Complex Nursing Care: Case Study Analysis and Nursing Interventions

This report analyzes a case study of a patient with surgical site infection and identifies the major health problems of infection and pain. It discusses the nursing interventions, such as prophylactic antibiotics and advanced dressing, to reduce infection and promote wound healing. The evaluation of patient outcomes and the importance of pain management are also highlighted.

Running head: COMPLEX NURSING CARE
Complex nursing care
Name of the student:
Name of the University:
Author’s note

1COMPLEX NURSING CARE
Introduction:
Complex nursing care involves critical assessment of patient’s objective and subjective
data to identify major health issues in patient and use clinical judgment and nursing knowledge
to implement appropriate nursing interventions for patient. The main purpose of this report is to
review the case study of Mr. Christopher Collins, a 54 year old male who is complaining of pain
at the incision site after left high tibia knee osteotomy and analyse the subjective and objective
data of patient to identify key problems in patient and the optimal patient outcomes needed to
resolved the issue. Based on the care plan developed, the report will focus on critical discussion
of two health problems for Mr. Collins and prioritize main nursing interventions that can be
undertaken by a newly graduate nurse to achieve desired health outcome for patient. The method
of evaluating the effectiveness of the intervention will also be explored.
Assessment data:
Mr. Christopher Collin is a patient who has been diagnosed with early stage osteoarthritis
in the left knee causing pain and affecting mobility. In response to this knee, a left high tibia
knee osteotomy was undertaken 5 days ago with an uneventful post-operative period. However,
Christopher represented at the ED with pain and others symptoms. The brief assessment data of
patient are as follows:
Airway: Objective data suggest patent airway indicating no airway obstruction
Breathing: Objective data RR 27 (normal respiratory rate is 12 to 20 breaths per minute) and
verbal report related to breathlessness suggest this as one of the problem for patient

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Circulation: HR 125 and BP 98/57 indicate risk of breathing related problem and tachycardia in
patient. He is also found to be hypotensive
Disability: The assessment of consciousness level using GCS revealed a score of 15. This is
indicative of the fact that there is no problem in terms of eye, verbal and motor response. As pain
may also contribute to disability and mobility related issues, the assessment of pain revealed a
score of 15 which means patient is suffering from moderate pain.
Exposure: Skin assessment is vital to identify any signs of infections. It revealed the
characteristics of the surgical site. The symptoms include sutures in skin, areas of dehiscence
with pus and shiny red swollen areas.
Fluids: Patient was on IV cannula
Glucose: Glucose 5.1 Nil
Two problems identified for the patient:
Based on the review of the assessment data and the links between each vital signs, the
key problems that has been identified for Mr. Collins includes pain, infection, breathlessness and
low blood pressure. Out of these health problems, the two major health problems that has been
identified for Mr. Collins include risk of infection and pain. The main rationale behind arriving
at these two health problem is that the characteristics of patient’s wound is indication of infection
at the surgical site. The symptom of redness, swelling, skin tightness, skin suture and dehiscence
with pus is a sign of bacterial infection at the wound site. As these symptoms have emerged in
patient after going through a surgical procedure (left high tibia knee osteotomy), it is indicative
of postoperative wound infections. Pus in the wound is indicative of necrosis. Symptoms like

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hematoma, wound dehiscence, necrosis and wound infection occurs because of penetration of
pathogen infection in the wound. The local proliferation of the infection along with
immunological response of the host organism to the pathogen results in inflammation and
presence of symptoms like redness, swelling and pus (Milne, Reeves and Blazeby 2016). Hence,
this pathophysiological explanation regarding the cause of redness, swelling and dehiscence has
helped to arrive at the conclusion that wound infection is one of the major health problems for
Mr. Collins.
Another major health issue that has been identified for patient includes pain due to
impaired skin integrity and infection. During representation to the ED, Mr. Collins had reported
about pain at incision site along with nausea and shaky feeling. As infection may further increase
the severity of pain, pain has been identified as the second health problem for patient. This issue
has been identified because both subjective and objective symptom of pain been experienced by
patient because of wound infection. Powers et al. (2016) defines that pain is a common
experience for patients with wounds and this mainly occurs because of tissue damage. The pain
is linked to inflammatory response and wound infection becomes painful because they occur
because of detrimental interaction between the host and the pathogen thus delaying wound
healing and amplifying wound pain. The key link between the health problem of pain and wound
infection is understood from the pathophysiological process associated with wound relate pain.
The penetration of infective microorganisms results in initiation of inflammatory response and
release of enzymes and free radicals which contribute to tissue damage. In addition, such patient
experience pain due to direct stimulation of peripheral pain receptors by the mediators and the
swelling of the wound area (Dumville et al. 2016). Hence, inflammation and tissue damage is the
main cause behind pain and identifying pain as a health problem for Mr. Collins.

