Interdisciplinary Care

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RUA: Interdisciplinary Care

Student names, name, name, name, name

Chamberlain University College of Nursing

NR341: Complex Adult Health

Dr. Julia Vicente

Month, year

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Background Summary

Demographics

For this paper, we will be identifying our client as Mr. A. Mr. A is a 24 -year-old,

African-American male who lives at home with his parents and is a full-time college student.

History of Present Illness

Mr. A has a history of sickle cell anemia. The patient reported having been cut on his left

foot between four and five months ago. Two weeks before the patient’s visit to the hospital, he

experienced increasing pain on the sore and noticed it was now draining. Because of thi s, he

decided to go to the University of Miami Hospital (UMH). Apart from the pain and mild

swelling on his left foot, the patient denied having fever, sweating at night, or chills, shortness of

breath (SOB), diarrhea, chest pain, or dysuria. Mr. A also de nied having any pain similar to a

sickle cell crisis.

Relevant Past Medical/ Surgical, Family & Social History

The patient has a past medical history of Attention Deficit Hyperactive Disorder

(ADHD), gallstones, sickle cell anemia, and sickle cell disease . The patient also had undergone a

cholecystectomy and corpora cavernosa shunt once. The patient’s mother and father had sickle

cell traits. Also, the father had high blood pressure. One of the sisters also had sickle cell anemia

while his other sister and brother had sickle cell traits. The patient denies ever smoking or using

smokeless tobacco, drinking alcohol, or engaging in substance abuse. The patient states he

practices safe sex and is in a monogamous relationship.

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Admitting Diagnosis

Upon examination of the vital signs and test results, the patient was diagnosed with left

leg cellulitis with an abscess of the left foot. Mr. A was then admitted for the management of

purulent cellulitis, which is a skin lesion that is linked to purulent drainage.

Course of Current Hospitalization to Date

This case is of Mr. A, a 24-year-old male who had presented with a left foot sore. The

patient was examined by the admitting doctor and podiatrist. It was established that he had dry

eschar on his left ankle that had not healed for months. Podiatry diagnosed him with left leg

cellulitis and put him on antibiotics, ointment, and pain management drugs.

Significant Assessment

Chief

Complaint

CNS and PNS

assessment

Airway

and lungs

Mental and

Neurological status

Vital Signs

Pain and

swelling of the

ankle. No fever,

chills,

diaphoresis, or

fatigue, chest

pain, and

palpitation.

Cardiovascular: normal

rate, no gallop, no

friction rub, or murmur

heard.

No falls, abdominal

pain, diarrhea, heartburn,

nausea, or vomiting.

Unlabored

and even

breathing,

no

adventitious

sounds

noted.

No depression, or

suicidal ideas, no

headache, weakness,

or dizziness.

BP 102/47

HR 62 BPM

Temp 98.3° F

RR: 15 BPM

SpO2: 99%

Laboratory and Diagnostic Tests

A CBC was done to assess leukocytosis. The high WBC count was indicating an

infection. The second observation from the CBC was normocytic anemia indicated by a low

number of RBC at 2.08 (L). The patient’s ESR was also elevated (58) indicating a severe

infection. The patient was also a bit hypotensive with a Blood Pressure of 102/47.

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With the CBC pointing to severe infection, X-ray was necessary to determine the area of

lucency. The X-ray results indicated the presence of lucency in the medial soft tissues implying

two things: a focus of subcutaneous emphysema or soft tissue defect. The finding was

complemented with a physical exam, which revealed that the soft tissues of the medial ankle had

swelled. Neither cortical destruction nor aggressive periosteal reaction was noted to indicate

evidence of acute osteomyelitis. There was also no dislocation or fracture. The ankle mortise was

intact on all non-stress views. All this information determined a soft tissue defect with a length

of 1.8 cm with both hypervascularity and surrounding subcutaneous edema, suggesting cellulitis.

