Nursing Assignment: Wound Management and Diabetes Mellitus

This nursing assignment focuses on wound management and the management of uncontrolled diabetes mellitus. It discusses the importance of effective wound management and the role of controlling blood glucose levels in promoting wound healing. The assignment also highlights the need for patient education and involvement of a multidisciplinary team in the care plan.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student:
Name of the University:
Author Note:

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Introduction:
While devising a nursing care for a patient, a number of factors have to be taken into
consideration. It should be noted in this regard that an effective nursing plan is governed by
the identification of proper care priorities. According to Levett-Jones (2018), the proper
identification of the care priorities and the application of appropriate nursing intervention
strategies help in promoting positive patient outcome. This paper intends to critically analyse
two clinical priorities for the patient Mrs. Gina Bacci who is a 49 year old, Italian lady who
has presented with the complaint of Diabetic foot ulcer. The clinical priorities would be
identified on the basis of the Levett Jones Clinical Reasoning Cycle. The patient problems
would be clearly identified and accordingly nursing goals would be set to acquire positive
patient outcome.
Response to Question 1:
According to the information provided by the case study it has been mentioned that
the patient’s wound site is located at the left foot and is cold to touch. Further, it has also
been mentioned that the capillary refill time is 2 to 3 seconds against the normal capillary
refill time being less than 2 seconds. Therefore, the high capillary refill time and the low
body temperature at the wound site indicates that there is a decreased flow of oxygen at the
wound site. This further indicates there is a decreased peripheral perfusion. Studies suggest
that a decreased rate of oxygenation and wound healing restricts the amount of blood flow at
the wound site (Amin & Doupis, 2016). As stated by Stoekenbroek et al. (2014), a decrease
in the blood flow at the wound site indicates a reduction in the infiltration rate of the blood
platelets as well as the blood plasma. Therefore, the process of the wound healing is delayed
due to the reduction in the infiltration rate of blood plasma as well as infiltrates. In addition to
this an increased oxidative stress on account of the extensive generation of reactive oxygen

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species (O3-) could be held accountable for enhancing the severity of the foot ulcer and this
would ultimately delay the process of wound healing (Stoekenbroek et al., 2014).
In addition to this the unmanaged TIIDM could be held accountable for the wound.
As can be deduced from the case study, it can be mentioned that the patient had been
suffering from Type II Diabetes for the past 6 years. In accordance to the patient objective
data it can be mentioned that the high BMI (40.4 m2) and high body weight (110 kg with the
height being 165 cm) at the age of 49 years and the high level of blood glucose level (12.6
mmol/L against the normal being 5.4 mmol/L) suggests that the patient’s Diabetes is
unmanaged. As mentioned by Tobe et al. (2013), high blood glucose level directly suggest
that the condition of TIID is unmanaged in a patient. The prescribed medication of the patient
includes daily dosage of Novorapid TDS and Lantus which are basically synthetic insulin
medication. Further, the unhealthy lifestyle habits of the patient could be held accountable for
triggering TIIDM. In addition to this, research studies mention that uncontrolled management
of Diabetes leads to problems such as the development of a Diabetic foot ulcer. Higher level
of blood glucose level for a long period of time has been studied to disrupt normal
neurotransmission functioning which subsequently leads to diabetic neuropathy which is also
known as Diabetic foot ulcer. (Byant et al., 2019)
Research studies indicate that higher blood glucose level affects the normal process of
fat disintegration (Bullock & Hales, 2019). The fatty acids or the triglycerides are directly
converted to low density lipo-protein and this LDL is deposited inside the arteries. The
accumulation of the LDL within the arteries leads to a condition of Arthrosclerosis (Bryant et
al., 2019). The condition causes the narrowing of the arteries and this delays the process of
wound healing. The delay in the wound healing process is critically indicated by the signs of
dehiscence near or adjacent to the suture lining with a presence of sloughy tissues.

