Vancomycin-Resistant Staphylococcus Aureus and Vancomycin-Resistant Enterococci - Case Study Example

Name: Professor: Course: Date of Submission: Patient ISBAR Report I Identity Role: Intensive Care Unit Nurse To the concerned physician Patient: Patient Seven Age: 59 Sex: Male S Situation Patient Seven is a 59 years-old male admitted from a nursing home and categorized under high-level care for Vancomycin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE). The patient’s medical history indicates that he had undergone right kidney percutaneous nephrolithotomy (RPCNIL), on 24/09/13 with the same procedure repeated on the 4/10/13. The procedure is performed on patients diagnosed with chronic kidney disease to remove large kidney stones from the urinary tract to enhance renal function and clearance rate. The patient’s pressure emerges as the major risk facing the patient requiring two-hourly pressure care area, which could be attributed to the tetraplegic condition. The patient’s medical history has indicated diagnosis of schizophrenia, depression, and tetraplegia. The patient has also undergone trasurethral resection of the prostrate (TURP) and diagnosed with gastro-oesophageal reflux disease as well as Type 2 diabetes mellitus (T2DM). The patient Blood sugar level during the time of BSL QID check was 8-10 with the patient showing signs of drowsiness after the redo PCNL. Patient Seven is also indicated to have undergone a long-term suprapubic catheterisation. B Background Patient Seven is from a nursing home where she had been undergoing treatment for different health conditions including Type 2 diabetes mellitus, schizophrenia, depression, and chronic kidney disease. The patient has also developed tetraplegia. However, chronic kidney disease emerges to have been the center of focus in the care of the patient as indicated by the various interventions aimed at improving the patient’s kidney and urinary system functions such RPCNIL and TURP. The patient’s medical history shows that the patient has undergone several treatments that predispose a patient to increased risk for bacterial infections and consequent use of antibiotics such as vancomycin. This perhaps explains the acquisition of MRSA and VRE. Some the treatment that could be associated with MRSA VRE situation include the transurethral resection of the prostrate, the long term suprapubic catheterization and the PCNIL In the process of the home care nursing, the patient acquired MRSA and VRE leading the patient to be put under high-level care. The tetraplegic condition identified with the patient has trigged significant pressure risks requiring the nurse to ensure a 2-hourly pressure care. Patient Seven has also been diagnosed with Type 2 diabetes mellitus, which may have contributed to the kidney condition under treatment. The long-term suprapubic catheterization may have particularly contributed to the reported infections. Patient Seven has also been diagnosed with gastro-oesophageal reflux disease. Urinary tract infections further emerges as a major complication the process of PCNIL and therefore could also account for the patient’s MRSA VRE situation. The last BSL QID check was 8-10 indicating that the patient’s blood glucose levels uncontrollable although this did not imply that the condition did not require further monitoring. Lastly, the patient indicated some signs of drowsiness. A Assessment From the reported MRSA VRE situation, it is clear that the patient has been under antibiotic treatment with the choice of medication as vancomycin. Patient Seven is also under medication for other health conditions including schizophrenia and Type 2 diabetes mellitus through the home nursing patient care arrangement. Patient Seven has undergone consecutive right kidney percutaneous nephrolithotomy aimed at removing large kidney stones to enhance kidney clearance and improve the urinary function (Huang et al2013). The patient has also undergone other treatments that significantly affect the patient’s movement including the transurethral resection of the prostrate, and the long-term suprapubic catheterization. Such interventions may resulted into Patient Seven being bed-ridden or incapacitate for long period. This perhaps explains the development of tetraplegia associated with the reported risk of pressure areas. The patient’s medical history also indicates experiences of gastro-oesophageal reflux manifested through symptoms such as heartburns. The risk of pressure identified with the patient has compelled the nurses to observe a 2-hourly pressure area care resulting from the tetraplegic situation to avert body part complications such rotting of tissues. The Sling lifter by 3pp is important especially in the pressure area care for lifting the patient without necessarily involving manual lifting, which may result to further complications or injury of the patient. Assessment of the patient’s skin indicated pressure areas that required the patient to be turned regularly to avert skin complication especially from the reported tetraplegia. Full Blood Count was conducted to determine the