mrsa pneumonia, hx pulmonary nodules 2/2 ca deposits, dm type ii, dysphagia. stage 3 decubitus. patient initially presented for sob, required emergency intubation, and had dialysis.
medical dx: mrsa bacteremia.
side note: patn is also positive for c. diff., and swabbed positive for vrse in the decubitus. patient has hx of leaving ama on multiple prior occasions. i witnessed a refusal of dialysis as well as a medication. this client, according to age, should be at the generativity vs. stagnation stage. however i feel this patient is in an earlier stage, initiative vs guilt. i say this because this stage is about asserting control and power over the environment. this patient is asserting control over the environment as evidenced by a history of leaving hospital ama, refusing dialysis, and refusing the heparin.
i understand that problems on care plans should be ranked according to maslow. however, we are supposed to use a different nursing dx for each of our patients.
problems (listed in from highest priority to lowest) impaired swallowing, impaired gas exchange r/t pneumonia, impaired skin integrity r/t decubitus, risk for falls, diarrhea r/t c. diff, risk for deficient fluid volume r/t diarrhea, ineffective tissue perfusion(renal), acute pain r/t decubitus, nutrition imbalanced less than body requires, risk for imbalanced fluid volume r/t esrd, risk for loneliness. i'm sure there are more problems to be added that i didn't think of. also i'm a bit unsure of my ranking order.
ok... look at the abcs, and rethink putting impaired swallowing - though i get the aspiration angle- ahead of the impaired gas exchange; circulation involves fluid volume- so those need to go ahead of skin and falls; non-compliance (ama; refusal of hd) are a starting place :) psychosocial issues always need to be addressed, but the esrd with hd refusal, and infections will kill him sooner (unless you have instructions to deal with the psychosoc); also- dm needs to be addressed if going with medical issues

i chose powerlessness r/t esrd aeb history of leaving ama.
interventions: (patient will)
acknowledge fears, feelings, and concerns about current situation, make decisions regarding course of treatment, participate in self care activities (checking perma cath for infection signs), decrease level of anxiety by changing stress response, express feeling of regained control.

if you're instructed to go with psychosocial issues vs medical/nursing priority, this is good. but the interventions are generally what the nurse does- not the patient. i think you might have interventions and outcomes backwards???

outcomes (nurse will)
listen to client talk about feelings concerns fears about current situation, explain to client choices regarding treatment course, educate client how to check for signs of infection at perma cath site, suggest some healthy coping mechanisms to deal with stressors, help patient learn about disease, treatment, prognosis to help patient feel in control.
here is where it gets weird sometimes. the outcomes have to be what the patient will accomplish :) otherwise it's a care plan about you ! you need to have "patient will verbalize_______" or "wound culture will be negative by _____" need a time frame, as well (or at least that's how i did them w/ltc care plan job) if there are changes that the nurse has to show what he/she does- then i apologize for not being aware of that format. i've always had to have goals for the patient. :) otherwise, it's not patient focused.

important labs:
wbc= 10.5(high) r/t infection from 3 types of organisms
hgb=7.3 (low)
hct=.25 (low)
platelets=451
na=137
k=3.5
cl=98
hco3=26
bun=37(high) r/t esrd
creat=4.7 (high) r/t esrd
glucose=172 (high)

anemia is indicated in this patn by low hb, low hematocrit, low rbc count(rbc=3.07), and low mchc(29.8). stool was bloody from c. diff. and could a reason for anemia. also malnutrition can cause it. nutrition has been a problem for this patient.
neutrophil: 93.4 (high)- due to the current bacterial infections.

sorry for posting a "book" lol but i figure too much info is better than not enough. i have 2 patho books and 1 micro one that are not helping me on this case. i really need guidance in a good online source for mrsa patho phys. if i can also get vrse and c. diff. pathos that would be awesome. i need reputable sites. i checked cdc and some nih sites but wasn't getting what i need. any help/suggestions y'all can give would be greatly appreciated.

