Situation: I am <name of the client>, a Registered Practical Nurse, calling from <……...>. 

I am calling about Mr. A., the 56 years old Male patient whom I am taking care of at the 3C Surgical Floor. 

Mr. A. had undergone abdominal surgery 3 days ago and now I am concerned that he has developed infection at the surgical site.

Background:

Pertinent history

Mr. A. underwent abdominal surgery to get an abdominal mass removed three days ago. 

Mr. A. has an IV which is now a saline lock. He is Type 2 diabetic and is currently managing diabetes through oral medications and diet. He is allergic to Penicillin. 

Mr. A’s Vital Signs this morning are as follows: 

Temperature -39-Degree Celsius

Pulse -98 beats per minute

Respiratory Rate -24 breaths per minute

Blood Pressure -130/78 mmHg

Pain perception Mr. A. also reported an elevated pain that measured 7/10. He had been given pain medication (Percocet) two hours ago. 

Mental Status and Wound Findings

Mental Status The patient is alert and oriented to time, place and person and cooperative. However, because of pain, he is discomforted.

The skin is red, swollen around the staples along with an open area of around half an inch with green, bloody and foul-smelling drainage.  

The patient right now is not oxygenated.

Assessment:

The situation of the patient is indicative of infection at the surgical site. As per the observation of the skin, which has green, bloody and foul-smelling discharge, the patient seems to have a surgical site infection. He is also febrile with temperature of 39 degrees Celsius and Pulse rate as well as Respiratory rate, both being on the higher side, that are suggestive of the systemic illness. 

Clinical Concerns

I believe that since the patient is diabetic, monitoring of blood sugar levels is a must for the healing of the surgical wound. Additionally, the patient is resistant to Penicillin, so it would alter the choice of drugs that should not be allergic to the patient. 

Mr. A. is also reporting pain and has measured it on a scale of 7/10. So, it should be taken care of.

I am not so sure about the problem of Mr. A., but I am really concerned as his condition is deteriorating. There is definitely something wrong with this patient.   

Recommendation:

Diagnostic Testing and Monitoring

I suggest you to please get the wound swab culture of the purulent discharge done for the confirmation of the surgical infection. Also, it will be good to get the Complete Blood Count (CBC) done along with other relevant tests.

The Vitals of this patient should be monitored every hour.  

Treatment and Blood Sugar Management

Since the patient is allergic to Penicillin, the choice of drugs for his treatment should be accordingly. May be immunosuppressants along with Antibiotics can be a safe option. The symptomatic treatment may include antipyretics and analgesics to combat fever and pain. 

Additionally, the sugar levels should be closely monitored to assure wound healing is proper and the drugs relevant to maintaining sugar levels should be given.