Unit XIII MDO PDF

4/29/2024 Chapter 21 Coordinating Care for Patients With Multidrug-Resistant Organism Infectious Disorders Copyright ©2024 F.A. Davis Company 1 Introduction  Contact  Airborne  Vehicle  Vector Copyright ©2024 F.A. Davis Company 2 MDRO Epidemiology  1.7 million hospitalized patients per year 98,...

4/29/2024 Chapter 21 Coordinating Care for Patients With Multidrug-Resistant Organism Infectious Disorders Copyright ©2024 F.A. Davis Company 1 Introduction  Contact  Airborne  Vehicle  Vector Copyright ©2024 F.A. Davis Company 2 MDRO Epidemiology  1.7 million hospitalized patients per year 98,000 (1/17) deaths  Increased with COVID-19 pandemic 65% increase in CLABSI in ICU 35% increase in VAE 43% increase in CAUTI Copyright ©2024 F.A. Davis Company 3 1 4/29/2024 Methicillin-Resistant Staphylococcus Aureus  Epidemiology 80% of staph aureus cultures Most common multi-drug resistant pathogen 70,000 severe infections with 9,000 deaths 68% acquire within 48 hours of hospitalization R/t poor antibiotic stewardship Copyright ©2024 F.A. Davis Company 4 Methicillin-Resistant Staphylococcus Aureus (continued_1)  Risk factors Hospitalization in last 12 months Soft tissue infection Hospitalization in intensive care Residing in a long-term care facility Immunosuppression Copyright ©2024 F.A. Davis Company 5 Methicillin-Resistant Staphylococcus Aureus (continued_2)  Pathophysiology Contact with pathogen Copyright ©2024 F.A. Davis Company 6 2 4/29/2024 Methicillin-Resistant Staphylococcus Aureus (continued_3) Copyright ©2024 F.A. Davis Company 7 Methicillin-Resistant Staphylococcus Aureus (continued_4)  Clinical manifestations Pneumonia Skin and soft tissue infection Bloodstream infection Copyright ©2024 F.A. Davis Company 8 Methicillin-Resistant Staphylococcus Aureus (continued_5)  Complications Increased morbidity and mortality Osteomyelitis Toxic shock syndrome Multisystem organ failure Copyright ©2024 F.A. Davis Company 9 3 4/29/2024 Vancomycin-Resistant Enterococci  Epidemiology Lower in western US than eastern US Higher incidence in larger teaching hospitals Lower incidence with hand-hygiene compliance Increased with poor antibiotic stewardship Pathophysiology ‒ Remain viable on environmental surfaces for 7 days to 2 months Copyright ©2024 F.A. Davis Company 10 Vancomycin-Resistant Enterococci (continued_1)  Risk factors Prolonged hospital stays Immunosuppressed Prolonged exposure to antibiotics Invasive procedures and devices Copyright ©2024 F.A. Davis Company 11 Vancomycin-Resistant Enterococci (continued_2)  Pathophysiology Direct contact from skin or patient care equipment Copyright ©2024 F.A. Davis Company 12 4 4/29/2024 Vancomycin-Resistant Enterococci (continued_3)  Clinical manifestations Urinary tract infections Peritonitis Bacteremia Wound infection Copyright ©2024 F.A. Davis Company 13 Vancomycin-Resistant Enterococci (continued_4)  Complications Vancomycin resistant S. aureus Prolonged hospital stay Prolonged antibiotic therapy Higher mortality Increased cost of hospitalization Endocarditis Copyright ©2024 F.A. Davis Company 14 Clostridioides Difficile  Epidemiology Most common cause of antibiotic-associated diarrhea 12% of all hospital acquired infections 50% of hospitalized patients are colonized 223,900 infections per year ‒ 12,800 deaths, 29,000 within initial diagnosis 80% of patients >65 years $4.8 billion annually in acute care Copyright ©2024 F.A. Davis Company 15 5 4/29/2024 Clostridioides Difficile (continued_1)  Risk factors Use of antimicrobials Age >64 years Immunosuppression Copyright ©2024 F.A. Davis Company 16 Clostridioides Difficile (continued_2)  Pathophysiology Spore-forming bacteria, gram + anaerobic bacillus Live on surfaces for months Oral-fecal transmission 3 ways patients exposed in hospitals ‒ Contact with health-care workers’ contaminated hands ‒ Contact with the contaminated environment ‒ Direct contact with a patient with a C diff infection Copyright ©2024 F.A. Davis Company 17 Clostridioides Difficile (continued_3)  Clinical manifestations Positive stool sample Diarrhea Copyright ©2024 F.A. Davis Company 18 6 4/29/2024 Clostridioides Difficile (continued_4)  Complications Volume depletion Renal insufficiency Electrolyte imbalance Hypoalbuminemia Peritonitis Paralytic ileus Toxic megacolon (rapid dilation of lg intestine) Fulminant pseudomembranous colitis Sepsis Death Copyright ©2024 F.A. Davis Company 19 Acinetobacter Baumannii  Epidemiology 17% to 26% of patients colonized with Acinetobacter in one or more sites may develop