impact of the MRSA VRE on the immune system. MRSA VRT may result from a comprise or weakening of the patient’s immune system as a result of the various interventions performed on the patient (Caroline, Elling & Smith 2012). The number of white blood cells was low depicting significant weakness in the immune system, a phenomenon that could account for the MRSA VRE situation. The number of neutrophils was also found to have declined as a result of the infection associated with MRSA and VRE acquired by the patient in the process of treatment. Review of the bowel chart reveal abnormalities in the bowel flow with reported discomfort. On the other hand, BSL (QID) indicated 8-10, a indication that the patient has experienced uncontrollable diabetes that require frequent monitoring. Lastly, patient’s observation indicated some signs of drowsiness, which could be associated with a potential drop in the blood glucose levels. R Recommendation Stabilization of the blood glucose levels should be prioritized in the treatment of the patient Seven in order to allow for further assessments and treatment. Controlling of the blood glucose levels is critical for the patient because further drop could result into more life threatening conditions associated with long-term uncontrollable diabetes mellitus such as total kidney failure, heart attack or stroke or organ failure (Schade 2001). The BSL (QID) of 8-10 depicted that the patient has uncontrollable diabetes, which need to be controlled first before further treatment. Control of the blood glucose level can be achieved putting the patient on a drip of 5 per cent dextrose with 10 units regular insulin, administered at the rate of 125ml/ hour. By so doing, the patient would be receiving 1.25 units of insulin and 6.25 gm of dextrose each hour (Manthappa 2008). This would ensure that the patient’s blood glucose is maintained at a reasonable level to avert any possible life threatening complications. However, this intervention should be accompanied by continued monitoring of the patient to ensure control of ketosis. The insulin dose should be adjusted according to the patient’s response to the blood glucose level control intervention. The rationale behind prioritization of blood sugar level control revolves around the complications associated with uncontrollable diabetes mellitus such as possible heart attack, coma, stroke, and increased infections. The reported tetraplegic informs the decision to ensure effective control of blood sugar levels in-patient Seven because failure to do so would probably elevate the tetraplegic condition to an anticipated stroke. The observed drowsiness could also be interpreted to imply significant drop in blood sugar levels hence the need to prioritize control of the blood sugar levels as one of the contributing factors to the patient’s current situation. Therefore, administration of the recommended drip would address the drowsiness problems in addition to prevention of further adverse diabetic complications. Since the patient MRSA care using vancomycin has been compromised by the development of resistance by the bacterial strain, the next step would be changing the medication to other antibiotics which the bacterial strain has not developed resistance such as linezolide (Zyvox) or synercid or daptomycin (Caroline, Elling & Smith 2012). Synercid or quinupristin/ dalfopristin combination has been particularly shown to offer activity against MRSA and vancomycin-resistant Enterococcus faecium (Rello, Lipman & Lisboa 2011). The drug has been approved by FDA due to its activity against infections associated with VRE and therefore should be administered to patient Seven in place of vancomycin. The gastro-oesophageal should be treated as one the contributing factors to either the infections or the uncontrollable diabetes. This is because, failure by the patient to eat due to the condition could contribute to the drop in blood sugar levels or lead to increase risk of bacterial infections due to reduced rectal emptying. The patient should administered with a prokinetic drug such as metoclopramide to address the problem of gastro-oesophageal sphincter function as well as increase gastric emptying to avoid accumulation of body waste material which contribute to increased bacterial infection (Joint Formulary Committee 2013). The rationale behind the focus on addressing the reported gastro-oesophageal reflex disease is to ensure effective intake of foods to nourish the body system as well as enhance gastric emptying to limit accumulation of body waste within delicate areas which have been operated (Joint Formulary Committee 2013). This would be one effective way of preventing infections from the vancomycin resistant bacterial strains. Prevention of further re-infection should be a major focus in the intervention to avert development further bacterial strain resistance to the recommended medication. The patient’s gastro-oesophageal reflex condition could also be improved through nursing interventions including encouragement of life style change and positioning of the position such as raising