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Upon analysing the post-operative wound condition, the presence of serous exudate
output is observed. Further the serous exudate is clear and watery and is not similar to the
purulent exudate which is thicker, viscos and opaque. It should be noted in this context that
the first phase of type 1 hypersensitivity is marked by inflammation (Bullock & Hales, 2019).
This phase is also characterized by the presence of de-granulated mast cells and infiltration of
the leucocytes which lead to the formation of the serous exudates. Bacterial infection at the
wound site leads to the change of the serous exudates into purulent exudates (Diabetes
Australia, 2019). However, the serous exudate at the wound site of the patient suggests that
the wound is free from infection. However, the wound indicates presence of serous exudate
after a week post-surgery. This suggests that process of healing is delayed. Also, studies
mention that the ideally the percentage of serous exudate must decrease within two or three
days after the surgery which was opposite in case of the patient (Brown et al., 2015). Further,
the area around the wound is warm, dark pink and causes pain on being touches which can be
compared to the initial stage of wound healing. As stated by Leaper et al. (2015), an
increased temperature at the wound site helps in the prevention and progression of bacterial
infection.
Response to Question 2:
Nursing priority 1: Wound management at surgical site
According to Daly et al. (2017), the use of effective nursing interventions can help in
the process of wound management and also reduce the possibility of infection at the wound
site. In addition to this, effective wound management can also help in preventing the chance
of sepsis development. As has already been discussed previously the patient has unmanaged
blood glucose level which indicates the poor management of the TIID symptoms. According
to Diabetes Australia (2019), elevated level of glucose within the blood interferes with the

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normal functioning of the hyaluronan and this subsequently impedes with the normal wound
healing process. In order to promote healing at the wound site, the blood glucose level needs
to be monitored. In addition to this, application of antiseptic ointment and changing wound
dressing could help in the process of wound healing. It is critical to note here that upon
controlling the blood glucose level, the wound site would exhibit rapid healing.
Nursing Priority 2: Management of uncontrolled Diabetes mellitus
According to Tobe et al. (2016), effective monitoring and control of the blood glucose
level can help in faster wound recovery among Diabetic patients. In the healing process, the
initial immune response involves the activation of the type I hypersensitivity reaction. The
reaction typically helps in the process of preventing the progression of the infection. The
subsequent step includes the generation of new cells at the wound site. The final step includes
the formation of a scar like tissue at the wound site. It should be noted here that the normal
process of wound healing is extensively delayed in case of patients with higher blood glucose
level. The delay of the healing process makes the wound susceptible to contamination or
infection by microbial agents. As stated by Shrivastave et al. (2013), upon maintaining the
blood glucose level within the optimal range, the possibility of acquiring a peripheral
neuropathy is considerably delayed. The reduction in the possibility of acquiring neuropathy
ensures proper signalling cascade and accelerates the process of recovery (Amin & Doupis,
2016). In addition to this, it promotes better infiltration of the blood cells and accelerates the
process of recovery. It should also be noted here that neuropathy is tightly associated with the
symptoms of experiencing cold feet or numbness within the feet at night. Patients are
recommended to wear socks in order to manage the symptom of cold feet, however, upon
covering the feet with socks, there is a significant possibility of deterioration of the wound
due to friction. Hence, it can be said that management of the blood glucose level can

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effectively help in controlling a major proportion of the symptoms related to Diabetic foot
and neuropathy.
Response to Question 3:
Nursing Management 1: Imparting patient education and self-management skills to
control TIIDM
Patient education forms an integral aspect of recovery. Nursing professionals must
promote patient empowerment by educating the patient about the disease condition and the
associated risk factors so as to involve the patient in the decision making process. Clearly, the
patient is unaware of the problems that have occurred due to the uncontrolled management of
her blood glucose level. In addition to this, it has also been mentioned that she feels that it is
not important to take her prescribed medication and even forgets to take her medication on
time. This reflects her lack of understanding about the seriousness of the disease and its
associated symptoms.
The care plan would include promoting health literacy about the need to follow a
strict diet plan that is low in carbohydrate intake. Further, she would be explained the risk
factors that contribute to the worsening of the illness and would be asked to make necessary
life changes. Also, she would be explained how to use a portable glucometer strip so that she
can monitor her blood glucose level. The patient would be educated by a nurse who is able to
speak and understand Italian, so as to render a culturally safe care.
Nursing Management 2: Effective wound dressing
It has been mentioned in the case study that upon presentment to the outpatient clinic,
the wound was found to be wet with serous exudates (Moura et al., 2013). It should be
mentioned here that dap wound dressing covering the wound for a long period of time
promotes infection. It is extremely important to conduct a wound assessment and replace the

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wound dressing. In this case, the application of Island dressing could help in the promotion of
accelerated wound recovery. The Island dressing typically comprises of an absorbent pad
with two adhesive sides (Leaper et al., 2015). The dressing is water proof and is widely used
to manage post-surgical wounds. Therefore, cleansing the wound, application of antiseptic
ointment followed by application of appropriate Island dressing can help in keeping the
wound dry and prevent the progression of infection.
Nursing Management 3: Involvement of multidisciplinary team
In order to devise the care plan for the patient, a multidisciplinary team would be
involved. The rationale for the same being, practicing collaborative practice so as to achieve
patient-centred care. The team would comprise of a dietician, a community nurse as well as
an occupational therapist. The rationale for collaborating with the occupational therapist can
be explained as the assistance in the form of energy saving techniques and managing
activities of daily living so as to avoid hurting the wound. The rationale for working with the
dietician can be explained as the assistance in the form of a diet plan so as to effectively
manage the high blood glucose level of the patient. The dietician would take into
consideration the food preferences of the patient so as to devise a culturally competent diet
plan. The community nurses would impart health literacy to the patient as well as the family
members so that the patient takes the prescribed medication timely.
Conclusion:
Therefore to conclude, it can be mentioned that the care priorities for the patient
would include managing the blood glucose level and effective wound management. The first
goal would be achieved by imparting health literacy to the patient and managing the diet of
the patient. Whereas, the second goal would be achieved by application of effective wound
dressing.

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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.
Brown, D., Edwards, H., Seaton, L. & Buckley, T. (Eds.) (2015). Lewis's medical-surgical
nursing. Assessment and management of clinical problems. Australian and New
Zealand Edition. (4th. ed.). Chatswood, NSW: Elsevier Australia.
Bryant, B., Knights, K., Rowland, A & Darroch, S. (2019). Pharmacology for health
professionals (5th ed.). Chatswood, NSW: Elsevier Australia.
Bullock, S., & Hales, M. (2019). Principles of pathophysiology. (2nd ed.) Australia: Pearson.
Craft,
Daly, J., Speedy, S., & Jackson, D. (2017). Contexts of nursing: An introduction. Elsevier
Health Sciences.
Diabetes Australia. (2019). Diabetes in Australia. Access date: 8th April. 2019. Retrieved
from: https://www.diabetesaustralia.com.au/diabetes-in-australia
Farrell, M. (Ed.) (2017). Smeltzer & Bare’s Textbook of Medical-Surgical Nursing. 4th
Australian and New Zealand Edition. Philadelphia: Wolters Kluwer.
Leaper, D. J., Tanner, J., Kiernan, M., Assadian, O., & Edmiston Jr, C. E. (2015). Surgical
site infection: poor compliance with guidelines and care bundles. International wound
journal, 12(3), 357-362.
Levett-Jones, T. (Ed.) (2018) Clinical Reasoning: Learning to think like a nurse. (2nd ed.)
Frenchs Forest, N.S.W.: Pearson.

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Moura, L. I., Dias, A. M., Carvalho, E., & de Sousa, H. C. (2013). Recent advances on the
development of wound dressings for diabetic foot ulcer treatment—a review. Acta
biomaterialia, 9(7), 7093-7114.
Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2013). Role of self-care in
management of diabetes mellitus. Journal of diabetes & Metabolic disorders, 12(1),
14.
Stoekenbroek, R. M., Santema, T. B., Legemate, D. A., Ubbink, D. T., Van Den Brink, A., &
Koelemay, M. J. W. (2014). Hyperbaric oxygen for the treatment of diabetic foot
ulcers: a systematic review. European journal of vascular and endovascular
surgery, 47(6), 647-655.
Tobe, S. W., Hua, D., & Twohig, P. (2013). Clinical practice guidelines. Future Medicine
Ltd.