re: the pathophysiology, when i see the recurrent infections, and probable multiple antibiotics needed to treat them, it increases the risk of developing a bug that is 'juice' resistant. as goofy as it sounds, try the wiki link for mrsa- i had it for a friend not long ago- and it explained things well, with additional sites listed; the vre and c.diff should also be available.

unless the guy has had c. diff for a while, i wouldn't expect the h&h to be that low. what are other, additional possibilities ? how much heparin does he get? what are the coag times? ptt?

this is what i've got from a quick look- i'll check back :) i'm an old fart- but aside from some changes in what they ask you to do these days, the patients are about the same- lol. i've worked hospitals, as well, so hope that is helpful :)

nurseprnRN, BSN, RN · Nov 1, 2011

low h&h is classic in renal failure patients because the kidneys are where erythropoietin comes from.

why is low h&h bad in somebody with a bad heart and nonhealing wounds? what would you look at to see about the effects of low oxygen-carrying capacity?

i agree c xtxrn that you need to be clearer on the difference between outcomes (the end result of your interventions) and nursing actions.

also, step back a bit from this train wreck of a patient situation and try to see the big picture.

she's got chronic infection/colonization, so she's a risk to others, including you. what would you do to protect other people from catching her bugs?

she has a chronic nonhealing wound. what are the main factors that influence wound healing, and what is she lacking? how come? anything nursing can do about any of them?

she's on dialysis, but came in with symptoms of fluid overload and refuses some dialysis-related care. what would you look for in terms of fluid overload, especially since she has a bad heart?

she's in renal failure and on dialysis and is therefore at risk for a lot of other complications. like what? are any of them dangerous? why? what would you do to decrease the risk?

she's on dialysis, but refusing some of the care needed to do that properly. good spot on the psych dx-- ever think that she could use a psychosocial referral? normally, we don't encourage nursing interventions that aren't nursing interventions, but see if you can find out about the plissit model of patient counseling (it's nifty) and see how nursing might implement that. hint: the last stage is "intensive therapy," generally thought of as being beyond the scope/ability of the bedside caregiver.

just sorta off the top of my head. there's a lot more, but this might get you started.

ncnative · Nov 1, 2011

Hey XTXRN,

Thanks for taking time to try and help me out :) I did indeed accidentally switch outcomes with interventions. I have corrected them now on my clinical paperwork. Since my instructor doesn't have a preference regarding psychosocial vs medical dx I would like to keep powerlessness to write up. Thank you for the suggestion to re arrange my problem ranking. I was thinking aspiration for impaired swallowing. I'm not sure why the H&H is low on this patient. It suggests a bleed to me or maybe something else is going on. I did see copious amounts of blood in the diarrhea. Unfortunately I was a big dummy and forgot to write down the dosage on NaHep. It is given Q12H. As far as antibiotics, Patn is receiving Flagyl 500 mg Q8H and Vancocin 1 Gm/Hr at dialysis. I shall continue to chase patho. I appreciate the suggestion of Wiki but just can't make myself trust that site lol. I would like to find info specific to respiratory MRSA. Patient had it in the lungs and was coughing up medium yellow thick sputum. The suspected theory for this patient is that the decubitus got infected by stool and became VRSE positive. They (staff) are speculating the MRSA entered the body at the perm cath site. Not sure about the C. Diff. I would suspect it preyed upon an immunocompromised individual. X ray showed opacities in patn lungs. Patn was suspected of having breast cancer last year. Biopsy was negative and further testing was refused. Not sure if cancer could drop H&H... Thank you once again for the help :)

ncnative · Nov 1, 2011

Hey GrnTea,

Thank you for your help. I had forgotten the f(x) of epo. I checked my patho book and see it is made in the kidney and stimulates erythrocyte production in the red bone marrow in response to tissue hypoxia. Since her hemaglobin is low this will delay healing. Also her diet is poor so that's not going to help heal her either. They had added a high protein supplement to diet but it was refused. I tried the education route about how it would help heal that decubitus but it fell on deaf ears. Low hemoglobin=low blood o2= stress on cardiac muscle as well.

