Surgical site infection PRACTICAL PRESENTATION.pptx

Glomerulonephritis

1. CASE PRESENTATION:SSI SECONDARY TO LAPAROTOMY BY MTIKU TEKA (AHN STUDENT)

2. OUT LINE: Over view of SSI Real Patient Nursing Health Assessment (ADPIE) Using Gordon Approach

3. INTRODUCTION SURGICAL SITE INFECTION (SSI): Definition : An infection which develop=< 30 days of surgery or within a year in the case of implants (CDC Guideline,2017). It leads to increased : morbidity mortality (70-80%) duration of hospital stay (7 days on an average ) and increased cost

4. EPIDEMIOLOGY: Third most reported nosocomial infections ( 16%) after Blood stream infection, Pneumonia, and UTI Most common surgical patient nosocomial infection (38 %) after UTI. (CDC, 2019)

5. SSI… Types of Incisional SSI: Superficial Incisional SSI Deep incisional SSI Organ or space SSI

6. 1 . superficial incisional SSI: < 30 days of procedure involve only the skin or subcutaneous tissue around the incision. 2. Deep incisional SSI: < 30 days of procedure (or one year in the case of implants) are related to the procedure involve deep soft tissues, such as the fascia and muscles . (CDC Guideline for prevention of SSI infection, 2017)

7. Types of SSI… 3. Organ or space SSI: Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or manipulated during the operative procedure Base on Severity, SSI can be further classified in to: Minor; discharge without cellulitis or deep tissue destruction 2 . Major: Pus discharge with tissue breakdown , Partial or total dehiscence of the deep fascial layers of wound Systemic illness is present.

8. RISK FACTORS FOR DEVELOPING SSI: Patient factor Local factor Microbial factor

9. RISK FACTORS… 1 . Patient factor: Older age Immunosuppression Obesity Diabetes mellitus Chronic inflammatory process Malnutrition Peripheral vascular disease Smoking Anemia Radiation Steroid use

10. RISK FACTORS… 2. Local factor: Poor skin preparation Contamination of instruments Inadequate antibiotic prophylaxis Prolonged procedure Site and complexity of procedure Local tissue necrosis Hypoxia Hypothermia

11. RISK FACTORS… 3. Microbial factor: Wound Class Prolonged hospitalization (leading to nosocomial organisms) Resistance

12. COMMON PATHOGEN IN SURGICAL PATIENTS (BAILEY, BMJ, 2018) PTHOGEN PERCENTAGE OF ISOLATES Staphylococcus (coagulase Negative) 25.6% Enterococcus (group D) 11.5% Staphylococcus Aureus 8.7% Candida Albicans 6.5% Escherichia coli 6.3% Pseudomonas Aeruginosa 6% Corynebacterium 4% Candida (non Albicans) 3.4% Alpha –hemolytic Streptococcus 3% Klepsiella Pneumoniae 2.8% Vancomycin -resistant Enterococcus 2.4%

13. MANAGEMENT OF SURGICAL SITE INFECTION (SSI): Most SSIs respond to the removal of sutures with drainage of pus if present and, occasionally, there is a need for debridement and open wound care. Prevention of SSI: Pre-op factors Intra-op factors Post-op factors

14. SSI Prevention… 1. PRE-OPERATIVE FACTORS: Preoperative antiseptic showering Preoperative hair removal Patient skin preparation in the operating room Preoperative hand/forearm antisepsis( Alcohol solution, Chlorhexidine gluconate, Iodophors) Antimicrobial prophylaxis: antibiotic prophylaxis to patients before surgery Do not use antibiotic prophylaxis routinely for clean uncomplicated surgery.

