Management of Hyperkalemia, Diabetic Foot, Pharmacological Management of Osteomyelitis, the Non-Pharmacological Interventions - Case Study Example

Case Study Author’s Name: Instructor’s Name: Course Details: Institutional Affiliation: Date of Submission: Question One: Hyperkalemia is characterized by the increase in the amount of potassium level in serum above 5.5 mEq/L. The balance between intracellular and extracellular levels of potassium is maintained by the Na-K-ATPase enzymes. The enzymes pump potassium into the cell and sodium out of the cell hence maintain the serum potassium concentration between 3.5-5.3 mmol/L. The condition is often common in patients with diabetes. In diabetics, the condition often results from Polyuria or diabetic ketoacidosis. Polyuria is common in diabetic patients. In Polyuria, Patients loose potassium through urine. Insulin is essential in the management of diabetes. Without insulin or increased bodily demands of insulin such as the occurrence of osteomyelitis in this patient, the patients develop severely elevated blood glucose level. Lack of insulin and increased bodily demands for insulin causes the breaking down of fat cells and proteins. The increased breakdown of fats and proteins leads to diabetes ketoacidosis. As a result, ketones are released into the blood stream hence increasing the acidity levels (Nyirenda et al., 2009). The already elevated blood glucose levels together with the ketoacidosis bring about the outward movement of fluids and potassium out of the cells into the blood stream (Cheer et al., 2009). The condition is further worsened in the patients with diabetes since they often have diminished kidney capacity to excrete potassium into urine. The diminished capability to excrete potassium into urine and the outward shift of potassium from cells into the blood stream is what leads to hyperkalemia (Nyirenda et al., 2009). Hyperkalemia is a priority in this patient since it posses adverse effects. Some of the affects characterized by hyperkalemia include: Circulatory Defects: Potassium is essential in the electrical conductivity of the heart. The heart muscles are able to contract and relax depending on the efflux and influx of the potassium ions. Hyperkalemia brings about abnormal functioning of the cardiac muscles by lowering their cell resting potential and hampering repolarization. Elevated levels of potassium lead to the occurrence of malignant cardiac arrhythmias. The arrhythmias lead to a disorderly blood flow (Nyirenda et al., 2009). Neurological Defects: Potassium is vital in the transmission of nerve impulses. The elevation of the potassium levels leads to altered or inaccurate signals being generated. Hence, neurological defects will be elicited. Some of the neurological defects include the muscle weakness and paralysis (Nyirenda et al., 2009). Management of Hyperkalemia: The management of hyperkalemia is aimed at shifting the potassium back to cells from the blood stream. The management of hyperkalemia can be done using exogenous administration of potassium (the use of supplements and maintenance iv fluids) or the use of medication that increase the levels of serum potassium such as the potassium sparing diuretics, angiotensin converting enzyme inhibitors and non steroidal anti inflammatory drugs (Chinari et al., 2009). The patient in the case study had a moderate elevation of the serum potassium levels. There management of the patient will be aimed at shifting the potassium ions intracellular. The management will entail: The use of potassium sparing diuretics such as IV furosemide 40-80 mg. The potassium sparing diuretics will reduce the amount of potassium that is lost through urine (Nyirenda et al., 2009). The patient will also be given 50 mEQ IV for over 5 minutes sodium bicarbonate. Sodium bicarbonate brings about the shifting of potassium from the extracellular to the intracellular compartment. Monitoring of the patients with hyperkalemia is done using the Echo cardiogram and the measuring of the electrolyte levels. When using the electrocardiogram, hyperkalemia is characterized by the high peaked T waves, depressed ST segments and a widened QRS complex (Nyirenda et al., 2009). Question Two: Diabetic foot is often preceded by osteomyelitis. Osteomyelitis is characterized by the infection of the bone. The infection ensues in diabetic foot as a result the development of ulceration on the foot. The ulceration brings about the removal of the protective epidermis hence exposing