Medications

The patient’s medications include acetaminophen-codeine, collagenase, enoxaparin,

sulfamethoxazole-trimethoprim, and vancomycin. The dosage for acetaminophen-codeine is

300/30mg PO q6hr PRN for pain. Acetaminophen (Tylenol) is an antipyretic/ nonopioid

analgesic used for the treatment of mild pain and fever when administered orally (PO) or

rectally. Major adverse effects include hepatotoxicity in high doses, acute generalized

exanthematous pustulosis, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Nurses

must assess overall alcohol usage before administration, assess the amount, frequency, and type

of drugs taken at home, assess pain and fever throughout therapy, and monitoring for increased

serum bilirubin, LDH, AST, ALT, and PTT that may indicate hepatotoxicity. Codeine is mainly

used for the management of mild to moderate pain. Adverse effects can consist of confusion,

sedation, hypotension, constipation, nausea, and vomiting. Nurses must assess BP, pulse, and

respiration before and periodically throughout treatment and assess pain before and one hour

after administration.

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Collagenase (SANTYL) ointment is an enzyme used for debriding chronic dermal ulcers.

There are no major adverse effects noted except for hypersensitivity when used over one year in

combination with cortisone. Nursing implications include assessing skin integrity and removing

excess skin with forceps and scissors before application.

Enoxaparin (Lovenox) 40mg SC daily is a low molecular weight heparin used for the

prevention of venous thromboembolism and/or pulmonary embolisms, prevention of ischemic

complications from unstable angina and non-ST elevations, and treatment of acute ST-segment

elevation MI. Enoxaparin is given to this patient for prophylactic purposes. The two major

adverse effects include bleeding and anemia. Major nursing implications include assessing for

signs of bleeding and hemorrhage and monitoring for toxicity.

Sulfamethoxazole- trimethoprim (Bactrim) 800/160 PO BID is a sulfonamide given to

this patient for the prevention of a bacterial infection and can also be used for bronchitis,

Shigella enteritis, otitis media, Pneumocystis jirovecci pneumonia (PCP), and UTIs. Major

adverse effects include Clostridium difficile-associated diarrhea (CDAD), hepatic necrosis,

erythema multiforme, agranulocytosis, and aplastic anemia. Some key nursing implications

include monitoring bowel function, assessing for rash throughout therapy, and monitoring labs

including CBC and UA periodically.

Vancomycin (Vancocin) 1,250mg in sodium chloride 0.9% 250mL IVPB q12hr is an

anti-infective used intravenously for the treatment of life-threatening infections (staphylococcus

in particular) and soft tissue infections like for our patient. The two major adverse effects are

nephrotoxicity and phlebitis. Major nursing implications are observing for anaphylaxis,

monitoring the IV site closely, and monitoring for toxicity signs.

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Nursing Diagnoses

Our first diagnosis is impaired tissue integrity related to infection as evidenced

by painful non-healing sore with purulent drainage. The diagnosis was made from the CBC

results showing that both the ESR and WBC levels were high: an indication of severe bacterial

infection (Chahine & Sucher, 2015). The X-ray also showed there was a soft tissue defect with a

length of 1.8 cm with both hypervascularity and surrounding subcutaneous edema.

Our second nursing diagnosis for Mr. A is Ineffective Tissue Perfusion related to

interruption to venous flow as evidence of non-healing sore for several months in the lower

extremity. The patient’s medical diagnosis of sickle cell is a major component of the patient’s

sore not properly healing along with the hypotension indicative of ineffective tissu e perfusion.

Mr. A was also experiencing decreased blood flow to the sore which is the purpose for our third

nursing diagnosis: risk for shock.

Nursing Diagnosis Expected Outcomes Collaborative

interventions

Nursing interventions

Impaired Tissue

Integrity related to

infection as evidence

by painful non-

healing sore with

purulent drainage

-Reduced pain and

swelling on the left foot by

the end of shift.

-Healing of the wound by

discharge.

-Elimination of infection

(cellulitis) by discharge.

-Change of medications

or dosage.

-Opening and draining

of abscess and pus.

-Decisions on

admissions and

discharge.

-Keeping a sterile

environment, especially

when changing the

dressing.

-Providing wound care.

-Monitoring signs of

complications.

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Ineffective Tissue

Perfusion related to

interruption to

venous flow as

evidenced by non-

healing sore for

several months in the

lower extremity.

-Maintain tissue perfusion

to organs throughout

treatment.