15. Common Antibiotic Prophylaxis : 1st generation Cephalosporin 2nd generation Cephalosporin For Penicillin Allergy: Vancomycin Clindamycin metronidazole

16. PROPHYLACTIC REGIMEN SUGGESTED Types of surgery Organisms encountered Prophylactic Regimen Suggested VASCULAR Staphylococcus epidermidis Staphylococcus aureus (MRSA) Aerobic Gran-negative bacilli Three doses of flucloxacillin with or with out Gentamycin, Vancomycin or Rifampicin if MRSA is a risk ORTHOPEDIC Staphylococcus epidermidis/Aureus One to three doses of broad spectrum cephalosporin OESOPHAGOGASTRIC Enterobacteriaceae Enterococci (including anaerobic/ viridans Streptococci) One to three doses of 2 nd generation cephalosporin and Metronidazole in severe contamination BILLIARY Enterobacteriaceae (Mainly e. coli ) Enterococci (including streptococcus fecalis ) One dose of 2 nd Generation cephalosporin SMALL BOWEL Enterobacteriaceae, Anaerobes (mainly Bacteroides) One dose of 2 nd Generation Cephalosporin with out metronidazole APPENDIX/COLORECTAL Enterobacteriaceae, Anaerobes (mainly Bacteroides) Three doses o 2 nd generation cephalosporin or Gentamycin with Metronidazole

17. 2. INTRA OPERATIVE FACTORS: Operating room environment; Temperature Relative humidity Air movement: from “clean to less clean” areas Surgical attire and drapes Asepsis and surgical technique SSI Prevention…

18. 3. POST OPERATIVE FACTORS: Incision care ; the incision is usually covered with a sterile dressing Changing dressings: Use an aseptic non-touch technique for changing or removing surgical wound dressings. Postoperative cleansing: Use sterile saline for wound cleansing after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus. Topical antimicrobial agents for wound healing by primary intention SSI Prevention…

19. SEVERE INFLAMMATORY RESPONSE SYNDROME(SIRS) AND SEPSIS SIRS: Two of the following; hyperthermia (> 38°C) or hypothermia (< 36°C) tachycardia (>100 b/min , no β-blockers) or tachypnea (> 20 /min) white cell count > 12 × 109 / l or < 4 × 109 l

20. SIRS &Sepsis… Sepsis: is SIRS with a documented infection Severe sepsis (MOD sepsis) is sepsis with evidence of one or more organ failures: acute respiratory distress syndrome, septic shock renal (usually acute tubular necrosis), hepatic , blood coagulation systems or central nervous system

21. Initial resuscitation with fluid therapy ( cvp :8-12 mm hg, MAP>65 mm hg and urine output>0.5 ml/kg/hr) Diagnosis ( via appropriate cultures) Antibiotic therapy Vasopressor/inotropic therapy ( MAP> 65) (nor epi and dopamine) Steroids Sepsis Mgt:

22. Sepsis Mgt… Other supportive therapy: Blood product administration (if Hgb < 7 mg/dL) Mechanical ventilation if needed Glucose control (infection can induce the body to secret higher amount of hormone such as adrenaline & cortisol.) Prophylaxis Source control

23. BIOGRAPHIC DATA: Name: Mosisa Alamayew Age: 50 years old Gender: Male Birthdate: -------- Ethnicity: Oromo Address : ------ Religion:----- Marital Status: Married Educational Status: Illiterate Work: Farmer Ward: Surgical Ward Admission Date and Time: ---- Card N0: 198213 Final Diagnosis : SSI 12/27/2023 By Mtiku T. (AHN Student) 23

24. C/C: Vomiting Abdominal pain Tenderness and Puss from the wound site

25. HPI: He is 50 years old male patient who admitted to WURH on 07/01/2016 E.C with the complain of abdominal pain, abdominal distension, failure to pass feces and flatus and vomiting of 3 episodes per day. After he diagnosed with acute abdomen secondary to generalized peritonitis secondary to large bowel obstruction (sigmoid volvulus), Laparotomy was done for him. After 1 week of treatment with in the hospital, he again developed abdominal pain, tenderness, puss from the wound site and fever.

