Case Study Analysis

This case study analysis focuses on the pathophysiology, nursing priorities, and safe nursing management of a diabetic foot wound. It discusses the risk factors for infection, impaired health maintenance, and provides recommendations for tissue debridement, infection control, moisture balance, pressure offloading, and patient education.

Running head: CASE STUDY ANALYSIS 1
Case study analysis
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CASE STUDY ANALYSIS 2
Case study Analysis
Introduction
In a certain case study, there was a patient by the name Mrs. Gina who has been diabetic
for some time presented at the General practitioner with complains about her wound. On
assessment, the wound had abnormal features such as a film dressing along the incisional wound.
Besides, the wound was dark pink in color and was painful on touch. The wound also had a
sloughy tissue and was wet due to the serous exudate output. These features clearly indicates a
nursing problem. Within the framework of this essay, there will be an analysis of the
pathophysiology of the presenting problem, the nursing health problem and the management of
the same.
Pathophysiology
After thorough examination of the wound, it was established that the wound had an island
film dressing along the incisional wound. The wound was also wet due to the serous exudate
output. Furthermore, the wound also had dehiscence along the suture line characterized by
sloughy tissues (Amin & Doupis, 2016). The surrounding skin to the wound was warm and dark
pink in color. Finally, the wound was painful to touch. This clearly indicates that there was an
underlying health care problem.
There are different theories behind the pathophysiology of the appearance of the wound.
They include both intrinsic and the extrinsic factors. The extrinsic factors are repeated trauma or
mechanical stress. Studies indicate that repeated stress on the wound is likely to lead to
dehiscence and rupture of sutures (Andrews, Houdek, & Kiemele, 2015). In this case, the wound
was on the foot and chances that the patient was exerting mechanical stress on it during
movement were very high. This eventually contributed to the features that were observed at the

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wound. The intrinsic factors on the other hand are quite complex. It involves an interplay
between different factors such as hyperglycemia, growth factors and different enzymes.
Hyperglycemia, a common condition in Type 2 diabetes leads to formation of advanced
glycation end products (AGEs).These products stimulate formation of the inflammatory
molecules known as TNF- , IL-1.These factors on the other hand impairs the process of collagen
synthesis. Another study propose that exposure to high levels of glucose results in changes in
cellular morphology, reduced proliferation and abnormalities in the differentiation of
keratinocytes (Arsanjani Shirazi, Nasiri, & Yazdanpanah, 2016). Another mechanism that
explains the pathophysiology of the wound status is immunosuppression. Studies indicate that
patients with diabetes tend to experience immunosuppression and this alters the process of
chemotaxis, phagocytosis, bacterial killing and low heat shock protein expression which play an
important role in the early healing stages of the wound (Bus et al., 2016). Consequently,
immunosuppression affects leukocyte infiltration and would fluid IL-6 which play important role
in the late inflammatory phase of the wound healing process. Furthermore, there is also an
impaired pattern of cytokine appearance at the wound. Research indicate that cytokines are
usually secreted by different cell types and their functions include regulating proliferation of
cells, differentiation, their migration and finally their metabolism (Forsythe & Hinchliffe, 2016).
In patients with diabetic ulcers, there is usually abnormal expression of growth factors. In the
event that the cytokines and the growth factors are trapped by different macromolecules such as
Albumin and fibrinogen at the wound, the healing process of the wound is subsequently altered.
Another mechanism behind the appearance of the wound status is increased degradation
of growth factors in wound fluids of diabetic patients. According to research, patients with
diabetic ulcer have elevated levels of Insulin Degrading enzyme (IDE).These enzymes are

CASE STUDY ANALYSIS 4
responsible for breakdown of growth factors and this is positively correlated to HbA1c levels. It
is this increased breakdown of growth factors that subsequently contributes to slow healing
process and the appearance of the wound in the case study.
Another model of the pathophysiology of the status of the wound argue that for a wound
to heal effectively, there should be balance between collagenous and non-collagenous
extracellular matrix components. These components are modelled by matrix metalloproteinases
(MMPs) and the tissue inhibitors of metalloproteinases (TIMPs).The MMPs play crucial role in
early stages of wound debridement, angiogenesis, epithelialization and remodeling of the scar
tissues (Frykberg & Banks, 2015). In chronic wounds such as the case of diabetic ulcer, there is
higher MMPs and low TIMPs. It is this imbalance that contributes to the general appearance of
the postoperative wound. Delayed wound healing can lead to devastating consequences, there is
the need to understand the pathophysiology of the same that will can be used to come up with
effective or safe nursing management plan.
Nursing priorities
Risk for infection is the first nursing health problem. In this case study, wound
dehiscence was observed. Wound dehiscence can be defined as a surgical complication where
the wound ruptures along the surgical incision. According to recent studies, wound dehiscence
opens up the wound and this poses the risk of infection by different microbial agents. The same
research notes that infection takes place whenever the natural defense mechanism of the body
fails. Organisms like bacteria, virus and fungus invade the body through injuries and exposures
like wounds (Lipsky, 2016). However, the human body has dedicated cells collectively known as
the immune system that help the body protect itself against such. If infections are not prevented
and treated on time, they usually prolong the healing process in wounds. There are three main

