I nеed tо respоnd to 3 of mу clаssmates dіscussion post with at least 250 words. I need to add on to the discussion to further the discussion by adding information.. maybe state what you thought was interesting and add information to further discussion.
Original discussion that we needed to respond on “Fiona is a 49-year-old female who experienced a spinal cord injury 20 years ago which resulted in paraplegia. She is being admitted to the unit today with sepsis. The sepsis is from an infected pressure ulcer on her buttocks. She has had multiple admissions for the same problem over the last couple of years.
A wound culture was done and the results showed MRSA present in her wound.
Her present orders include:
Vancomycin 1g IV every 12hours via newly inserted PICC (peripherally inserted central catheter) Vancomycin peak and trough with third dose
Gentamycin 80mg IV every 8 hours
The third dose of Vancomycin is due on your shift.
So what would you do for Fiona?
Be sure to address:
What assessments will be important for Fiona?
How will you carry out these orders?
How do you administer Vancomycin and Gentamycin? Why are both of these ordered?”
What I am going to do for this patient is check her vitals and temperature often. I am also going to position her so that pressure is off pressure ulcer so the area can get good perfusion and blood flow so it can start healing. “Changing a patient’s position in bed every 2 hours helps keep blood flowing. This helps the skin stay healthy and prevents bedsores.” (medlineplus.org) I will make sure the dressings get changed often and when bandages are wet and keep wound clean and dry at all times. This will help prevent the infection from getting worse and promote healing. The assessments I would do is frequent wound check charting color, drainage, wetness, odor, redness, formation of granulated tissue, debridement, and size. I would also check temperature, vitals, and make sure the patient is repositioned every 2 hours. When we sit for periods of time we are changing our positions all the time without even noticing it. Since the patient is a paraplegic she cannot do that and she can’t feel when there is too much pressure on her bottom and its time to move. That is why theses patients have problems with pressure wounds.
MRSA is a type of bacterial infection that typically affects the skin. This infection commonly occurs at sites of visible skin trauma ,such as cuts and abrasions, and areas of the body covered by hair such as the back of the neck, groin, buttocks, armpits, or beard area of men. MRSA is a contagious infection and is spread by direct skin-to-skin contact with an infected person or by touching a contaminated surface. Treatment typically involves antibiotics.(bacteria.emedtv.com) Since MRSA can be spread by direct skin-to-skin contact or by touching a contaminated surface I would make sure that the patient is on contact precautions, there is a sign on the patients door to alert anyone who enters her room, correct PPE is worn at all times, proper hand hygiene is used, and disinfect contaminated areas. I would educate the patient on why these rules have to be in place and that if she were to leave her room that she will also need to wear PPE so the infection does not spread.
Before administering the antibiotics it is important to get blood samples, tissue samples, and culture swabs. Laboratory tests may include examination of urine, stool, spinal fluid, sputum, blood, or purulent drainage for microorganisms. Organisms isolated from the specimens are grown in the laboratory and identified. After identification, the laboratory tests different antibiotics to determine which is most effective against the infecting -microorganism. This process of growing the pathogen and identifying the most effective antibiotic is called culture and sensitivity (C&S) testing. Other laboratory ¬techniques include examination of the blood for specific antibodies, direct antigen detection, and DNA probe hybridization. Because antibiotic therapy alters the composition of infected fluids, samples should be collected prior to starting pharmacotherapy. However, laboratory testing and identification may take several days and, in the case of some viruses, several weeks. If the infection is severe, therapy is often begun with a broad-spectrum antibiotic, one that is effective against a wide variety of different microbial species. After laboratory testing is completed, the drug may be changed to a narrow- spectrum antibiotic, one that is effective against a smaller group of microbes or only the isolated species. In general, narrow-spectrum antibiotics have less effect on normal host flora, thus causing fewer side effects. For mild infections, laboratory identification is not always necessary. (Pharmacology for Nurses)