-Sore will show signs of

healing by discharge

-Will not experience

further complications such

as respiratory distress by

discharge.

-Provide oxygen therapy

as needed

-Foot care and education

from Podiatrist

-Administering

antibiotics and fluids to

promote better perfusion

and to regulate blood

pressure.

-Assist with position

changes

-Perform active Range

of Motion exercises to

promote circulation.

-Educate the client to

rest and encourage them

drink fluids to prevent

sickle cell crisis.

Risk for shock

related to a decrease

in venous and/or

arterial blood flow

-Show signs of adequate

perfusion by discharge.

-Maintain vital signs stable

within 1 hour of

administration of

medications.

-Maintain urine output

greater than 0.5 mL/kg/hr

by discharge.

-Administer oxygen to

maintain O2 saturation

above 90%

-Administer antibiotics

-Prepare for the

placement of an

additional IV line,

central line, and/or a

pulmonary artery

catheter if prescribed

-Monitor circulation

status and serum lactate.

- Monitor trends in

noninvasive

hemodynamic

parameters

-Educate the client and

family on symptoms of

low blood pressure

Interventions: Routine Nursing Management

Administering Medication

Normally, after the prescriptions are given, the nurse has the job of administering them.

In this case, the patient was put on several medications, such as continuing IV vancomycin

15mg/kg every 12 hours and for DVT prevention, he was placed on enoxaparin 40mg every 24

hours. The nurse was administering the IV medications while educating Mr. A on the importance

of following the medication regimen. This is vital since the main drugs were antibiotics requiring

strict adherence.

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Physical Care

The physical care needed for the cellulitis included dressing changes and raising the

affected leg above the level of the heart. The nurses were to clean the wound and apply

collagenase (Santyl) ointment. The ointment helps in the healing of Mr. A’s wound after

breaking up and removing the affected tissues.

Monitoring of Progress

The nurses are expected to continuously monitor the progress of the infection, pain, and

any discharge from the patient’s wound. Monitoring enables appropriate adjustments to be made

for quick recovery.

Interdisciplinary Care: Collaborative Management

Admitting Doctor

The MD on call examined Mr. A just after his admission to the hospital on October 27 th.

He identified the problems, including the dry eschar that had not healed, tenderness on palpation,

and strong dorsalis pedal pulses. The doctor requested for a podiatry evaluation and later

discussed the appropriate antibiotic medication with the podiatrist. The doctor also documented

the history of the patient’s illness, past medical history, a review of the systems, physical

examination, and interpretation of the CRC and X-ray results, giving a diagnosis along with

orders to be fulfilled and medications to be administered.

Podiatrist

The podiatrist ordered the X-ray and evaluated if the patient needed debridement and/or

deep tissue sampling. This doctor also approved the need for antibiotics.

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Certified Radiologic Technologist

The certified radiologic technologist performed the x -ray, the MRI without contrast, and

CRC. These results enabled the medical doctors to narrow down on the most probable diagnoses.

Nurses

Nurses are the managers of patient care in the hospital. The nurses are in charge of

administering medications, providing physical assistance to the patient, and directly monitoring

the patient’s progress. Aside from that, they were also involved in wound care. For monitoring of

progress, the nurses continuously watch the progress of infection, tenderness, pain, discharge,

laboratory values, and vital signs.

Interdisciplinary Care: Therapeutic Modalities

It is worth noting that there is one main therapeutic modality that is very important for

patients with cellulitis in which nurses are directly involved: adjunctive therapy. In this case, it

involves elevating the affected area above the heart. Unlike physicians, nurses are trained to use

an aggressive therapy approach to ensure the disease is managed. For instance, Tleyjeh et al.

(2014) observed that it has been made mandatory for nurses to promptly treat tinea pedis among

those with cellulitis involving a lower extremity. The resolution of the infection lowers the

possibility of recurrence of lower extremity cellulitis. Although the management of the disease

includes pharmacologic interventions, non-pharmacological interventions, such as massage

therapy and compression stockings, are also initiated throughout.