the head of the bed (Jacob 2012). With the patient’s infections mainly associated with the various interventions aimed at improving and the kidney and urinary system performance, treatment of the patient should be followed by antibacterial and viral prevention measures including administration of medications capable of controlling any bacterial infections. It is important to note that the patient’s immune system may have been weakened by the various procedures and conditions exposed to the patient hence the need for interventions aimed at strengthening the patient’s immune system (Gilbert et al. 2009). This should entail nursing intervention for preventing cross-contaminations during delivery of patient’s care and promotion of high hygienic standards. On the other hand, the patient could also be provided with nutritional guidelines aimed at boosting the patient’s immune system In order to address pressure areas as a major risk to Patient Seven’s wellbeing, several nursing interventions should be adhered to including frequent and accurate monitoring for signs of inflammation, broken skin and signs of poor blood flow in all areas of the patient’s body. Checking of skin temperature for different parts of the body could also assist in identifying the pressure areas. A thorough record should be maintained to ensure that none of the identified pressure areas are left unattended. Nurses should ensure position change as frequent as after every two hours. Improvement or changes on these parts should be noted to assist in further interventions if necessary. Nurses could also consider massaging the patient’s pressure areas to improve blood or fluid circulation to and from such areas. Other nursing interventions include keeping the bedline straight or sitting the patient upright in a chair to avoid unnecessary pressure on some vulnerable areas and proper maintenance of the patient’s skin through application of lotion as well as keeping the skin sample enough to avoid skin breaks (Kyriacos, Khanyile, Duma & Puoane 2008). Lastly, the patient should be educated on the various ways of preventing the various complications identified including the infections and pressure areas as well as understanding her condition. This could be achieved through supply of interesting reading materials on the health condition, open discussions, and videos. Lastly, the patient should be kept under close monitoring to identify and further complications from the already performed interventions. The recommended place should be continued admission in the high value care until significant improvement is observed. Conclusion Patient Seven’s infection with the resistance bacteria strains could be associated with previous treatment including the uncontrollable diabetes mellitus, percutaneous nephrolithotomy, the long-term suprapubic catheterization, and trasurethral resection of the prostrate, which increase the risk of infection and drug resistance development. Controlling of the blood glucose levels is critical for the patient because further drop could result into more life threatening conditions associated with long-term uncontrollable diabetes mellitus such as total kidney failure, heart attack or stroke or organ failure. Control of the blood glucose level can be achieved putting the patient on a drip of 5 per cent dextrose with 10 units regular insulin, administered at the rate of 125ml/ hour. The next step would be changing the medication to other antibiotics which the bacterial strain has not developed resistance such as linezolide (Zyvox) or synercid or daptomycin. Nurses could also consider massaging the patient’s pressure areas to improve blood or fluid circulation to and from such areas. Other nursing interventions include keeping the bedline straight or sitting the patient upright in a chair to avoid unnecessary pressure on some vulnerable areas and proper maintenance of the patient’s skin through application of lotion as well as keeping the skin sample enough to avoid skin breaks. References Caroline, N, Elling, B & Smith, M 2012, Nancy Caroline's emergency care in the streets, Jones & Bartlett Publishers, New York. Gilbert, S et al. 2009, National kidney foundation’s primer on kidney diseases. Elsevier, Philadelphia. Huang, Z et al. 2013, ‘Extracorporeal shock wave lithotripsy of management of residual stones after ureterolithotripsy versus mini-percutaneous nephrolithotomy: a restrospective study.’ PLoS ONE, Vol.8, no. 6, 1-12. Jacob, E 2012, Medifocus guidebook on: gastroesophageal reflux disease. Medifocus_com Inc. New York. Joint Formulary Committee. 2013. British national formulary, Volume 65. Pharmaceutical Press. New York. Kyriacos, M, Khanyile, H, Duma, M & Puoane, M 2008, Fresh perspectives: fundamentals of nursing, Pearson South Africa, Johannesburg. Manthappa, M 2008, How to manage your diabetes and lead a normal life. Peacock Books, London. Rello, J, Lipman, J & Lisboa, T 2011, Sepsis management: PIRO and MODS. Springer, New York. Schade, S 2001, ‘The ultimate diabetes challenge: controlling the uncontrollable.’Lancet, Vol. 358, no. 1021, 1-3. Read More