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goals and outcomes for this health priority. First, it is to ensure that the patient remains free of
infection. Secondly, the goal is to ensure early recognition of infection so that there is prompt
treatment. Finally, the patient is to demonstrate meticulous hand washing technique.
It is therefore imperative to states that the risk for infection is a priority nursing problem
due to impaired integrity of the skin in form of post-operative wounds that is characterized by
dehiscence. There is the need for urgent management or nursing intervention for risk of infection
(Lipsky, 2016). However, the nursing intervention depend on different factors such as nature and
severity of the risk.
The second nursing priority in this case is the risk for ineffective health maintenance. In
this case study, there is a likelihood that the patient might be unable to identify, manage and then
seek out help so as to maintain effective health. The risk factors for this nursing priority include
impaired functional status, lack of a similar previous condition, the need for long term pressure
management and finally possible needs for special equipment (Peters et al., 2016). There are two
major desired objectives or outcomes in this case and they include: The patient should be able to
talk about the aspects of home care such as nutrition, pressure relief and effective wound care.
Secondly, the patient as well as the care giver should verbalize ability to sustain adequately with
available condition and provide assistance as stipulated.
Safe nursing management
Studies propose different appropriate and safe nursing management of the patient during
such times. The management includes tissue debridement, infection control, moisture balance,
pressure offloading and patient education.

CASE STUDY ANALYSIS 6
During tissue debridement, the nurse and other experienced healthcare physicians remove
necrotic tissues around the wound. Different studies have been conducted and found out that
removal of the necrotic tissue reduce pressure around the wound (S, 2018). Furthermore, it
allows inspection of the underlying tissue. In the long run, it will improve secretion as well as
wound drainage and this optimizes on the effectiveness of wound dressing. It involves the use of
sharp scalpel of scissors. However, other options such as larval, autolytic and ultrasonic can also
be utilized. This nursing intervention ought to be conducted by a very experienced nurse who
knows exactly which section of the tissue should be removed so that there is no damage to the
blood vessels, nerves and tendons.
Secondly, infection control is important nursing management of postoperative wounds.
One of the biggest concerns in postoperative wounds among diabetic patients is the risk for
infections. In fact, infections to the wounds is the one that contributes to high rates of morbidity
and mortality. In this case, the nursing interventions include use of antibiotics. Studies
recommend both oral and topical antibiotics to prevent infections (Satish, 2015).Proper wound
dressing is the next nursing intervention. Dressing involves application of bandages at the
wound. Studies recommend use of appropriate to avoid infections and dehiscence around
wounds in diabetic post-operative wounds. In most cases, nurses impregnate the dressings with
compounds such as silver, iodine, medical grade honey, polyhexamethylene biguanide. These are
antimicrobial agents that help to prevent infection at the wounds.
Moisture balance can be used to properly manage the wound. For a wound to heal
properly and avoid such complications, there is the need to provide a good environment. The
environment should neither be too wet nor dry (Schaper, 2016). The role of the nurse in this
nursing intervention exercise is to locate or rather find out the optimal dressing to be utilized.