26. History of Past Illness: He hospitalized with acute abdomen in the past 3 weeks. He has no known case of HTN, diabetes, & any other medical problem Personal History: Diet- mixed No sleep disturbance Absent bowel sound and bladder habits is normal Social History: He is chronic smoker and alcohol drinker Surgical history: He has no past surgical history

27. P/E: The physical exam on admission revealed the following findings: G/A: ASL He is conscious and alert V/S: Temprature: 38 d/c Pulse rate: 115 bpm Respiratory rate: 20 bpm Blood Pressure: 90/ 70 mmhg SPO2 : 95%

28. P/E… HEENT : Pink conjunctiva and wet sclera Chest: Clear and bilaterally good air entry & moves with respiration Lungs: Normal bilateral vesicular sounds heard Abdomen: - Surgical wound dressing vertically and horizontally -Tenderness, rigidity, & pain on palpation seen CVS : S1 & S2 well heard , no murmur/ rubs/ gallops GUS: NAD CNS: Oriented to TPP and GCS is 15/15

29. OTHER INVESTIGATIONS: X-ray abdomen: suspected some abnormality in the abdomen Chest-X- ray: normal diagnosis : SSI secondary to laparotomy

30. XI. LABORATORY FINDINGS 1 . COMPLETE BLOOD COUNT (CBC) TESTS RESULTS NORMAL RANGE Comment Hgb 12 gm/dl 13.8-17.2 gm/dl Hematocrit 42% 40-54 % RBC 4 4.5-5.5 x 10*12/L indicate infection ESR 15.5 mm/hr <15 mm/hr high ESR indicate inflammation WBC 13,000/ McL 4500-11,000 /McL Infection Neutrophils 90 37-72 indicate bacterial infection Lymphocytes 9 20-50 Decrease (lymphopenia) which indicates infection

31. XI. LABORATORY FINDINGS TESTS RESULTS NORMAL RANGE Comment Creatinine 0.8 mg/dL 0.7-1.3mg/dL Normal Na 138 mEq/L 135-145 mEq/L Normal K 3.8mEq/L 3.5-5.5 mEq/L Normal Urea Nitrogen 6.5 mg/dL 5-20 mgl dL Normal 2. ELECTROLYTES

32. Current Medication: Maintenance fluid; N/S Metronidazole 500mg/100ml IV infusion TID Ceftriaxone 1gm IV BID Tramadol 50mg IV BID Cimetidine 400mg IV BID

33. GORDON’S FUNCTIONAL HEALTH PATTERN AND PHYSICAL ASSESSMENT ON PERFORATED DUODENAL ULCER 12/27/2023 By Mtiku T. (AHN Student) 33

34. HEALTH PATTERN 1. Health Perception- Health Management Pattern: He felt well until 1 week prior to admission Buys and takes over the counter drugs such as Ibuprofen for pain. Currently confined at surgical ward. He is oriented to TPP he follows Doctor’s order about his presentations and medications. 12/27/2023 By Mtiku T. (AHN Student) 34

35. 2. Nutrition- Metabolic Pattern: He is smoker and drinks alcohol he likes eating salty meals three times a day lips are dry buccal mucosa seen to be dry no lesions on tongue 12/27/2023 By Mtiku T. (AHN Student) 35

36. 3. Elimination Pattern: Patient voids 3-4 times a day which is yellow in color. No urgency and frequency of urine The patient defecates every 3 other day No burning sensation/pain felt during urination, but difficult to defecate. abdomen is tender to touch and swelling present Decreased bowel sound is seen 12/27/2023 By Mtiku T. (AHN Student) 36

37. 4. Activity- Exercise Pattern: Move by him self & perform his ADL before he develop the disease . He is bed ridden now In ability to perform his ADL as previous. requires help for exercises from family and staff to maintain mobility.   5. Sexuality- Reproductive Pattern : No noted abnormalities around genitalia No problem regarding to sexual intercourse 12/27/2023 By Mtiku T. (AHN Student) 37