In treating complicated MRSA infections, many clinicians combine vancomycin with another agent, such as gentamicin, in the expectation of a more rapid bacteriologic response based on a synergistic interaction between the two antibiotics. A standard time-kill method was used to study the interaction between vancomycin and gentamicin for HLGR and non-HLGR strains of MRSA. They set up the MRSA bacteria with the same colony count in each dish. One dish had no antibiotic for the control, one had vancomycin, one had gentamicin, and the last had vancomycin and gentamicin. Counts where made at 0, 4 and 24 hours they looked at each dish and found that the most bacteria that had been killed off and the fastest was the one with the vancomycin and gentamicin. They also found that 9 strains of the bacteria were resistant to gentamicin but other stains were not. Vancomycin in result the best treatment, but if used with gentamicin on the strains that are not resistant it can more rapidly kill the infection. That is why they give both together. (aac.asm.org)
Vancomycin solution, used intravenously is indicated in the therapy of severe, potentially life- threatening infections due to susceptible gram-positive microorganisms which cannot be treated with or failed to respond to other effective, less toxic antimicrobial medicinal products, such as penicillins and cephalosporins. Vancomycin powder for solution for infusion must be administered intravenously. Each dose should be administered at a rate not exceeding 10 mg/min or over a period of time of at least 60 minutes. Adults and adolescents above 12 years of age recommended daily intravenous dose is 2000 mg, divided into doses of 500 mg every 6 hours or 1000 mg every 12 hours.(medicines.org.uk) Gentamicin is normally given by the intramuscular route, but can be given intravenously when intramuscular administration is not feasible. When given intravenously, the prescribed dose should be administered slowly over no less than 3 minutes directly into a vein or into the rubber tubing of a giving set. Rapid, direct intravenous administration may give rise, initially, to potentially neurotoxic concentrations and it is essential that the prescribed dose is administered over the recommended period of time. Alternatively the prescribed dose should be dissolved in up to 100 ml of normal saline or 5% glucose in water, but not solutions containing bicarbonate and the solution infused over no longer than 20 minutes. The daily dose recommended in children, adolescents and adults with normal renal function, is 3-6 mg/kg body weight per day as 1 preferred up to 2 single doses. (medicines.org.uk) How do you do a vancomycin peak and trough blood level?
Do not draw specimens until steady state is achieved. Draw sample before fourth dose.
Draw trough specimen immediately before ?30 min next dose.
Draw peak specimen 1-2 hours after completion of intravenous dosage.
The patient has a picc line so it is ok to use to draw the same off. Just make sure you are drawing off the opposite port from where the medication is infusion. Make sure the infusion is off prior to drawing the blood so the sample does not get contaminated by the medication. Flush really good and draw 5-10 mls of blood as a waste prior to getting the actual sample. It is also important to watch the picc line for any signs of infection. Picc lines can be a big source of infection so it is important to keep them very clean and watch them close.Discussion 2:
Sepsis is a serious life-threatening response to infection with the threat of tissue damage, organ failure and death is imminent if not treated right away. Sepsis is a very hard to predict, diagnose and treat. The treatment can be prolonged and can be costly. MRSA also known as Methicillin Resistance Staphylococcus aureus which is gram positive bacteria.
As nurses we must be proactive and try to prevent measures to stop MRSA from becoming septic. Some ways are
–Meticulous hand washing between patient cares.
-Cleaning medical equipment with appropriate disinfectants.
-Patients with MRSA should never be in the same room with a surgical patient. Personal protective equipment must be worn to prevent the spread of MRSA. Visitors and family should be educated on the disease as well. Persons who enter the room must wash their hands before/after post cares or visitations.
As the admitting nurse I would make sure that my staff know that Fiona will be on isolation precautions due to MRSA. Set the patient room specific to the isolation with appropriate disposal of linen and garbage disposal. Also making sure that she has her own vital equipment. As Fiona enters the unit baseline vitals will be obtained. A head to toe assessment to be completed along with history, allergies and antibiotic history. Obtaining a blood and wound cultures at this time is also important for initiating wound care. An in house wound care personal should also be accessed to aide with treatment. Staff should all be proactive to assist with repositioning and turning to prevent further complications or breakdown of skin. It is also imperative to do a hearing test prior to antibiotics due to hearing loss or ringing of the ears.
How will you carry out these orders?
