Case Study Analysis

This essay focuses on the pathophysiology of a clinical condition and two clinical priorities for Mrs. Gina Bacci. It also discusses interventions for effective wound management and diabetes and obesity management.

Running head: CASE STUDY ANALYSIS
CASE STUDY ANALYSIS
Name of the Student
Name of the university
Author’s note

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CASE STUDY ANALYSIS
Case study analysis
Clinical reasoning cycle has long been used to understand the underlying
pathophysiology of any clinical condition, with the main aim is to provide a patient centred care.
A Levett Jones clinical reasoning cycle has been used to apply critical thinking skills (Levett-
Jones, 2018). The following essay centres round two clinical priority of Mrs. Gina Bacci, who is
a 49 years old woman and has been admitted in to the hospital for the partial amputation of the
forefoot and the great and the first toes. The patient had a history of Type II diabetes, obesity and
peripheral vascular disease. This paper will focus on the pathophysiology of the current clinical
condition of the patient and will also reflect on two clinical priorities for Mrs. Gina Bacci. The
essay would also aim to provide with the interventions in response to the clinical priority chosen
As evident from the objective assessment of Mrs. Gina Bacci, the capillary refill of her
right foot is 2-3 seconds and the toes are cool to touch. The normal capillary refill time is about 2
seconds and hence value for Mrs Bacci is usual than the normal value. A high capillary refill
time indicates less blood flow at the site of the wound, which can again be linked to less
peripheral transfusion. This results in the decreased infiltration of the thrombocytes at the site. It
ultimately causes a delay in healing of the wound. It should be mentioned that low body
temperature can cause multiple enzyme dysfunction and the enzymes are important in the repair
of the wear tissue of the skin.
Upon observational assessment, it was found that the wound was painful to touch,
swollen, inflamed and red in colour and warm. The healing of a wound is a complex process and
involve three over lapping inflammatory reactions-proliferation and remodelling. The

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inflammatory phase is characterised by coagulation of blood homeostasis as well as some
cellular events, including the infiltration of the leukocytes with a varied functions in the
antimicrobial and cytokine release that initiates the proliferative response for the wound
response, due to these series of events the wound might be swollen and pink. The wound has also
been noted with some dehiscence along the surture lines (Grauhan et al., 2017). The surrounding
skin has been found to be warm, which is a part of the inflammatory process. Sloughy tissue can
also be found at the wound site due to which the sutures might appear tight and under kin around
the wound. According to Winfield, Reese, Bochicchio, Mazuski & Bochicchio, (2016), using
improper sutures can increase tension on the skin that might lead to breaking of the sutures. The
main cause of the wound dehiscence is the presence of sub-acute infection due to inappropriate
asceptic techniques. It is to be noted that serous exudate is a sign of wound healing however, it
can be found that the serum exudate is still present after 7 days after the surgery, which can be
considered as a delayed wound healing. The presence of slough indicates that the wound is stuck
in the inflammatory phase and the body is attempting to clear the wound bed in preparation for
the healing. Slough is usually a combination of bacteria leukocytes, debris or devitalised tissues.
Baltzis, Eleftheriadou and Veves, (2014), have stated , that some of the other cause of wound
healing can be the presence of weak tissue or the muscles at the area of the wound, overweight
and increasing age. It is known that Mrs Bacci used bed socks as she is has cold feet. Hence
socks might cause friction causing the sutures to open. During the immunologic reaction of the
wound, several enzymes and free radicals are released by the body at the site of the wound
causing the wound to be painful and swollen. Other vital signs of Mrs Bacci indicates that her
body temperature is high, which might be a possible indication of infections. The rise in the
temperature is the response of a body to any kind of infections for preventing the growth of the

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bacteria. The vital signs of the body includes Basal metabolic rate and high body weight which is
quite higher than the normal value (12.6mmol/L; normal: 4.0 to 5.4 mmol/L). The high blood
glucose level indicates a high unmanaged state of diabetes, contributing to a delayed healing of
the wound (Schaper et al., 2016). It is surprising to the found the Mrs Bacci is still having high
diabetic level even after the consumption of the medicine, which proves that that her diabetes is
unmanaged that can lead to macrovascular complications, where a body fails to convert HDL
cholesterol in to LDL cholesterol (Huang et al, 2017). The deposition of the LDL occurs in the
arteries causing arthrosclerosis. In this condition, the narrowing of the arteries occur causing a
restriction of the blood flow in to the peripheral regions of the body.
The primary clinical priority chosen for Mrs Gina Bacci would be effective wound
management. It is already known that diabetic foot ulcers show delayed wound healing, if not
treated properly (Han & Ceilley, 2017). Nursing management of the wound would involve
proper dressing of the wound with an application of proper ointments. Improper wound cleansing
might lead to wound dehiscence, infection and necrosis. Further negligence may lead to further
deterioration like diabetes neuropathy causing nerve damage (Sunshein & Samouilov, 2017).
Lack of blood flow in to the cells and the tissue can cause necrosis that might cause entire leg to
be amputed. Hence, patients suffering from post-surgical wounds should be treated properly
including cleansing of the wound and the use of appropriate dressings. One of the important
element of the wound management is the self-management of wound. As after a patient is being
discharged from the hospital, it is te accountability of the patient to take care of the dressings,
reviewing the wound status and asking for regular follow up with the doctors.
The second important clinical priority is the management of diabetes and obesity. It is
evident from the case study, that there were signs of dehiscence along the suture lines. People

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with obesity have a seven fold increased risk of wound infection and also carries an increased
chance of broken sutures and it poses an increase pressure at the incision site (Winfield et al,
2016). Furthermore, obese patients are susceptible to poor control of diabetes. According to
American Diabetes Association. (2015), for those people who are obese, a loss of 5 % of the
body weight have been found to be useful in improving the blood glucose level. This due to the
fact that body mass index has an important relationship with insulin resistance. Obese people are
associated with an increased amount of non-esterified fatty acids, hormones, glycerol, cytokines
and proinflammatory markers that causes to develop insulin resistance in the obese individuals.
Al-Goblan, Al-Alfi and Khan, (2014) has mentioned that wound healing in diabetes is delayed
due to poor circulation of blood due to damaged nerves. Thus, delayed wound healing signifies
that someone with diabetes would develop infections and complications (Han & Ceilley, 2017).
An infected wound affects the quality of life of a person as it makes a person functionally weak
causing difficulty in free mobility.
As discussed earlier, the prime priority of Mrs. Gina is the management of her diabetic
wound. The nursing interventions should mainly focus on the foot wound and the surgical site,
preventing further breakdown of the skin and keeping the blood glucose level under control
(Aalaa, Malazy, Sanjari, Peimani & Mohajeri-Tehrani, 2012). Effective interventions involve
examination of the wound and screening for the presence of peripheral neuropathy and
peripheral vascular infections and disease (Forbes & Watt, 2016). Selection of appropriate
dressings for covering the wound is again an important step of wound management. Selection of
the dressing should depend upon whether the wound is wet or dry. The dressing should be made
such that the wound moisture is maintained as it helps in reducing the number of bacteria. Again,
the nurses play an important role in educating the patients about the management of wound.

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Nurses might teach the patients how they can perform physical examination on their own and
take care of their feet on a daily basis. Nurses can encourage the patients to take some simple
precautions, such as checking the shoe before wearing it, keeping the wound clean and
continuing care of the nails and skin. Following up diabetic patients are a part of the nursing care
plan. Self-management of the diabetic foot might get delayed in patients having impaired vision,
in such cases, nurses can make home visits for a regular follow up of the patients. Peripheral
vascular tissue, decreased sensation of the foot in combination with a delayed wound healing can
cause difficulty in the foot care. In order to reduce the pain and swelling, the patient will be
provided with suitable broad spectrum antibiotic to rule out the prevalence of infection. Pain can
be assessed by using pain scale, Apart from the pharmacological interventions to reduce the pain,
other complementary therapies such as touch therapy, music therapy can be used.
As mentioned earlier, another priority is the management of obesity and type 2 diabetes.
According to the standard blood glucose level of an individual is about 5.5mmol/L, but the BGL
of the patient was 12 mmol/L, which is much higher than the standard value. Sunshein and
Samouilov, (2017), have stated elevated BGL is one of the main reason of her delayed healing
of the wound. High diabetes might cause a condition called neuropathy, where the nerve gets
damaged restricting the flow of blood in to the limbs. Diabetic nerve might cause tingling
sensation. However, management of diabetes and obesity involves pharmacological management
of diabetes, followed by maintaining a proper diet regimen. Since, the BGL level is very high,
she might be given with intravenous insulin for controlling the blood sugar level. The patient can
be encouraged to take nutritious food and avoid food having high glycemic values. Choosing
healthy and fibrous food will not only maintain his BGL, but will also assist her to manage her
weight (Salas-Salvadó et al, 2017). As stated by Han and Ceilley, (2017), the effect of high

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proteins and fats increases the immunologic responses in the proximity of the incision site.
Another main intervention would be to follow an exercise regimen as per the age and the weight
of the patient. Although the patient had undergone a surgery, but she could be educated to do
mild incidental exercises.
In conclusion in can be said that the two main clinical priorities that has been identified in
this case are effective management of the wound and controlling the high blood glucose level.
The main nursing interventions involves proper screening and administration of antibiotics and
application of proper dressings. However, the essay had emphasised on the self-management of
wound and diabetes by taking care of the wound, following a proper diet, exercise and
medication adherence.

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References
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Al-Goblan, A. S., Al-Alfi, M. A., & Khan, M. Z. (2014). Mechanism linking diabetes mellitus
and obesity. Diabetes, metabolic syndrome and obesity: targets and therapy, 7, 587.
American Diabetes Association. (2015). Standards of medical care in diabetes—2015 abridged
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Han, G., & Ceilley, R. (2017). Chronic wound healing: a review of current management and
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