the wound to the environment. As a result, the ulceration is colonized by microorganisms. The most notable microorganism is staphylococcus aureus. The infection spreads from the ulceration site into the subcutaneous tissues and finally gets to the bone (Teh, 2009). The management of osteomyelitis can be broadly classified into pharmacological and non-pharmacological management. Until recently, most used form was the non-pharmacological means. However, with the advent of pharmacology the pharmacological option has proved to be more effective than the surgical option (Morbach et al., 2012). Pharmacological Management of Osteomyelitis: The pharmacological management of osteomyelitis is conducted after carrying out microbial studies. The areas infected are swabbed and the culture and sensitivity is conducted to identify the causative microbial agents. Knowledge of the respective microbial agents responsible for the infection is essential in choosing the most effective antimicrobial agent. The antimicrobial agent of choice should be effective in either limiting the multiplication of the microbes or totally lead to their elimination/death. Other factors that influence the choice of the antimicrobial agents include factors such as the mode of administration, the mode of action and spectrum of action, the dosage, and mode of excretion (Cecilia-Matilla et al., 2012). Mode of Administration: The choice of the antibiotic is greatly influenced by the mode of administration. The most effective antibiotic will be that which is able to achieve the desired therapeutic drug concentration at the site of infection. Mostly commonly used pharmacological agents are thus administered intravenously (Lipsky, 2012). Mode of Action: The drug of choice ought to be effective in eliminating or controlling the spread of the causative microbial agents (Malay, 2013). Dosage: The dosage of the drug is key in choosing the antimicrobial drugs. The antimicrobial agents ought to have the dosages which are will spread out to attain the desired serum level of the drugs (Edwards and Stapley, 2010). Mode of Excretion: The patients are likely to use the drugs for a longer duration. Hence, the choice of drug will be influenced by the mode of excretion. The drugs that are well excreted from the body are likely to be used since less toxicity will be achieved (Aragón-Sánchez et al., 2013). The Non-Pharmacological Interventions: The non-pharmacological interventions range from the use of surgical means, the hyperbaric chamber, revascularisation and oedema control (Copley et al., 2013). Surgical Management: The surgical management entails the identification of the magnitude of infection. The areas which have been infected are surgically removed. This will entail the conducting of surgical debridement as well as various forms of (Pääkkönen and Peltola., 2013). Hyperbaric Oxygenation: The use of hyperbaric chamber is aimed at increasing the supply of oxygen to the ischeamic tissues. The increased oxygen supply prevents the further spread of infection while at the same time improving wound healing (Navaneethan et al., 2009). Pharmacological Management: Pharmacological management is also used in the case study. Mr. Smith is administered with six hourly intravenous Cefazolin. The management with intravenous Cefazolin is based on the fact that the most common causative microorganisms for osteomyelitis secondary to diabetic foot is staphylococcus aureus. Cefazolin is more sensitive to the staphylococcal beta lactamase unlike most of the antimicrobial agents. In addition, very few microorganisms are resistant to Cefazolin. The dosage of Cefazolin is also advantageous since it is administered six hourly. Consequently, the serum half-life of Cefazolin is approximately 1.8 hours meaning that its pharmacological activity is begins a short while after administration. Furthermore, the use of Cefazolin results in limited toxicity since 70-80% of it is readily eliminated through urine. The administration of Cefazolin is also advantageous since it is not only effective in the management of both the infections to the soft tissues and bones (Cheer et al., 2009). QUESTION 3: Mr. Smith is a diabetic patient. Diabetic patients are prone to various complications since their condition lowers their immune system and increases chances of getting infections (Morbach et al., 2012). The most important educational aspect to Mr. Smith will be on foot care and maintenance of hygiene. Mr. Smith should be informed on the