BACHELOR NURSING ASSIGNMENT.

Running head: BACHELOR NURSING ASSIGNMENT 1
Bachelor Nursing Assignment
Student’s Name
Institutional Affiliation

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Introduction
` The essay is based on a case scenario of Mrs. Gina Bacci from Italy who is 49 years old
and was admitted to a hospital two weeks ago for surgery following complications from a right
foot ulcer. She underwent a partial amputation of the forefoot and the great and first toes. After
being discharged seven days ago, she visits the hospital for wound assessment and management.
By using the clinical reasoning cycle, the essay will discuss the pathophysiology and causes of
the wound status along with identifying the main nursing priorities of care for the patient. Also, it
will cover the appropriate and safe nursing management of the patient during this time.
Based on the case study, critically analyze and discuss the underlying pathophysiology and
causes of the patient’s post-operative wound status.
On admission, Gina admits that she has not been taking her medications because she
sometimes forgets and doesn’t think that she needs to take all of them. Furthermore, when her
wound is examined an island film dressing along the incisional wound is noted which is wet
from serous exudate output. The wound also has dehiscence along the suture line, and some
sloughy tissue is identified. Moreover, the surrounding skin is warm and dark pink and painful to
touch.
From her medical history, she has obesity, Peripheral Vascular Disease (PVD) and Type
2 Diabetes which was diagnosed six years ago. Because of her worsening diabetes, during her
admission to the hospital, she is commenced on insulin. When her vital signs are taken, some are
normal such as pulse 88 bpm regular, Respiratory Rate 18 bpm, blood pressure of 120/70mmHg
and SpO2 at 97% but the others are very high such as temperature of 37.8° C and blood glucose
level of 12.6mmol/L.

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From this information, diabetes leads to high blood glucose level which affects the nerves
and results in reduced blood circulation making it strenuous for blood required for skin repair to
extend areas of the body with wounds (Malone, 2016). This could cause the wounds to heal
slowly and increase risks of bacterial infections. Moreover, when blood sugar levels remain too
high, the function of white blood cells is compromised. The impairment of white blood cells
along with less effective immune responses in the inflammation phase of wound healing
increases the infection risk. Also, diabetes does not permit the body to effectively handle
glucose. Therefore, maintaining an optimal blood glucose level is a challenge; hence body's
ability to fight infections becomes lower (Van Niekerk, Davis & Engelbrecht, 2017).
According to the state of the patient, in the process of healing, the post-operative wound
was fighting invading bacteria to the site which is indicated by the warmth around the wound and
the high temperatures. Bacteria had started colonizing the wound, and because of the high blood
sugar level, the body's immune system was inefficient in fighting the germs. Wound infections
happen when microbes outcompete the patient’s natural immune system causing a series of
systemic along with local inflammatory responses (Pickard, Zeng, Caruso & Núñez, 2017).
After a surgical procedure, skin is the common cause of bacterial infections. Methicillin-
sensitive Staphylococcus aureus (MSSA) and Methicillin-sensitive Staphylococcus aureus
(MRSA) are bacteria spread by contact (Boswihi & Udo, 2018). MSSA and MRSA live with
other microbes on the skin of an individual, and when things are contacted to the person, the
organisms are spread. Post-operative wounds can tolerate some degree of harm from the host
locally and a specific amount of bacterial flora. The microbial flora and the wound state are
reticular, and if either of these outpaces an endurable threshold, an infection may develop. The
limit may be affected by comorbidities such as type 2 diabetes.

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What triggered the post-operative wound infection are bacteria. Most of the common
pathogens which cause post-operative infections include Pseudomonas, Staphylococcus, and
Streptococcus (Khan, Ahmad & Mehboob, 2015). Diabetes contributes significantly to the
weakening of the body's immune system. In this case, if the immune system is not functioning
effectively in fighting any penetrating bacteria to the wound site, it would be possible for the
microorganisms to invade the place and colonize causing infection. These pathogens may be
already on the skin surface which then spread to the surgical wound site. Organisms which are
inside the body or from the organ in which the medical procedure was performed may also cause
an infection. Moreover, microbes that are in the environment around the person like infected
surgical equipment or on the hands of the health care professional may also colonize the wound
(Leaper, Assadian & Edmiston, 2015).
Identify two main nursing priorities of care for this patient and provide justification and
rationale for each.
Gina’s problem is escalated by the fact that she has diabetes and it is worsening. In this
case, since her immune system is affected that is the reason bacteria have been able to colonize
the surgical wound. The primary nursing care priorities for Mrs. Gina Bacci is first removing the
sloughy tissue and then determining the source of the infection and carrying out a susceptibility
test for the correct antibiotic for the identified bacteria. The reason behind first removing the
sloughy tissue is that it may be harboring some bacteria and that is why it must be eliminated
before progressing with the wound care. Moreover, the aim of identifying the pathogen is to
avoid the wrong antimicrobials from being used hence worsening the health of the patient
(Lipsky et al., 2016).