Fiona will have I.V. antibiotics through her PICC line. Assessment of her PICC line is also vital. Vancomycin is an antibiotic to treat gram positive bacteria. The reference range for vanco trough levels 10-20 up/mL. The reference range for peak is 25-50 up/mL. The PICC line is a catheter that is positioned in the large vein that carries blood into the heart which is commonly used for long term antibiotic administration. The PICC should be assessed for signs and symptoms for infection at the insertion site. It should be flushed before and after administration. Dressings should be changedweekly or as needed if soiled or loose.
A peak and trough is the key to administration of how much of the medication she will receive. Administration should be given slow to prevent nephrotoxicity. Fiona should be monitored for abdominal pain, nausea, bloating, swelling of the face, extremities, bloody urine, convulsions, dry mouth, fever, irregular heartbeat, SOB and loss of appetite.
Why are these ordered?
Gentamycin and Vanco combination may be useful in the presence of the complicated wound. These medications work synergistically against PCN resistant pneumococci. Per orders noted the Vanco will be given via PICC and Gentamycin will be infused with IV over 8 hours.
Individuals with spinal cord injuries are at increased risk for the development of pressure ulcers (Dana, 2015). This will put them at a higher risk of receiving infections due to prolonged healing of wounds. Methicillin-resistant Staphylococcus aureus (MRSA) is associated with difficult-to-treat infections and high levels of morbidity (Green, 2012).
1. So, what would you do for Fiona? What assessments will be important for Fiona?
I would first do a head to toe assessment. I would check all her vitals, ask for pain rating, and I would ensure to do a full skin assessment due to this patient being immobile. I would assess the patients pressure ulcer on her buttocks during my assessment. If Fiona has not been placed on contact precautions already, I would implement this due to diagnosis of MRSA. Due to the open pressure ulcer on her buttocks I would ensure the patient is being turned every two hours. During her turnings I would be checking the buttocks and ensuring she is clean and not soiled. For this patient throughout my shift I would continue to monitor for signs and symptoms of adverse effects, and worsening sepsis. Side effects of vancomycin include wheezing, red man syndrome, low blood pressure, hives, itching, and dizziness. Side effects of gentamicin include nausea, vomiting, loss of appetite, hearing loss, and dizziness. For this patient I would watch closely for deterioration signs. Oxygenation changes are one of the earliest signs of deterioration in sepsis patients. Signs could include, respiratory rate rises, pulse oximetry values decline, lessened urine output, worsening dehydration, poor skin turgor, dry mucous membranes, and a decline in mental status.
2. How will you carry out these orders?
Because the third dose of vancomycin is due on my shift, I would carry out the order of obtaining vancomycin peak and trough levels. I will obtain the trough collection directly before the third dose is given. Trough concentrations should normally be checked prior to third dose (Martin, 2010). And I would draw the peak level between one and two hours after IV infusion has completed. I would monitor for signs and symptoms of toxicity from the two ordered medications.
3. How do you administer Vancomycin and Gentamycin?
The order is vancomycin 1g every 12 hours via newly inserted PICC line. And gentamycin is ordered for 80 mg IV every eight hours. I would administer Vancomycin through the PICC line, and I would administer Gentamicin through the IV. I would look in the chart to see when both doses were last given to make sure I’m administering the next doses at the correct time on my shift. I would ensure I had done proper hand hygiene and put on gloves. Before administration I would clean the port where the medications are being administered on both the PICC and the IV. I would flush the IV with normal saline before and after administration. For the PICC I would follow the SASH acronym. This stands for, saline flush, administer medication, saline flush, then heparin flush. If the patient’s condition permits, heparin in low concentrations is helpful in closing off the catheter after completing the medication infusion (Randolph, 2008). Heparin helps prevent clot formation within the catheters lumen, a PICC line has on average fifty to sixty-five cm of length where a clot can develop.
4. Why are both of these ordered?
Vancomycin is often combined with a second antibiotic, most often rifampin or gentamicin, for the treatment of serious methicillin-resistant Staphylococcus aureus infections. Intravenously administered vancomycin is the drug of choice for the treatment of MRSA infections. Treating complicated MRSA infections, many doctors will combine vancomycin with another agent such as gentamicin. The doctor would expect a more rapid bacteriologic response based on synergistic interaction between the two antibiotics (Green, 2012). Both these medications are ordered to better the chance of treating the MRSA.
Originally posted 2017-10-23 18:35:09.