Nurses are trained to drain abscesses as soon as they are identified. As they do this

procedure, they also obtain a culture. When the draining is done adequately for a wound whose

diameter is below five cm, the patient may not have to be put under systemic antibiotics, except

in cases of presence of significant cellulitis (Tleyjeh et al., 2014). However, it must be

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acknowledged that for nurses to implement optimal therapy, the laboratory technologists have to

be competent in their tests after which the results should also be accura tely interpreted by the

physicians. It would require the accurate use of modern technologies in the laboratories as well

as other procedural tools. Therefore, the skills of a clinician or physician in patient evaluation

would end up affecting the effectiveness of patient therapy by nurses.

Nursing Role Reflection

Communication Style Preferences

One of the most effective styles of communication that have been embraced within the

healthcare system is interdisciplinary team rounds. It involves various healthcare professionals

coming together in their observation of patients during which they can conclusively address all

queries from both a patient and their families. The approach has been shown to eliminate errors

resulting from miscommunication between healthcare professionals (Gausvik et al., 2015).

Nurse-physician communication has been associated with positive patient outcomes. The

interactions are based on tools, such as the SBAR (situation, background, assessment, and

recommendation), which provides the required structure for the communication. When structured

well, interdisciplinary bedside rounds give rise to a validated structure for interdisciplinary

communication while bringing together various bedside care providers with an emphasis on the

inclusion of both the patient and family.

Impact of Own Communication Style on Others

One of the impacts of communication style amongst one-another is the preference for

face-to-face communication instead of a telephone conversation. Hence, why sometimes nurses

and general physicians have miscommunication over the phone.

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System Barriers and Facilitators

One of the barriers to quality care has been errors emanating from negative perception

and related miscommunication among healthcare providers. A good example is the complaint by

specialists that referrals written by GPs are always shallow and complaints by GPs that their

queries are not sufficiently addressed by specialists (Gausvik et al., 2015). The perception creates

a back and forth conflict that hinders the timely provision of healthcare services. Hospitals that

have embraced an interdisciplinary approach to healthcare provision have greatly managed to

improve the quality of their healthcare.

Recommendations to the Organizational Systems

One of the sure ways of enhancing interdisciplinary collaboration is by training

healthcare providers in written communication. A study by Vermeir et al. (2015) noted that

written communication has remained the most common communication means between primary

and specialized care, and training on basic communication skills can greatly improve

interdisciplinary collaboration in a healthcare setup. Another study by Kreps (2016) , stressed on

the need for healthcare facilities to embrace structured interdisciplinary bedside rounds, wh ich

provides a good structure for interdisciplinary communication.

Personal Plan

We can all benefit from fortifying our communication skills. We consider communication

the foundation for our effectiveness and growth as healthcare providers based on the rol e it plays

in enabling us to benefit from the experience of other specialists in our field.

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References

Ackley, B. J., Ladwig, G. B., & Flynn Makic, M. B. (2017). Nursing Diagnosis

Handbook: An evidence-based guide to planning care (11th ed.). Elsevier.

Chahine, E. B., & Sucher, A. (2015). Skin and soft tissue infections.

https://www.accp.com/docs/bookstore/psap/2015B1.SampleChapter.pdf

Davari, M., Khorasani, E., & Tigabu, B. M. (2018). Factors influencing prescribing decisions of

physicians: A review. Ethiopian Journal of Health Science, 28(6), 795–804.

Gausvik, C. (2015). Structured nursing communication on interdisciplinary acute care teams

improves perceptions of safety, efficiency, understanding of care plan and teamwork as

well as job satisfaction. Journal of Multidisciplinary Healthcare, 8(1), 33-37.

Kreps, G. L. (2016). Communication and effective interprofessional health care teams.

International Archive of Nursing Health Care, 2 (51). doi: 10.23937/2469-5823/1510051

Sullivan, T., & Barra, E. (2018). Diagnosis and management of cellulitis. Clinical Medicine,

18(2), 160–163. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303460/

Tleyjeh, I.M., Burdette, S.D., & Baddour, L.M. (2014). Cellulitis.

http://www.antimicrobe.org/new/e1.asp

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., Hallaert, G.,

Van Daele, S., Buylaert, W., & Vogelaers, D. (2015). Communication in healthcare: A

narrative review of the literature and practical recommendations. International Journal of

Clinical Practice, 69(11), 1257–1267.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758389