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A sloughy tissue presents a barrier against efficient wound healing. Therefore, its
removal enhances healing and minimizes areas where pathogens can attach and form biofilms,
effectively decreasing the infection risk. The process of removing a sloughy tissue called
desloughing should be an on-going process to help in attaining and keeping a healthy wound bed
and assist in the removal of wound biofilms thus enhancing wound healing. The wound
specimen obtained for culture also reduces the spread of infection because once the bacteria are
recognized the appropriate antimicrobials are used hence controlling the epidemic.
The primary nursing goals for all acute and chronic wounds are to foster healing by
enhancing the patient’s healing prospective and to deliver effectual local wound care by
minimizing the infection risk and impediments (Ding, Lin & Gillespie, 2016). To determine the
treatment goals, the health care professional should use the right dosage, right route, and the right
medication so that the health of the patient is safe. Furthermore, the treatment goals will be
achieved if only the patient adheres to the doctors’ instructions on the medication by taking them
at the correct time.
From your identified priorities, outline and justify the appropriate and safe nursing
management of the patient during this time.
The care priorities are removing the sloughy tissue and then identifying the source of
infection. The objective of nursing management following an infection identified and antibiotic
sensitivities determined is to optimize the patient’s general health status (Lake, Germack &
Viscardi, 2016). Moreover, it reduces the bacterial burden, enhances healing and minimizes the
risk of cross infection. Nurses have to follow steps that will help in the management of nursing
care in identifying the infection source. For instance, when a swab is specified, the patient must

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be provided with a brief clarification of the need for microbiological investigations and what the
procedure entails (Copeland-Halperin, Kaminsky, Bluefeld & Miraliakbari, 2016).
The correct swab culture is obtained from a clean tissue, and therefore clinical nurses
should ensure that any contaminating materials like exudate and dressing residue are removed
(Stallard, 2018). This could be achieved by cleansing the wound bed using normal saline first to
make sure that the swab exemplifies the microbiology in the deep wound compartment. This will
minimize the probability that the culture will recognize a surface contaminant. Consequently, the
nurse should use a swab moistened with sterile saline to elevate the likelihood of retrieving
microbes from the wound site.
Care should be taken to make sure that the swab only comes into contact with the wound
surface. Immediately after collection of the specimen, the swab should be returned to its
container and then labeled accurately. He should ensure that the laboratory slip determines the
exact anatomic site of the wound and make a note on the lab slip if the patient was taking
antibiotics before the culture was acquired (Stallard, 2018). This information will be helpful to
the laboratory staff to assist their use of the standard operating protocol like any ongoing
treatment, significant co-morbidities, wound location and the age of the patient.
The swabs must be transferred to the laboratory immediately and ideally processed within
4 hours of collection. After this period, the laboratory report must list the probable
microorganisms secluded and the amount of growth discovered. Moreover, the antibiotic
sensitivities of any bacteria existing in the wound may be incorporated, but whether the isolates
are of clinical significance or antibiotic treatment is needed is a matter of clinical judgment
(Stallard, 2018). From the susceptibility test, the correct antibiotic will be determined and given
to the patient to control the infection spread. They will destroy the bacteria or prevent it from

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multiplying which will fasten the healing. In case the wrong antibiotic is administered to the
patient, it may adversely affect her worsening her condition. Therefore, health professionals need
to be accurate with the results for the safety of the patient.
To increase the comfortability of patient pain management is also essential. It should
include pain assessment before; during and after every dressing change to make sure that the
patient's pain is adequately managed (Ahmadi et al., 2016). The ongoing assessment will enable
clinical nurses to identify any triggers which can be averted or modified to minimize the pain.
The nurses have to use the appropriate separate analgesic strategies which may be useful for
background pain and the pain arising from wound procedures (Ahmadi et al., 2016).
The effectiveness of therapy will depend on the wounded nature, the degree of infection
and the bacteria responsible. The initial line of action of the drugs prescribed to Gina could have
been useful if only she had taken them as instructed. However, the same medications should be
continued for the provision of insulin such as Novorapid TDS 12units and Lantus 30units nocte
since Gina’s diabetes is worsening. Also, to minimize her pain, Paracetamol 1g QID and
Pregabalin 75mg mane should be prescribed.
Conclusion
Diabetes leads to a high blood sugar level in the body whereby the extra glucose aids in the
development of microorganisms. The high blood sugar level also interferes with the
effectiveness of the body's immune system hence becomes very difficult for the body to fight
invading germs penetrating to a wound site. To care for infected wounds after a surgical
procedure, removal of the sloughy tissue and identification of the infection source along with the
determination of the appropriate antimicrobials through susceptibility test is a priority in nursing

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care. Also, to do the nursing care correctly and achieve great results steps have to be followed
like hand hygiene and using the correct instruments to obtain the specimen.

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References
Ahmadi, A., Bazargan-Hejazi, S., Zadie, Z. H., Euasobhon, P., Ketumarn, P., Karbasfrushan, A.,
& Mohammadi, R. (2016). Pain management in trauma: A review study. Journal of
Injury and Violence Research, 8(2), 89.
Boswihi, S. S., & Udo, E. E. (2018). Methicillin-resistant Staphylococcus aureus: An update on
the epidemiology, treatment options, and infection control. Current Medicine Research
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Copeland-Halperin, L. R., Kaminsky, A. J., Bluefeld, N., & Miraliakbari, R. (2016). Sample
procurement for cultures of infected wounds: a systematic review. Journal of wound
care, 25(Sup4), S4-S10.
Ding, S., Lin, F., & Gillespie, B. M. (2016). Surgical wound assessment and documentation of
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Khan, H. A., Ahmad, A., & Mehboob, R. (2015). Nosocomial infections and their control
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