- How would you proceed with this patient?
- What could be the underlying problem?
2……..This patient presents with an AV graft that is red and warm to touch. He probably has cellulitis. Cellulitis is a bacterial infection that can be staphylococcal or streptococcal in nature (Eden, 2014). It is often marked by a reddened skin area that is warm-hot to touch. For this patient, his WBC is already elevated at 36,000, and he now presents with nausea and vomiting, fever, back pain, and lower extremity swelling. What started out as a local infection has now probably spread and become more systemic. I would get a set of vital signs first. It is known that he is febrile; an accurate temperature would be important to know how high it is. It may require an antipyretic, like Tylenol or Ibuprofen. An elevated heart rate would be a normal finding for one with a fever. A low blood pressure would be an indicator of how aggressive the medical staff should respond. This patient could be on the verge of becoming septic; this would need to be ruled out. Additional labs would need to be drawn: Lactic acid ( used as an indicator for sepsis), blood cultures x 2 sets, chemistry panel, with magnesium and phosphorus. This is a renal patient; a baseline evaluation of his renal function and electrolytes would need to be established. A CBC has already been done. This patient would definitely need antibiotics; once the blood cultures are drawn he could be started on a broad spectrum antibiotic. Along with the vital signs, I would get a weight on the patient. This is a renal patient who is presenting with edema to his legs. This could be due to his poor renal function, or it could be due to some other underlying cause. I probably would start the patient on a “gentle” rehydration bolus of IV fluids. Again, this is a renal patient. If this patient has not been feeling well, his oral intake may have been poor and he could have become dehydrated. This patient also complains of pain. A pain assessment would be performed. This patient would also be given analgesic for his pain as well as an anti-emetic for his nausea. Another consideration would be to place a vascular catheter to use until the AV graft could be further assessed for infection. A nephrologist or vascular surgeon would need to be consulted for that. Lastly, this patient’s blood sugars would need to be monitored and treated. It is normal response for a diabetic’s blood sugar to rise during an illness; consequently, his insulin requirements may increase as well.