a clinical infection Copyright ©2024 F.A. Davis Company 20 Acinetobacter Baumannii (continued_1)  Risk factors Recent surgery Central venous catheters Tracheostomy Mechanical ventilation Enteral feedings Exposure to antimicrobials Vascular catheters in the respiratory tract Copyright ©2024 F.A. Davis Company 21 7 4/29/2024 Acinetobacter Baumannii (continued_2)  Pathophysiology Naturally inhabits water, soil, animals, and humans Recovered from human skin, throat, and rectum May colonize respiratory tract Can survive for weeks to months on surfaces Copyright ©2024 F.A. Davis Company 22 Acinetobacter Baumannii (continued_3)  Clinical manifestations Ventilator-associated pneumonia Bloodstream infections Copyright ©2024 F.A. Davis Company 23 Acinetobacter Baumannii (continued_4)  Complications Increased morbidity and mortality Increased ICU and hospital length of stay Increased ventilator days Copyright ©2024 F.A. Davis Company 24 8 4/29/2024 Management of Multidrug-Resistant Organisms  Medical management—Diagnosis Surveillance Cultures Copyright ©2024 F.A. Davis Company 25 Management of Multidrug-Resistant Organisms (continued_1)  Medical management—Treatment Hand hygiene Isolation Medications ‒ Correct antibiotic Copyright ©2024 F.A. Davis Company 26 Management of Multidrug-Resistant Organisms (continued_2)  Medical management—Medications  MSRA: Vancomycin Trough levels Nephrotoxic and ototoxic Can use Linezolid (bacteriostatic), equally effective as vanco. 14-28 days. If more than 10 days need to monitor CBC  VRE: difficult to treat resistant to PCN and ampicillin. Need susceptibility testing to treat  C-Diff: stop causative antibiotic. Oral vanco, probiotics, fecal microbiota transplantation Copyright ©2024 F.A. Davis Company 27 9 4/29/2024 Management of Multidrug-Resistant Organisms (continued_3)  Nursing management—Assessment and analysis  Look for typical signs of infection Fever Tachycardia Tachypnea Hypovolemia Diarrhea (C diff) Wound infections (MRSA) red, warm, purulent drainage Copyright ©2024 F.A. Davis Company 28 Management of Multidrug-Resistant Organisms (continued_4)  Nursing management—Nursing diagnoses Risk for deficient fluid volume Ineffective airway clearance Alteration in comfort Risk for perineal skin breakdown Impaired tissue integrity Impaired urinary elimination Acute pain Copyright ©2024 F.A. Davis Company 29 Management of Multidrug-Resistant Organisms (continued_5)  Nursing interventions—Assessments Vital signs Pain Oxygen saturation Skin turgor Urine output Wound or surgical site White blood cell count Serum creatinine level Electrolyte and albumin levels Bowel movement frequency and consistency Skin integrity Copyright ©2024 F.A. Davis Company 30 10 4/29/2024 Management of Multidrug-Resistant Organisms (continued_6)  Nursing interventions—Actions Hand hygiene Place patient on isolation precautions Administer antibiotics as ordered Administer fever reducer Administer pain medications Administer IV fluids as ordered Administer supplemental oxygen Administer chest physiotherapy Encourage early mobilization Copyright ©2024 F.A. Davis Company 31 Management of Multidrug-Resistant Organisms (continued_7)  Nursing interventions—Actions (continued) Stop administration of causative antimicrobial agent Perform wound care Cleanse perineum and apply moisture barriers Use fecal diversion or containment systems in the stool-incontinent patient Encourage family visits and the use of the telephone and television Copyright ©2024 F.A. Davis Company 32 Management of Multidrug-Resistant Organisms (continued_8)  Nursing interventions—Teaching Contact-isolation precautions Take medications as prescribed Clinical manifestations of infection Sun protection Copyright ©2024 F.A. Davis Company 33 11 4/29/2024 Management of Multidrug-Resistant Organisms (continued_9)  Nursing management—Evaluating care outcomes Take antibiotic regimen as ordered Prevention of recurring infection Copyright ©2024 F.A. Davis Company 34 Case Study: Episode 1 Joe Brown is a 76-year-old male patient who presents to his healthcare provider from his nursing home residence with a painful, red, swollen abdominal surgical wound that is warm to the touch and is draining pus. Joe had a cholecystectomy last week and is returning to his healthcare provider to get the staples removed. Joe has just finished his antibiotics. He takes metformin for his diabetes mellitus type 2 and is on Coumadin for atrial fibrillation. Copyright ©2024 F.A. Davis Company 35 Case Study: Episode 2 With a temperature of 