I tried to practice infection control with lots of thorough hand washing skills. I made sure that whatever I took in the room stayed in that room. I had to take in the vitals cart b/c there aren't enough for every room to have one. When I brought it out I wiped it down with Cavi (sp?) wipes. I was trying to figure out why this patn wasn't on droplet iso, just contact. It really bugged me patn was coughing and door was left open. Every time I tried to shut it, patn complained the room was too hot. Was told to dispose of C. diff diarrhea contaminated linens into rolling hallway laundry cart. Didn't feel this was the right way to do this but couldn't defy authority. As far as the non healing wound goes I see a few things impeding it. First she is diabetic and they tend to heal slower. Second I advocated for a bedside commode for her since that was what was used at home. My theory there was to decrease stool from on getting on that ulcer. patn wasn't truly incontinent but stated bedpan use was painful in sacral decubitus. Diet is an issue with this patn. Since we are dealing with a renal patient we can't up protein excessively or kidneys will be stressed. However protein aids wound healing. Hopefully Flagyl will eradicate VRSE from that wound and aid in its healing. I wonder if a wound vac would help? Symptoms of fluid overload are edema, crackles in lungs, ascites, CHF, and SOB. Renal failure puts her at risk for anemia, bleeding from stomach or intestines, brain dysfunction/confusion/dementia, electrolyte fluctuation, blood sugar fluctuation, damage to arm/leg nerves, pleural effusion, CHF, CAD, HT, pericarditis, stroke, hep b/c, liver failure, hyperparathyroidism, increased risk of infection, malnutrition, seizures, and skin dryness. Nursing can help prevent some of these by carefully monitoring diet, educating patient about diet, teaching patient to weigh daily (to see Dr. if wt. gain), proper handwashing, turn patient Q2H, monitor labs closely. Yes some of these possibilities are dangerous bleeding (depending on severity can be deadly), blood sugar flux (can lead to coma if severe), pleural effusion (impacts breathing/O2 sat), CHF (can be deadly), CAD can lead to MI, HT can lead to stroke, pericarditis can lead to cardiac tamponade(poss. deadly), stroke (can be deadly depending on how long brain doesn't have O2), Hep B/C can destroy liver and kill that way, hyperparathyroidism could kill indirectly, infection can be deadly, malnutrition can be deadly if severe, a seizure, if grand mal, could indirectly kill a patn. I do feel this patient could use a psychosocial referral. I think she is overwhelmed with all the things going wrong and feels she has no control. I googled Plissit and I see it appears to be for sexual therapy. How does that apply to this patient? Thanks once again for your help :)

ncnative · Nov 2, 2011

First I would like to thank again XTXRN and GrnTea. Thank both of you for your kindness and guidance:) I went with emedicine.com for my patho write up. I appreciated the suggestion of Wiki and it was interesting. However my instructor doesn't like that site, says it's not reputable. I understand that since anyone can be an author on there. It did give me some good background info. I found more what I was searching for on the emedicine.com site. The articles were more scholarly and probably to my instructors liking. I ended up writing up patho on all 3 of the invading organisms. Here is what I will turn in. Hope I covered it thoroughly.

Patho for MRSA: according to Tolan, MRSA is methicillin resistant Staphylococcus aureus. It is a bacteria that is typically found on the body. Typically it causes no harm. S. aureus is a gram positive, aerobic, non spore forming, non motile cocci. It is a hardy organism. S. Aureus can resist temperatures up to 50 degrees C, high salt concentration, and drying. However sometimes it will cause an infection. These infections were treated in the past with penicillin. The Staph developed resistance to penicillin. So patients were treated with methicillin. Now S. aureus has evolved to be resistant to that antibiotic. MRSA is treated with Vancomycin now and is starting to develop a resistance to that. Tolan says that S. Aureus to clot plasma and to react with prothrombin. There are 2 forms of MRSA: community associated MRSA(CA-MRSA) and hospital acquired MRSA(HA-MRSA). CA-MRSA appears to colonize the anterior nares; while HA-MRSA is found in the perineal area, rectum, lady parts, pharynx, and gut. S. Aureus infection occurs when there is a break in the integument to allow entry. Typically MRSA infection is characterized by an pus-filled abscess. The infection moves into the blood stream and is transported all over the body. It can result in pneumonia, as well as infection of heart valves, bones, and joints. In immunocompromised patients 20-30% develop serious or fatal complications.Treatment: Vancomycin

