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:
1. Superficial Incisional SSI
2. Deep incisional SSI
3. 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:
1. 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:
1. Patient factor
2. Local factor
3. 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:
1. Pre-op factors
2. Intra-op factors
3. 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
OESOPHAGOGASTRI
C
Enterobacteriaceae
Enterococci (including anaerobic/
viridans Streptococci)
One to three doses of 2nd generation
cephalosporin and Metronidazole in
severe contamination
BILLIARY Enterobacteriaceae (Mainly e. coli)
Enterococci (including streptococcus
fecalis)
One dose of 2nd Generation
cephalosporin
SMALL BOWEL Enterobacteriaceae, Anaerobes (mainly
Bacteroides)
One dose of 2nd Generation
Cephalosporin with out metronidazole
APPENDIX/COLOREC
TAL
Enterobacteriaceae, Anaerobes (mainly
Bacteroides)
Three doses o 2nd 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
2/7/2024 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 mgldL 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
2/7/2024 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.
2/7/2024 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
2/7/2024 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
2/7/2024 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
2/7/2024 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
2/7/2024 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
2/7/2024 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
2/7/2024 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
2/7/2024 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 %
2/7/2024 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
2/7/2024 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
2/7/2024 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.
2/7/2024 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.
2/7/2024 By Mtiku T. (AHN Student) 46

47. NURSING CARE PLAN
Date &
Time
Prioritized
Problem
Goal Expected Outcomes
ate:
11-17/4/016
ime:
8:30
AM
LT
.
Activity
intolerance
related
to
generalized
eakness
as
evidenced
by
verbal
reports
of
atigue
&
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.
2/7/2024 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.
2/7/2024 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
2/7/2024 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
2/7/2024 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.
2/7/2024 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 mgldL 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
2/7/2024 By Mtiku T. (AHN Student) 54

55. 1) The patient became normovolemic as evidenced by improvement of skin
turgor, moist mucous membranes, vital signs with in 48 hours.
2) V/S become normalized
3) Patient report a decrease in pain on 0/10 scale after the administration of
pain medication
4) The wound site remains free of purulent drainage
5) He able to verbalizes sense of comfort & demonstrate behaviors of optimal
level of ease
6) He able to perform his activities of daily living.
EVALUATION
2/7/2024 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…
2/7/2024 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
2/7/2024 By Mtiku T. (AHN Student) 57

58. THANK YOU!
2/7/2024 By Mtiku T. (AHN Student) 58