100.5°F, and purulent drainage from the wound, the physician decides not to take out the staples at this time and admit him to the hospital. Mr. Brown’s abdominal wound is cultured. It is determined that he has an MRSA infection. His vital signs are: (BP): 110/66 (HR): 110; atrial fibrillation noted on ECG (RR): 18 (T): 100.5°F (38°C) Bedside blood glucose monitoring: 140 Copyright ©2024 F.A. Davis Company 36 12 4/29/2024 Case Study: Episode 2 (continued_1) Because of his history of diabetes and the presence of atrial fibrillation, it is essential that Mr. Brown receives prompt attention for his wound infection to avoid a systemic infection. He started on a course of IV vancomycin to be given every 12 hours. Copyright ©2024 F.A. Davis Company 37 Case Study: Wrap-up Upon his admission to the hospital, and although the wound is open in areas and draining, Mr. Brown’s abdominal sutures are removed. The wound is irrigated; a sterile dressing is applied. The wound is left open and unsutured to facilitate drainage and allow for wound care. After 2 days and four doses of 1 g of IV vancomycin administration, Mr. Brown’s wound infection is resolving. He remains in the hospital for 1 more day and two more doses of IV vancomycin. A vital sign check reveals: BP: 130/80 HR: 80; atrial fibrillation still present RR: 18 T: 98°F (37°C) Bedside glucose monitoring: 98 Copyright ©2024 F.A. Davis Company 38 Case Study: Wrap-up (continued_1) At discharge, Mr. Brown receives instructions that include how to monitor his wound and follow-up with the nursing home staff is arranged to help with dressing-change management. A follow-up appointment with his provider is set up for 2 weeks postdischarge. Mr. Brown is counseled to report any changes in the wound to his healthcare provider. Copyright ©2024 F.A. Davis Company 39 13 4/29/2024 Case Study 1. The nurse understands that Mr. Brown is at increased risk for an MRSA infection because of which factors? (Select all that apply.) A. B. C. D. E. His recent hospitalization His history of atrial fibrillation His recent surgical procedure His residence in a long-term care facility His current use of the medication Coumadin Copyright ©2024 F.A. Davis Company 40 Case Study (continued_1) 2. The nurse monitors for which clinical manifestations of MRSA in Mr. Brown’s wound infection? A. B. C. D. Hyperglycemia Tachycardia Tachypnea Red, edematous, draining wound Copyright ©2024 F.A. Davis Company 41 Case Study (continued_2) 3. The nurse should intervene immediately if Mr. Brown is noted to have which of the following symptoms? A. B. C. D. Depression Oliguria Decreased appetite Pain at the incision site Copyright ©2024 F.A. Davis Company 42 14 4/29/2024 Case Study (continued_3) 4. Which statement by Mr. Brown indicates the need for further teaching? A. “I need to be careful about the antibiotics I take.” B. “I’ll stop taking my antibiotics when I’m feeling better.” C. “I never want to go to the hospital again.” D. “I’ll call my doctor if my blood sugar goes up.” Copyright ©2024 F.A. Davis Company 43 Case Study (continued_4) 5. Important transitional care plans for Mr. Brown include which of the following? (Select all that apply.) A. B. C. D. E. Follow-up with a home-care nurse Follow-up with a physical therapist Follow-up with his healthcare provider Follow-up with the emergency department Follow-up with a nutritionist Copyright ©2024 F.A. Davis Company 44 Making Connections to Clinical Judgment 1. Recognizing Cues: What clinical manifestations are observed in this patient? Copyright ©2024 F.A. Davis Company 45 15 4/29/2024 Making Connections to Clinical Judgment (continued_1) 2. Analyzing Cues: How do the clinical manifestations correlate to the underlying pathophysiology? Copyright ©2024 F.A. Davis Company 46 Making Connections to Clinical Judgment (continued_2) 3. Prioritizing Hypotheses: What could happen if this patient’s symptoms are not effectively managed? Copyright ©2024 F.A. Davis Company 47 Making Connections to Clinical Judgment (continued_3) 4. Generating Solutions: What treatments are included to manage this patient’s condition? Copyright ©2024 F.A. Davis Company 48 16 4/29/2024 Making Connections to Clinical Judgment (continued_4) 5. Taking Actions: What are the priority interventions for this patient? Copyright ©2024 F.A. Davis Company 49 Making Connections to Clinical Judgment (continued_5) 6. Evaluating Outcomes: What findings demonstrate that the treatment plan is effective? What follow-up data are needed? Copyright ©2024 F.A. Davis Company 50 17