Clinical Reasoning Cycle of Wound Management

CLINICAL REASONING CYCLE OF WOUND MANAGEMENT
CLINICAL REASONING CYCLE OF WOUND MANAGEMENT
According to the evidence-based practice, the generation of patient-centred care plan in
the profession of healthcare helps in improving overall health outcome while decreasing the
length of stay at the hospital. In order to generate patient-centred care plan, the prime
requirement is the identification of the clinical priority based on the needs of the patient (Crisp et
al., 2017). The identification of clinical priority by the application of the proper critical thinking
skills can be done with the help of the Levette Jones Clinical Reasoning Cycle Framework
(Levett-Jones, 2018). The following essay aims to identify two clinical priority of Mrs Gina
Bacci. She is a 49-year old lady who was diagnosed with type-2 diabetes six years ago and at
present suffering from foot ulcer for that she had undergone surgery.
The wound site of Gina Bacci is cold with capillary re-fill time of two to three seconds
(normal time: less than 2 seconds) (Hall, 2016). Thus the capillary re-fill time of Mrs Bacci is
higher than the normal. The high capillary re-fill time indicates decrease in the oxygen flow at
the wound site. The decrease in the flow of the oxygen indicates the sign of lack of optimal
peripheral perfusion. In the absence of proper peripheral perfusion, the proper flow of the blood
at the wound site is decrease. This causes decrease in the infiltration of platelets or thrombocytes
at the wound site and delaying the process of wound healing (Bullock & Hales, 2019). The
decrease temperature at the wound site is attributable to diabetic neuropathy which is one of the
first indication of the microvascular complication of diabetes apart from peripheral neuropathy.
In Peripheral neuropathy, the body or the periphery of the body suffers from oxidative stress
leading to the generation of reactive oxygen species. The generation of reactive oxygen species
delays the process of wound healing (Sunshein & Samouilov, 2017). The peripheral neuropathy

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CLINICAL REASONING CYCLE OF WOUND MANAGEMENT
and diabetic foot ulcer as microvascular complications of diabetes mainly arise due to prolong
tenure of unmanaged state of diabetes. The blood glucose level (BGL) of Mrs Bacci is higher
than the normal (12.6mmol/L; normal: 4.0 to 5.4 mmol/L) with high blood pressure
(12.6mmol/L; normal: 4.0 to 5.4 mmol/L), high level of Basal Metabolic Index [BMI] (40.4m2)
and high body weight (110 Kg with 165 cm height and age 49 years; ideal weight: 56 to 60
kilograms) (Hall, 2016). All the vital statistics and BGL indicates highly unmanaged state of
diabetes and thereby leading to delay in wound healing or diabetic foot ulcer. Han and Ceilley,
(2017) are of the opinion that long-term type 2 diabetes lead to the generation of high blood
glucose level and high level of insulin insensitivity. This might be the case of Mrs Gina Bacci as
she is having high BGL even under insulin medication (Novorapid TDS and Lantus) and thus
further indicating unmanaged diabetes state along with increased chance of diabetic neuropathy
and delay in wound healing (Han & Ceilley, 2017). Huang et al. (2017) reported that unmanaged
state of diabetes also leads to macro vascular complications where the body in unable to convert
LDL (low-density-lipoprotein or bad cholesterol) to HDL (high-density-lipoprotein or good
cholesterol). The LDL gets deposited in the arteries leading to arthrosclerosis. In arthrosclerosis
cause narrowing of arteries, hampering the flow of the blood and thereby reducing the blood
flow at the peripheral parts of the body like feet and hampering the process of wound healing.
The appearance of the serous exudate is the first sign of wound healing but it lasts for two
to three days. However, in case of Mrs Bacci, the presence of serum exudate is still visible after
7 days of the surgery and this can be considered as a process of delayed wound healing (Bryant
& Nix, 2015). The presence of the sloughy tissue at the site of the wound along with dehiscence
along the suture line might have resulted in the use of sock by Mrs Bacci at night in order keep
her feet warm as she used to suffer from cold feet arising out of peripheral diabetic neuropathy.

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CLINICAL REASONING CYCLE OF WOUND MANAGEMENT
Price, Moffatt and Crofts (2015) reported that wearing of socks over the wound creates friction
leading to disruption of the tender tissue of the wound and causing abdominal wound dehiscence.
Her vital parameters indicate that her body temperature is high (37.8ºC; normal: 38-degree C)
though she is under the medication of the paracetamol. This might be a possible signs infection
as the temperature of the body increased through neuro-signalling in the hypothalamus, occurs
mainly during the bacterial infection in the body. The rise in the body temperature helps to
prevent the growth of the bacteria (Forbes & Watt, 2016). Other vital signs of Mrs Bacci were
normal starting from blood pressure, heart rate, pulse rate and oxygen saturation.
Effective wound management is the first nursing priority. According to patients who are
suffering from unmanaged diabetes and is having foot ulcer, the nursing intervention must
involve effective management of the wound. As per the evidence-based practice, effective-
management of wound deals with regular change of dressing use of proper ointment (Greatrex‐
White and Moxey, 2015). At present she has visited the out-patient department posts her surgery.
She had undergone amputation in her forefoot, first and great toes and thus effective
management of wound is important for faster recovery (Hamlin et al., 2016). Moreover, the
wound site of Mrs. Bacci has dehiscence along with sloughy that can aggravate the negative
prognosis of the wound and thus require urgent nursing intervention.
Promotion of the self-management skills for diabetes management will be second nursing
priority. The pathophysiology analysis of the case study highlighted that the roout cause of the
complication in Mrs Bacci like foot ulcer, delay wound healing, peripheral vascular disease,
weight gain are result of her management state of diabetes. High blood glucose level even under
the presence of inulin medication might be an indication unhealthy lifestyles habits like improper
diet or improper medication management after discharge (Chrvala, Sherr & Lipman, 2016). Thus