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Identified health outcomes for the problem:
The chosen outcome for Mr. Collins in relation to the problem of infection is to reduce
the risk of delayed wound healing and minimize chances of complications and hospitalization for
patient. This is important because postoperative wound infection prolongs hospital stay, increase
morbidity and mortality and increase the cost associated with care. Badia et al. (2017) gives the
evidence that hospital readmission rate and increased health care cost is one of the consequences
of surgical wound infection. It increases the economic and clinical burden of surgery. Such
types of infection negatively influence physical and mental health of patient and delay wound
healing as patient becomes more susceptible to secondary complications. Hence, targeting
wound healing would help to implement appropriate nursing intervention that not only reduce
the severity of infection for Mr. Collins but also promote rapid wound healing and reducing the
cost associated with hospitalization.
In relation to the second health problem for pain, the key health outcome that has been
chosen is to provide pain relief and comfort to patient. This outcome has been prioritized because
pain is associated with restlessness and discomfort for patient. Wound pain caused by infection
and tissue damage is an indicator of ineffective wound management. The pathophysiological
process that increases discomfort for patient with pain includes the initiation of the biochemical
process in the wound due to nerve damage. Increase in wound pain can also lead to lack of
compliance to treatment (Frescos, 2011). Hence, targeting reduction in pain is vital to achieve
positive health outcomes and reduce discomfort for Mr. Collins.
Nursing interventions for the two problems identified:

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As infection of the surgical wound has been identified as a major health problem for Mr.
Collins, there is a need to implement many independent as well as dependent interventions to
reduce infection and promote wound healing. The key nursing intervention that needs to be
provided to Mr. Collins includes applied compression stockings and elevation of the wound. The
dependent nursing intervention that has been prioritized for Mr. Collins includes initiation of
prophylactic antibiotic and advanced dressing. The key rationale behind each of the independent
and dependent nursing intervention is as follows:
1. Prophylactic antibiotics: The nursing intervention of antibiotic treatment is vital for
patient with surgical site infection because administration of antibiotic can reduce the
infection rate. The utility of this intervention is that antibiotic kill or disrupt the growth of
microorganisms causing infection and prevent it from spreading. This may help to control
the inflammantory process and reduce symptom of redness and swelling in patient
(Norman et al., 2016). The Clinical Excellence Commission (2018) guideline also
supports increasing antibiotic treatment as a surgical prophylaxis to ensure reduction in
infection rate post surgery.
2. Advanced dressing: The dependent nursing priority is to provide advanced dressing to
Mr. Collins to provide good moisture to the wound and keep the wound site free from
any infection and microbial contamination. Another advantage of advanced dressing is
that advanced dressing can help to maintain optimum pH and temperature for wound
healing (Dumville et al. 2016). The evidence by Boateng and Catanzano (2015) suggest
that advanced dressing like hydrogel and hydrocolloids is necessary for wound healing as
they promote biological activity and controlled delivery of drug to the wound sites.
Proper dressing also control wound secretion and reduce bacterial contamination.

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3. Compression stockings: The first priority nursing intervention is to provide compression
stockings to patient. The main rationale behind such stockings for Mr. Collins is that it
can work to reduce swelling in the infection site by increasing the pressure under the skin
and reducing the excess fluids that build up in the legs. The pressure on the knee can also
improve venous flow speeds thus facilitation wound healing and preventing infection.
Another advantage of compression stocking is that reduction in fluid accumulation would
facilitate the skin to receive oxygen for wound healing (Winge et al. 2018).
In relation to the problem of pain, there is a need to implement dependent intervention like
NSAIDs (Non-steroidal anti-inflammatory drugs), opioid and cold pack for Mr. Collins. The
dependent intervention that needs to provide include environmental changes. The rationale
behind these interventions is as follows:
1. NSAIDs: NSAID drugs display both analgesic and anti-inflammatory properties thus
promoting pain management. It lend this effect through the inhibition of the enzyme
cyclooxygenases 1 and 2 (COX). Wound healing requires the events like homeostasis,
proliferation, inflammation and remodelling. The effectiveness of NSAIDs is that it can
disrupt processes in the proliferation stage through the inhibition of COX pathway.
Hence, this is vital to manage post-surgical complication in patient (Zhao-Fleming et al.
2018).
2. Environmental change: As pain is associated with discomfort for patient, another major
intervention that is needed is to make changes in the surrounding environment of patient
to provide comfort to patient. This involves maintaining and quiet and silent room and
ensuring that Mr. Collin can take adequate rest without any disruption. This can enhance
patient experience during hospital stay (Drake and Williams 2017).

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Evaluation:
To evaluate the outcome of patient, it is planned to conduct wound assessment and pain
score assessment of patient after 2-3 days. This will help to detect improvement in relation to
reduction in symptom of infection such as redness and swelling. The pain score assessment will
help to identify reduction in pain scores. The verbal feedback will also help to identify whether
the patient is feeling relief from pain or not.
Conclusion:
To conclude, the analysis of the case scenario of Mr. Collins suggests that pain
management and infection is a critical issue for post operative patients with surgical wound
infection. In response to the analysis of patient assessment data, two health problems of infection
and pain have been identified for Collins. The focus is to achieve the outcome of promoting
wound healing, reducing hospitalization rate, pain relief and decrease discomfort for patient. The
review of interventions prioritized for Mr. Collins suggest that systematic implementation of
evidence based dependent and independent nursing intervention can play a role in quick recovery
and treatment of patient with surgical site infection.

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References:
Badia, J. M., Casey, A. L., Petrosillo, N., Hudson, P. M., Mitchell, S. A., & Crosby, C. (2017).
Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in
six European countries. Journal of Hospital Infection, 96(1), 1-15.
Boateng, J. and Catanzano, O., 2015. Advanced therapeutic dressings for effective wound
healing—a review. Journal of Pharmaceutical Sciences, 104(11), pp.3653-3680.
Clinical Excellence Commission 2018. Improving antibiotic prescribing for surgical
prophylaxis. Retrieved from:
http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/394262/2017AAW-Pres-Surgical-
antibiotic-prophylaxis-combined-slides.pdf
Drake, G. and Williams, A.C.D.C., 2017. Nursing education interventions for managing acute
pain in hospital settings: a systematic review of clinical outcomes and teaching methods. Pain
Management Nursing, 18(1), pp.3-15.
Dumville, J. C., Gray, T. A., Walter, C. J., Sharp, C. A., Page, T., Macefield, R., ... & Blazeby, J.
(2016). Dressings for the prevention of surgical site infection. Cochrane Database of Systematic
Reviews, (12).
Dumville, J.C., Gray, T.A., Walter, C.J., Sharp, C.A., Page, T., Macefield, R., Blencowe, N.,
Milne, T.K., Reeves, B.C. and Blazeby, J., 2016. Dressings for the prevention of surgical site
infection. Cochrane Database of Systematic Reviews, (12).
Frescos, N. (2011). What causes wound pain?. Journal of foot and ankle research, 4(1), P22.

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Milne, T.K., Reeves, B.C. and Blazeby, J., 2016. Dressings for the prevention of surgical site
infection. Cochrane Database of Systematic Reviews, (12).
Norman, G., Dumville, J. C., Mohapatra, D. P., Owens, G. L., and Crosbie, E. J. 2016.
Antibiotics and antiseptics for surgical wounds healing by secondary intention. Cochrane
Database of Systematic Reviews, (3).
Powers, J. G., Higham, C., Broussard, K., and Phillips, T. J. 2016. Wound healing and treating
wounds: Chronic wound care and management. Journal of the American Academy of
Dermatology, 74(4), 607-625.
Winge, R., Ryge, C., Bayer, L., Klausen, T. W., and Gottlieb, H. 2018. Wound complications
after ankle surgery. Does compression treatment work? A randomized, controlled trial. European
Journal of Trauma and Emergency Surgery, 44(6), 947-956.
Zhao-Fleming, H., Hand, A., Zhang, K., Polak, R., Northcut, A., Jacob, D., Dissanaike, S. and
Rumbaugh, K.P., 2018. Effect of non-steroidal anti-inflammatory drugs on post-surgical
complications against the backdrop of the opioid crisis. Burns & trauma, 6(1), p.25.

Running head: COMPLEX NURSING CARE
PLAN OF CARE
PATIENT or NURSING ORIENTED PROBLEM OR
PATIENT NEED
PATIENT ASSESSMENT DATA OPTIMAL PATIENT OUTCOME or GOAL
1. Christopher Collins is at risk of
infection due to impaired skin
integrity
Evidence by exposure assessment which revealed
swollen, shiny and red wound with skin tightness.
Several areas of dehiscence found
Reduce infection, prevent hospitalization and
promote wound healing
2. Pain due to potential tissue damage Objective data: Pain score of left knee 5/10
Subjective data: Patient complains of pain at the
incision site
Reduce level of pain and discomfort for patient
3. Risk of breathlessness RR is 27 and HR is 125 Breathing support needs to be provided for effective
breathing
4. Low blood pressure Blood pressure 98/57 and the Reduce blood pressure to enhance blood flow and
promote wound healing

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5.
6.