importance of attending to the routine podiatry care and foot assessment. Foot assessment is vital in diabetic care. It involves both patients and the professionals. Mr. Smith ought to check the feet every day and be able to identify cuts or ulcers as soon as they appear (Chinari et al., 2009). Information on Self Examination Tips and Maintenance of Hygiene: Mr. Smith will thus be equipped with information on self examination tips. Mr. Smith will also be informed on the best ways to maintaining hygiene and how to moisturize the skin effectively. At the same time, Mr. Smith will be made fully aware of the possible consequences that result from the neglect of the feet. Here, Mr. Smith will be acquitted with the knowledge of the possible complications and the ways they can be able to prevent them and detect them on time (Cheer et al., 2009). Mechanical Interventions Preventing Further Ulceration of the Foot: The occurrence of the ulcers precipitates the setting in of complications such as osteomyelitis. However, there are various mechanical interventions that Mr. Smith can be made aware off that prevent ulcers from forming. Consequently this prevents the infection of bone from taking toll. Some of the mechanical interventions include the use of use of appropriate foot (Pinzur and Belmares, 2012). Taking of Antibiotics to Prevent and Manage Infections: Mr. Smith ought to comply with the prescriptions which have been given to them. In addition, Mr. Smith s ought to be informed of how the medication can be made more effective and the possible repercussions of not adhering to the prescriptions (Copley et al., 2013). Control of Blood Sugars: Control of blood sugars in diabetic patients is essential. Mr. Smith s ought to be made aware of the complications that arise as a result of poor management of the sugar levels (Lipsky, 2012). Mr. Smith also needs to be advised on how to effectively monitor their diet and how to adhere to the sugar control regiments (Hall, 2011). References Nyirenda, MJ., Tang, JI., Padield, PL., Seckl, JR., (2009). Hyperkalemia. British Medical Journal; 339. Cheer, K., Shearman, C., and Jude, EB., (2009). Managing complications of the diabetic foot. National Institute for Health and Clinical Excellence. British Medical Journal; 339: 1304-07. Chinari, P., Subudhi, k., Chadwick, p., (2009).Infection specialist input in management of diabetic foot infections. British Medical Journal; 339: 1304-07. Teh, J., (2009). Consultant radiologist, Tony Berendt, consultant physician, Benjamin A Lipsky, professor of medicine. Rational Imaging .Investigating suspected bone infection in the diabetic foot. British Medical Journal: 339:1205-34. Hall, M., (2011). A quarter of diabetic patients miss out on annual foot checks, UK survey warns. British Medical Journal. 18.11.2011 p.1020. Morbach, S., Furchert, H., Gröblinghoff, U., Hoffmeier, H., Kersten, K., Klauke, GT., (2012). Long-Term Prognosis of Diabetic Foot Patients and Their Limbs: Amputation and death over the course of a decade. Diabetes Care. Medscape. Pinzur, S., and Belmares, J., (2012). Treatment of Osteomyelitis in Charcot Foot with Single-Stage Resection of Infection, Correction of Deformity, and Maintenance with Ring Fixation. CINAHL. Cecilia-Matilla, A.,Lázaro-Martínez, J., Aragón-Sánchez, J., García-Morales, E.,García-Alvarez, Y.,Beneit-Montesinos, J., (2012). Histopathologic characteristics of bone infection complicating foot ulcers in diabetic patients. CINAHL. Lipsky, B., Berendt, A.,Cornia, B., Pile, James C,Peters, Edgar J G,Armstrong, David G,Deery, H Gunner,Embil, John M, Warren J., Karchmer, S., Adolf, W.,Pinzur, M., Senneville, E., (2012). Infectious Diseases Society of America Clinical Practice Guideline for the diagnosis and treatment of diabetic foot infections. CINAHL. Malay, D., (2013). Osteomyelitis and the Tarnished Gold Standard. CINAHL. Edwards, J., Stapley, S., (2010). Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews. Aragón-Sánchez, J.,Lipsky, A.,Lázaro-Martínez, J., (2013). Gram-Negative Diabetic Foot Osteomyelitis: Risk Factors and Clinical Presentation. CINAHL. . Copley, L., Kinsler, M., Gheen, T.,Shar, A., Browne, R., (2013). The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis. CINAHL. Pääkkönen, M., Peltola, H., (2013). Bone and Joint Infections. CINAHL. Navaneethan, SD., Nigwekar, SU., Sehgal, AR., Strippoli, GF., (2009). Aldosterone antagonists for preventing the progression of chronic kidney disease. Cochrane Database Systemic Review. Read More