Pathophysiology for VRE: Fraser states that enteroccoci are normal intestinal flora but can also cause disease. They are gram positive, anaerobic cocci that are hardy. They are able to survive 6.5% sodium chloride. The VRE strain is resistant to penicillin as well as Vancomycin. In this patient VRE likely came from stool incontinence. It infected the sacral decubitus and started to grow.

Treatment: Flagyl

Pathophysiology for Clostridium difficile: According to Aberra C. Diff is an anaerobic, spore-forming bacillus. It causes antibiotic related diarrhea and colitis. This infection is evidenced by mild to moderate diarrhea and cramping. Roughly 20% of hospitalized people will get C. Diff. This bacteria release toxins that inflame and damage intestinal mucosa. Contamination occurs via a fecal oral route. These spores are heat resistant and can survive months or years.

Treatment: Flagyl

I googled how to kill C. Diff. and it appears bleach is very effective. Not sure how long it has to be in contact to be effective. I also see Chlorox has come out with something called Dispatch that kills C. Diff.

ncnative · Nov 2, 2011

GrnTea,

I've already turned in my clinical assignment but that PLISSIT model is bugging me. I couldn't figure out how to relate a sexual health model to this patient.

She is still of course a sexual being, but I didn't see that as a problem. I couldn't see the forest for the trees lol. I googled the model and then clarity started to appear after I searched AN for it. I found a thread you had posted May 29, 2011 trying to help someone whose mom was suffering from cancer. I think you were trying to get me to see this patient needs help from an outside experienced source. I felt she was struggling with her health issues and not accepting them. I couldn't decide if the patient was in denial of her problems or if she was close to giving up. Not sure who she could be referred to. I guess maybe a psyche eval could help determine her frame of mind. Am I on the right track? Thanks once again.

nurseprnRN, BSN, RN · Nov 2, 2011

gold star, good work, and an exemplar for other students on how to go look for data to help you make an analysis. :yeah:

i agree c your instructor that you cannot cite wikipedia for facts, because although it is structured for peer review, it's not considered reliable (although it's better on medical topics than on, say, justin bieber). however, i use it often to refresh my memory or get graphics, and you can follow up on the references given at the bottom of the articles.

as to plissit, it was developed for use in sexual counseling. however, the concept of permission to discuss, limited information, specific suggestions, and intensive therapy can be extrapolated to any patient care condition or concern.

this patient clearly has issues beyond the bedside nurse's ability to manage, especially given the limited amount of time they give us to develop a therapeutic relationship these days. a psych eval would be an excellent idea. bear in mind that it might determine that she is completely aware of the consequences of refusing care, and she is entitled to do that even if we don't like it. these are hard cases to deal c because they tug at our hearts, but people are always allowed to say no to any care unless legally determined to be incompetent (this is not a medical or nursing decision).

good luck with your classes! sounds like you'll do very well so far.

xtxrn, ASN, RN · Nov 2, 2011

Agree- Wiki is not something I'd want to put as a reference - LOL... but it's a quick reminder, and has sites listed at the bottom from more solid sources. :)

You did a great job w/finding the pathophys on the bugs :up:

ncnative · Nov 2, 2011

Thank you once again to both GrnTea and XTXRN. I appreciate the guidance. Thanks GrnTea for helping me understand the PLISSIT model. I get my new clinical assignment tonight. We shall see who I get this time :)