38. 6.Sleep- Rest Pattern: Can sleep for only 5-6 hours per night He has also difficulty in sleeping when stressed and has anxiety Interrupted sleep due to hospitalizations.   patient appear not well rested & he is irritable. 7. Cognitive- Perceptual Pattern: Able to feel touch, pain, temprature No hearing, visual, and smell impairments was noticed. 8.Role Relationship Pattern: He is married and lives with his wife, 2 sons & 2daughters He has good relation ship with his family & other people 12/27/2023 By Mtiku T. (AHN Student) 38

39. 9. Self-perception-self Concept Pattern : He is afraid to get severely hospitalized hence he is always compliant. The patient is well socialized with family members & other people. He partly blames him self because he thinks that his drinking habits and life style resulted getting this problem. Slightly anxious and is some times depressed . He disturbed and confused 12/27/2023 By Mtiku T. (AHN Student) 39

40. 10. Coping-stress Tolerance Pattern: He always talks to his wife about his problem. His wife tries to delineate the problems one by one to come up with good advice He smokes cigarettes and drink alcohol to aids with his stress. 11. Value-belief Pattern: He is Orthodox and go to church every Sunday Presence of religious materials (Bible ) around him 12/27/2023 By Mtiku T. (AHN Student) 40

41. SUMMARY OF SUBJECTIVE AND OBJECTIVE DATA Subjective Data: Abdominal pain Loss of appetite Weakness Objective Data: tender to touch Damaged tissue/skin Redness, Puss Swelling Low blood pressure Tachycardia Dehydration with lip & mucosal dryness 12/27/2023 By Mtiku T. (AHN Student) 41

42. Objective Data… V/S on the day of admission: HR:115 b/min Height: 162cm RR: 20 bpm Weight: 57kg BP: 90/70 mmhg BMI: 20 kg/m2 Temp:38 d/C SPO2: 95 % 12/27/2023 By Mtiku T. (AHN Student) 42

43. NURSING DIAGNOSIS Problem No. Nursing Diagnosis Date Resolved 1. Impaired skin integrity related to surgical incision as evidenced by surgical wound infection Date: 10/4/016 Time: 3:00 AM LT 2. Acute pain related to necrotic tissue as evidenced by restlessness & verbal report of pain Date: 10/4/016 Time: 5:00 AM LT 3. Knowledge deficit related to importance of wound care as evidenced by non adherence to wound care management Date: 12/4/016 Time: 3:00 AM LT 4. Fluid volume deficit as evidenced by poor skin turgor and dry mucus membrane . Date: 14/4/016 Time: 3:00 AM LT 5. Readiness for enhanced comfort. Date: 13/4/016 Time: 8:00 AM LT 6 Activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue & exertional discomfort . Date: 10-17/4/016 Time: 8:00 AM LT 12/27/2023 By Mtiku T. (AHN Student) 43

44. NURSING CARE PLAN Date & Time Prioritized Problem Goal Expected Outcomes Date: 10/4/016 Time: 3:00 AM LT 1. Fluid volume deficit as evidenced by poor skin turgor and dry mucus membrane . Administer IV fluids as ordered continuously to improve in skin turgor and mucous membranes The patient will be normovolemic as evidenced by improvement of skin turgor , moist mucous membranes, vital signs with in 48 hours. V/S: Temprature: 36.5 c HR:60-100 b/minutes RR: 12-20 b/minutes BP: 120/80 mmhg Urine Out put: 0.5ml/kg/hr Date: 10/4/016 Time: 5:00 AM LT 2. Acute pain related to necrotic tissue as evidenced by restlessness & verbal report of pain Pre medicate prior to wound care Educate on pain control Prevent surrounding symptoms (excessive dryness, drainage, edema,) by keeping the extremity elevated & changing wound dressing at appropriate interval. Patient will be able to verbalize the resolution of pain to the wound Patient will report a decrease in pain on 0-10 scale after the administration of pain medication Patient will be able to perform daily activities with out complaints of pain in the wound 12/27/2023 By Mtiku T. (AHN Student) 44

