Sam Smith is 57-year-old Caucasian male that presented to the ED on 1/5/23 with LLE swelling. The leg was hot to touch and was swollen

Sam Smith is 57-year-old Caucasian male that presented to the ED on 1/5/23 with LLE swelling. The leg was hot to touch and was swollen. Sam decided to come in because he states his pain is severe and the swelling is getting worse. He says that 3 days ago he got what he thought was just a bug bite, but he can’t stand the pain anymore. He can’t even walk up the stairs in his two-story home. He has been icing it and taking Tylenol, but nothing is helping with the pain and the swelling. His wife finally convinced him to come to the ED. He didn’t want to come in because he can’t afford to miss work since he is his own boss and doesn’t have medial insurance. Sam is also worried that he won’t be able to drive his young daughter to school and soccer anymore. ER doctor decided to admit Sam and put orders for ultrasound of LLE, blood cultures, CBC, BMP, A1C, wound cultures and ask that they start the antibiotics after blood cultures have been obtained, and consult infectious disease doctor. When asked patient if he had a living will he said he did and his with can bring it who is also his DPOA.

Past medical Hx:  Diabetes Type II, HTN, HLD, anxiety, Appendectomy, Cholecystectomy, right knee replacement

Allergies: Penicillin (anaphylaxis), cats (itchy eyes, runny nose)

Weight: 230lb Height: 5’7″

Admitting Dx: LLE Cellulitis

Social History: Smoked cigarettes for 3 years as a teenager / Drinks a cup of scotch on the rocks about once a week.

Vitals and Lab Results:

Focused Assessment:

Pt A/O X4 c/o of LLE pain of 4/10 that feels sharp. Says the pain is better now that he got Dilaudid. LLE is hot to touch, looks erythema, and has +3 edema. Patient tried to ambulate to urinate but was unable to.  Patient states he can’t feel the nurse touching his left leg. He used the urinal to void a total of 600ml.  He also used the walker to pivot to the BSC and had a type 4 bowel movement. patient is currently anxious and states he is worried about returning to work. He is asking for a Christian pastor to come see him later on today because that always helps his anxiety. He just feels all this is happening because of his weight, but no matter how hard he tries he can’t lose weight. He just doesn’t like how big he has gotten since he was going to school and got his master’s in computer science. This morning he told the morning nurse he just feels like having breakfast now and wants to be left alone to rest because of all the beeping at night he was only able to get 3 hours of sleep.

MD Orders:

• Full code
• Admit to med surge floor
• Diet: general 60g carb
• Nursing: administer vancomycin  IV 1g every 12 hours for 6 days.
• Placed an order for PT to assess
• Consult case manager please set up Home Health (HH) so patient can go home with IV antibiotics and can get dressing changes for his cellulitis.

Medications:

• Atorvastatin 20 mg PO QHS (every night at bedtime)
• Lisinopril 10mg PO daily
• Gabapentin 100mg PO TID (Three Times a Day)
• Lantus 6units HS (at bed time)
• Humulin R based on medium scale ACHS (before meals and at bet time)
• 9% Sodium chloride continuous IV infusion @75 mL/hr
• Dilaudid 0.4mg IVP Q4hrs PRN for severe pain level of 7 to 10
• Acetaminophen 650 mg PO Q6hrs PRN for moderate pain level of 4 to 6 and fever

Diagnostic results: LLE ultrasound was negative for DVT and anything acute, blood cultures are negative, wound cultures came back positive for staphylococcus, Physical therapy is recommending patient use walker until leg heals.

Nurse report to doctor in the AM: Hi doctor Jones, calling about patient Sam Smith 57 old male, here for LLE cellulitis. Unfortunately, he is a really hard stick and didn’t have an IV all night so hasn’t gotten his IV vanco. His vitals are

, gave Tylenol X1 will wait an hour to recheck temp. Can I please get an order for an ultrasound IV and can we do something about his low BP?

Questions:

1. Patient education:

2. Discharge planning:

3. Interprofessional Consults:

a) Infection disease doctor

– Rationale:

– Current interventions:

b) Physical therapy

– Rationale:

– Current interventions:

c) Christian pastor – for anxiety

– Rationale:

– Current interventions:

4. Erickson’s Developmental Stage

Generativity vs. Stagnation (patient is 57-year-old)

5. 3 psychosocial concerns:

a) Frustration

– How will you address this concern?:

b) Anxiety

– How will you address this concern?:

c) need to add**

– How will you address this concern?: