Determination of Priority of Care

This essay discusses the importance of determining clinical priorities in nursing care and focuses on the case of Mrs. Gina Bacci, a patient with a diabetic foot ulcer. The essay identifies two clinical priorities for Mrs. Bacci, which are effective wound management and diabetes self-management. It explains the significance of these priorities and provides nursing interventions for each. The essay emphasizes the importance of proper wound care and the promotion of self-management skills for diabetes in improving patient outcomes.

Running head: CLINICAL REASONING CYCLE
Determination of Priority of Care
As per the evidence-based nursing practice, development of person centred care plan in
nursing helps to improve the overall health-related outcomes. In order to generate person-centred
care plan, proper identification of the clinical priority is of prime need (Crisp et al., 2017). The
identification of the clinical priority must be done based on the person’s physical and mental
needs. The Levette Jones Clinical Reasoning Cycle helps in proper identification of the clinical
priority of the healthcare service users (Levett-Jones, 2018). The following essay aims to identify
two clinical priorities of Mrs Gina Bacci, a 49 year old lady who had recently undergone surgery
for diabetic foot ulcer.
Mrs Gina Bacci wound site is cold to touch with a capillary refill time of two to three
seconds. This is higher than the normal capillary refill time (less than two seconds). The high
capillary refill time along with clod temperature indicates reduction in the flow of the oxygen at
the wound site that is decreased peripheral perfusion. Lack of optimal peripheral perfusion
signifies that there is improper flow of blood at the site of the wound. Lack of proper platelets or
thrombocytes through blood at the wound site decreases the process of wound healing (Bullock
& Hales, 2019). The wound site is cold to tough and this might be attributed to diabetic
neuropath arising out of microvascular complications of diabetes. In peripheral neuropathy there
occurs increase in the oxidative stress followed by generation of reactive oxygen species and
thereby reducing the process of wound healing at the peripheral site of the body (Hall, 2016).
The generation of peripheral neuropathy is attributed to her unmanaged state of diabetes. Her
parameters indicates that her condition of diabetes management of extremely poor. High level
BGL (12.6mmol/L; normal: 4.0 to 5.4 mmol/L), high level of Basal Metabolic Index [BMI]

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(40.4m2) and high body weight (110 Kg with 165 cm height and age 49 years). Her diabetes was
detected six years before and at present high BGL and body weight even under the insulin
medication, Novorapid TDS and Lantus indicates her unmanaged state of type 2 diabetes
mellitus (T2DM) leading to delayed or undamaged wound with poor capillary refill (Bullock &
Hales, 2019). The unmanaged diabetes impairs the normal functioning of the hepatic cells
leading to the increase in the blood cholesterols level (low density lipo-protein or bad
cholesterol). The high blood cholesterol gets deposited in the arteries and leading to narrowing of
the arteries. The narrowing of the arteries limits the flow of the blood at the peripheral sites of
the body leading to delay in the process of wound healing (peripheral neuropathy) (Hall, 2016).
The presence of the serous exudate even after 7 days post-surgical wound is another
indicator of the delayed wound healing resulting in the formation of dehiscence at the surgical
site along with the formation of sloughy tissue. Generally serous exudate is a normal by-product
of wound healing that last for 48 to 72 hours after the post-surgical wound. Thus presence of
serous exudate even at 7th day of post-surgical wound is a direct indicator of delayed process of
wound healing (Bryant & Nix, 2015).The surrounding skin of the wound is warm, colour is dark
pink and is painful to touch. The high temperature at the wound site indicates that the wound is
helping to prevent the possible chances of the bacterial infection. The painful signs of wound
might be due to the infiltration of the macrophages at the wound site after the generation of type
1 hypersensitivity reaction. The pain and redness might also indicate the possible signs of the
bacterial infection or signs of combating any impending site of bacterial infections. The high
body temperature (37.8ºC; normal: 38-degree C) further indicates the possible site of infection as
body increases the temperature by sensing the hypothalamus in order to prevent the colonization
of the microbial cells within the body. The wet area at the wound site is another mechanism of

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wound healing used to retain the moisture at the site of the wound (Bryant & Nix, 2015). Her
other vital parameters like the blood pressure (120/70mmHg), pulse rate (88 bpm) and
respiratory rate (18 bpm) and oxygen saturation (97% on RA) are within the normal rate and thus
indicating no possible signs of cardiac problem and pulmonary problem (Forbes & Watt, 2016).
Effective wound management is the first nursing priority for Mrs Gina Bacci because
she was admitted to hospital 2 weeks ago in order to conduct surgery following her
complications from a right foot ulcer. She went for surgery under general anaesthesia and
underdone partial amputation of forefoot, great and first toes. At present she has visit to the
hospital post seven days in the out-patient department for wound assessment and management
(Hamlin et al., 2016). Thus primary nursing goal will be effective management of her wound, the
main concern. Wound management for Mrs Gina Bacci is further important because she has
unmanaged diabetes that delays the process of wound healing and the same time her wound has
some dehiscence along the suture line along with certain sloughy tissue which are again signs of
delayed wound healing (Forbes & Watt, 2016).
Promoting self-management skills of diabetes is the second nursing priority. Mrs Gina
Bacci was diagnosed with T2DM six years ago. At present she has peripheral vascular disease
(PVD) and Obesity ((BMI 40.4m2; Height 165cm weight 110kgs). The case study had also
reflected that her worsening condition of diabetes has led to the administration of insulin
(Novorapid TDS 12units and Lantus 30units nocte). All these symptoms indicate that she is
suffering from unmanaged diabetes mellitus (Martini, Nath & Bartholomew, 2018). Her blood
glucose level (BGL) [12.6mmol/L; normal 5.6 to 6.9 mmol/L] is further giving indication of
unmanaged diabetes. Unmanaged diabetes for a prolong period of time leads to the development
of peripheral diabetic neuropathy (micro-vascular complications of diabetes). Mrs Gina Bacci

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also has cold feet and this indicates positive signs of diabetic neuropathy. This uncontrolled yet
severe state of diabetes hampers the process of wound healing by decreasing the infiltration of
platelets at the wound site and at the same time increases the severity of diabetic foot ulcers
(Martini, Nath & Bartholomew, 2018). This increases the tendency of re-occurrence. Effective
management of diabetes with the help of self-management skills will help to reduce high BGL
and thereby promoting faster wound recovery and improving the overall quality of life by
reducing body weight (Chrvala et al., 2016). Powers et al. (2017) further reported that inducing
self-management skills is one of the effective non-pharmacological interventions for T2DM
management.
Education and health-awareness for self-management of diabetes will be the first
nursing intervention. According to the Standard 2 of the National Safety and Quality Health
Service Standards by Australian Commission on Safety and Quality in Health Care (ACSQHC)
(2012), partnering with the consumers helps to improve the overall participation of the customers
in the healthcare plan and at the same time helps to ensure clinical governance (standard 1).
Proper observance of clinical governance helps to increase the patient participation in the care
plan. In the domain of diabetes health education about the process of disease prognosis helps to
increase the sense of clinical governance and at the same time helps to increase the partnering
with the clients. The generation of effective partnership with the client helps to increase the
diabetes self-management skills (Forbes & Watt, 2016). Mrs. Gina Bacci lacks proper
knowledge in the domain of self-management of diabetes and this is reflected in her high body
weight and high BMI. Moreover, she at times feel that she is not required to take medication for
her diabetes management. Thus education about the healthy lifestyle of diabetes management
(non-pharmacological interventions) and at the same time awareness about the importance of

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medication in diabetes management (pharmacological medications) will help to increase her
adherence to therapy and improvement in the self-management skills (Crisp et al., 2017).
Education will be given by either a residential care nurse or a diabetic nurse under the presence
of a bilingual nurse or culturally and linguistically (CALD) nurse this is because, Mrs. Gina
Bacci is an Italian with poor English. Presence of CLAD nurse will help to act as an interpreter
and thus promoting effective understanding of the disease progression and self-management
skills (Schaffler et al., 2019). The lifestyle for Mrs Gina Bacci will be directed towards change in
the feeding habits. Low calories (restricted carbohydrate) and high protein diet will be suitable
for Mrs Gina Bacci for reducing the BMI and body weight and thereby helping to manage
diabetes (Ponzo et al., 2018). Change in lifestyle through physical education might not be
suitable for her as she under recently undergone surgery in her leg.
Change of Dressing and wound management will be second nursing intervention. Mrs
Gina Bacci wound is wet with serous exudate and thus the priority will be removal and
replacement of the Island film dressing. Island dressing consist of an absorbent pad fitted over a
conformable fixative layer that is soft yet simple to use. It is effective in managing the sutured or
the post-operative wound. The breathable covers along with highly absorbent pad will help to
ensure proper aeration while helping to soak the excess of serum exudate and thereby helping to
keep the wound region dry and free from microbes (Hamlin et al., 2016). In order to alleviate the
pain from the wound site after the replacement of the dressing, music therapy or aromatherapy
can be used. Such non-pharmacological interventions help to distract the mind and thereby
helping to reduce the sensation of conscious pain (Bryant & Nix, 2015). The entire operation of
the wound dressing must be done under aseptic condition in order to reduce the chance of cross-
infection (Hamlin et al, 2016). Consultation with the healthcare physicians is also important in

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order to administered proper drugs and ointments to fasten the process of wound healing. For
example use of antibiotic ointments helps to ensure faster wound healing while preventing the
chance of bacterial infection (Hamlin et al, 2016). Mrs. Gina Bacci should be educated that use
of shocks is not recommended at her current stage as it might increase the friction at the wound
site leading to decrease in the process of wound healing (Hamlin et al, 2016).
Thus from the above discussion, it can be concluded that two major clinical priorities that
were identified based on the collection and processing of clues are effective wound care and
management by removal and replacement of the wound and effective management of diabetes by
promotion of self-management skills through diabetes education. In the self-management of
diabetes emphasis must be given to observance of effective diet plan and use of CALD nurses to
develop culturally competent plan and to ensure effective communication with Mrs Gina Bacci.

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References
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Craft
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