45. NURSING CARE PLAN Date & Time Prioritized Problem Goal Expected Outcomes Date: 12/4/016 Time: 3:00 AM LT 3. Impaired skin integrity related to surgical incision as evidenced by surgical wound infection Disinfect the site with antiseptic Decontaminate the skin injury Remove any dying tissue Apply appropriate wound dressing Apply topical antibiotics & antiseptics as recommended Remove suture for surgical wound Patient will remain free of purulent drainage in the wound Patient will demonstrate clean wound edges Patient will verbalize an understanding of wound care management Patient will be able to participate in performing wound care. 12/27/2023 By Mtiku T. (AHN Student) 45

46. NURSING CARE PLAN Date & Time Prioritized Problem Goal Expected Outcomes Date: 13/4/016 Time: 3:00 AM LT 4. Readiness for enhanced comfort. Patient will appear calm & relaxed Before discharge the patient will be able to verbalizes sense of comfort & demonstrate behaviors of optimal level of ease Date: 11-17/4/016 Time: 8:00 AM LT 5. Knowledge deficit related to importance of wound care as evidenced by non adherence to wound care management Teach the patient about wound care & wound healing Allow time for inquiries; to build trust & misinformation to encourage cooperation b/n the patient & care giver Emphasize practicing infection control measures & aseptic procedures in wound care. Advice about dietary management Patient will be able to verbalize an understanding of wound care management Patient will demonstrate adherence to the wound care treatment plan Patient will verbalize strategies to prevent wound infection. 12/27/2023 By Mtiku T. (AHN Student) 46

47. NURSING CARE PLAN Date & Time Prioritized Problem Goal Expected Outcomes Date: 11-17/4/016 Time: 8:30 AM LT 6. Activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue & exertional discomfort . Begin with range of motion (ROM) exercises. Monitor V/S throughout activity Provide frequent position change Provide appropriate nutritional supplement Utilize appropriate assistive device & treat pain if needed. Provide emotional support. Educate about how to safely increase Activity level at home. The patient will exhibit a stable cardiopulmonary status as evidenced by the following: HR< 120 bpm Systolic BP with in 20 mmhg increase over resting systolic BP RR < 20b/min. The patient will report 0 or a decreased rating of perceived exertion after a physical activity. He report absence of fatigue He perform activities of daily living. 12/27/2023 By Mtiku T. (AHN Student) 47

48. IMPLIMENTATION Date Identified and Time Problems Implementations Date: 07/4/016 Time: 3:00 AM LT 1. Fluid volume deficit as evidenced by poor skin turgor and dry mucus membrane . 0.9 % N/S is administered as ordered. 12/27/2023 By Mtiku T. (AHN Student) 48

49. IMPLIMENTATION Date Identified and Time Identified Problem Implementations Date: 10/4/016 Time: 5:00 AMLT 2. Acute pain related to necrotic tissue as evidenced by restlessness & verbal report of pain Tramadol 50 mg IV in TID is administered The patient and care giver educated on pain control Proper wound care is implemented. Date: 14/4/016 Time: 3:00 AM LT 3. Impaired skin integrity related to surgical incision as evidenced by surgical wound infection The injured skin decontaminated & the site disinfected with antiseptic Dead tissue removed appropriate wound dressing performed 12/27/2023 By Mtiku T. (AHN Student) 49

50. IMPLIMENTATION Date Identified and Time Identified Problem Implementations Date: 13/4/016 Time: 3:00 AM LT 4. Readiness for enhanced comfort. Bed bath & back care provided Positioning is performed every 2 hours Tramadol 50mg/3ml TID is administered Patient appear calm & relaxed Date: 10-17/4/016 Time: 3:00 AM LT 5. Knowledge deficit related to importance of wound care as evidenced by non adherence to wound care management The patient & care giver educated about proper timing of wound care & follow up. the patient & care giver emphasized practicing infection control measures and about dietary management 12/27/2023 By Mtiku T. (AHN Student) 50