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Studies note that the dressing used should ensure moisture balance within the wound.
Furthermore, the dressings proposed by study findings include alginates, hydrocolloids and
films.
Pressure offloading can be incorporated in this case. In the case study, the wound is on
the leg and this means mechanical stress due to the force exerted by the body while walking.
Mechanical stress further worsens the wound and derails the healing process. Nurses should
therefore consider strategies to offload the pressure. In this case, pressure offloading devices can
be used. They include removable cast walkers, Scotch cast boots and healing sandals (Shearman,
2015). However, this method has different challenges .One of the greatest challenge is that some
patients don’t know how to wear them. In fact, studies indicate that only 30% of diabetic patients
wears them correctly. It is therefore the role of the nurse to ensure that the patient correctly wears
the removable offloading devices.
Patient education is another effective way of wound management. This involves
educating the patient on some of the risk factors and proper management. Recent studies indicate
that patient education can reduce the risk of diabetic ulcers by 62% (Sulistyo, 2018). In this case,
the nurse should educate the patient on good hygiene practice. The patient should also be
educated on nutrition such as smoke cessation. If the patient and the nurse takes into account the
recommended nursing management of the wound, the healing process would improve and within
a short time, the patient will feel better.
Conclusion
In conclusion, diabetic patients develop ulcers on their foot in most cases. The remedy for
this ulcer is surgery. However, chances of post-operative complications to the wound are

CASE STUDY ANALYSIS 8
common. In this case, the wound was dehisced with abnormal coloration. This poses the risk of
infection due to impaired integrity in the skin which acts as the primary barrier to any microbial
infection. The nursing interventions lies in proper identification of the pathophysiology and
identifying the nursing priorities. Nurses should ensure proper management of the wound such as
pressure offloading and suitable environment to the wound so as to prevent adverse
consequences like death.

CASE STUDY ANALYSIS 9
References
Amin, N., & Doupis, J. (2016). Diabetic foot disease: From the evaluation of the “foot at
risk” to the novel diabetic ulcer treatment modalities. World Journal of Diabetes,
7(7), 153. doi:10.4239/wjd.v7.i7.153
Andrews, K. L., Houdek, M. T., & Kiemele, L. J. (2015). Wound management of chronic
diabetic foot ulcers: From the basics to regenerative medicine. Prosthetics and
Orthotics International, 39(1), 29-39. doi:10.1177/0309364614534296
Arsanjani Shirazi, A., Nasiri, M., & Yazdanpanah, L. (2016). Dermatological and
musculoskeletal assessment of diabetic foot: A narrative review. Diabetes &
Metabolic Syndrome: Clinical Research & Reviews, 10(2), S158-S164.
doi:10.1016/j.dsx.2016.03.004
Bus, S. A., Van Deursen, R. W., Armstrong, D. G., Lewis, J. E., Caravaggi, C. F., &
Cavanagh, P. R. (2016). Footwear and offloading interventions to prevent and heal
foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review.
Diabetes/Metabolism Research and Reviews, 32, 99-118. doi:10.1002/dmrr.2702
Forsythe, R. O., & Hinchliffe, R. J. (2016). Assessment of foot perfusion in patients with a
diabetic foot ulcer. Diabetes/Metabolism Research and Reviews, 32, 232-238.
doi:10.1002/dmrr.2756
Frykberg, R. G., & Banks, J. (2015). Challenges in the Treatment of Chronic Wounds.
Advances in Wound Care, 4(9), 560-582. doi:10.1089/wound.2015.0635
Janisse, D., & Janisse, E. (2015). Pedorthic management of the diabetic foot. Prosthetics and
Orthotics International, 39(1), 40-47. doi:10.1177/0309364614535233

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Lipsky, B. A. (2016). Diabetic foot infections: Current treatment and delaying the ‘post-
antibiotic era’. Diabetes/Metabolism Research and Reviews, 32, 246-253.
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Peters, E. J., Lipsky, B. A., Aragón-Sánchez, J., Boyko, E. J., Diggle, M., & Embil, J. M.
(2016). Interventions in the management of infection in the foot in diabetes: a
systematic review. Diabetes/Metabolism Research and Reviews, 32, 145-153.
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S, S. (2018). An Overview on Diabetic Foot Ulcer (DFU): Mini Review. Diabetes Case
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Satish, L. (2015). Chemokines as Therapeutic Targets to Improve Healing Efficiency of
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Schaper, N. C., Van Netten, J. J., Apelqvist, J., Lipsky, B. A., & Bakker, K. (2016).
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Diabetes/Metabolism Research and Reviews, 32, 7-15. doi:10.1002/dmrr.2695
Shearman, C. P. (2015). Foot Complications in Diabetes: The Problem. Management of
Diabetic Foot Complications, 1-7. doi:10.1007/978-1-4471-4525-7_1
Sulistyo, A. A. (2018). MANAGEMENT OF DIABETIC FOOT ULCER: A LITERATURE
REVIEW. Jurnal Keperawatan Indonesia, 21(2), 84. doi:10.7454/jki.v21i2.634