51. IMPLIMENTATION Date Identified and Time Identified Problem Implementations Date: 12-14/4/016 Time: 8:00 AM LT 6. Activity intolerance related to generalized weakness as evidenced by verbal reports of fatigue & exertional discomfort . Active ROM exercises in is provided. Frequent position change performed Deep breathing exercises 3x/day Walking in room 1-2 minutes 3x/day Walking outside the house. Appropriate nutritional supplement HR reduced to 90 bpm BP normalized to 120/80 mmhg RR reduced to 16 b/min. He reported absence of fatigue He performed activities of daily living. 12/27/2023 By Mtiku T. (AHN Student) 51

52. XI. LABORATORY FINDINGS 1 . COMPLETE BLOOD COUNT (CBC) TESTS RESULTS NORMAL RANGE Comment Hgb 14 gm/dl 13.8-17.2 gm/dl Normal Hematocrit 43% 40-54 % Normal RBC 5.3 4.5-5.5 x 10*12/L Normal ESR 8 mm/hr <15 mm/hr Normal WBC 6,000 / McL 4500-11,000 /McL Normal Neutrophils 40 37-72 Normal Lymphocytes 32 20-50 Normal

53. XI. LABORATORY FINDINGS TESTS RESULTS NORMAL RANGE Comment Creatinine 0.8 mg/dL 0.7-1.3mg/dL Normal Na 138 mEq/L 135-145 mEq/L Normal K 3.8mEq/L 3.5-5.5 mEq/L Normal Urea Nitrogen 6.5 mg/dL 5-20 mgl dL Normal 2. ELECTROLYTES

54. Vital Sign at the end of treatment: HR : 80/min Height:162cm RR: 18/min Weight: 58kg BP:115/80mmhg BMI:22 kg/m2 Temp : 36 d/C SPO2: 98 % Urine Out put: 0.5ml/kg/hr 12/27/2023 By Mtiku T. (AHN Student) 54

55. The patient became normovolemic as evidenced by improvement of skin turgor, moist mucous membranes, vital signs with in 48 hours. V/S become normalized Patient report a decrease in pain on 0/10 scale after the administration of pain medication The wound site remains free of purulent drainage He able to verbalizes sense of comfort & demonstrate behaviors of optimal level of ease He able to perform his activities of daily living. EVALUATION 12/27/2023 By Mtiku T. (AHN Student) 55

56. So , goal met. Finally , The patient improved and discharged on 17/04/2016 At 5 :30 AM LT EVALUATION… 12/27/2023 By Mtiku T. (AHN Student) 56

57. REFERENCE Peden, A. & Vaughan, J. (2006). American Journal of Infection Control. Hand Hygiene , 34(5), E60. Retrieved from http://www.ajicjournal.org/handhygiene Odom- Forren , J. (2006). Preventing surgical site infections. Nursing Management, 36 , 58-64. Retrieved from http://journals.lww.com/nursingmanagement/Pages/issuelist.aspx Ramos, A., Asenslo, A., Munez, E., Torre-Cisneros, J., Montejo, M., Aguado, J.,… Cisneros, J. (2008). Incisional surgical site infection in kidney transplantation. Reconstructive Urology, 72 , 119-123. doi:10.1016/j.urology.2007.11.030 Wynne, R., Botti, M., Stedman, H., Holsworth, L., Harinos, M., Flavell, O., & Manterfield, C. (2004, January). Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds. Chest Journal, 125 , 43-49. Retrieved from http://intl.chestjournal.org 12/27/2023 By Mtiku T. (AHN Student) 57

58. THANK YOU! 12/27/2023 By Mtiku T. (AHN Student) 58