Pathophysiology and Nursing Priorities in Post-Operative Wound Infection

This article discusses the pathophysiology and causes of post-operative wound infection and identifies the main nursing priorities of care for the patient. It also outlines and justifies the appropriate and safe nursing management during this time.

Running head: NURSING ASSIGNMENT 1
Nursing Assignment
Student’s Name
Institutional Affiliation

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Introduction
The case study on the discussion is about an Italian lady, Mrs. Gina Bacci of 49 years old who
was admitted to the hospital two weeks ago for partial amputation following complications from
a right foot ulcer. In her medical history, she has Peripheral Vascular Disease, obesity and type 2
diabetes which was diagnosed six years ago. She returns to the hospital after seven days for
further wound assessment and management. Using the clinical reasoning cycle, the essay will
cover the pathophysiology and the causes of the wound status and identify the main nursing
priorities of care for Gina’s wound. Moreover, it will outline and justify the appropriate and safe
nursing management of Gina during this time.
Based on the case study, critically analyze and discuss the underlying pathophysiology and
causes of the patient’s post-operative wound status.
Considering the patient’s condition, the current medications used by Gina are Novorapid
TDS 12units, Lantus 30units nocte, Pregabalin 75mg mane along with Paracetamol 1g QID. She
admits that she sometimes forgets and does not think she needs to take all these medications.
Upon examination of her wound, an island film dressing along the incisional wound is noted
which is wet from serous exudate output. Also, the injury has some dehiscence along the suture
line, and there is a sloughy tissue. Further examination shows that the surrounding skin to the
wound is warm, dark pink and painful to touch.
From the information gathered, Gina has a history of obesity, Peripheral Vascular Disease, and
Diabetes. Also, when the vital signs are taken the blood pressure, pulse rate, respiratory rate,
SpO2 are found to be normal, but the temperature and blood glucose level are very high than
usual. From this information, when the body has difficulty metabolizing glucose, the blood
glucose level becomes very high (Xu & Chen, 2017). Under these circumstances, the high blood

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sugar level halts the immune system from operating precisely, and if it's not functioning well, the
body may attempt to fight bacteria that bring about infection (Yu et al., 2017). Moreover, higher
than normal blood sugar levels escalates the possibility of contamination since bacteria grow on
the additional sugar that is feasible in the bloodstream. It also prevents the immune cells from
fighting off penetrating bacteria (Jafar, Edriss & Nugent, 2016).
Once this information is processed, it is clear that in the process of wound healing the
body had a challenge in fighting off the invading bacteria to the wound site due to the high blood
glucose level. Therefore, bacteria seem to have colonized the wound site and caused an infection
which is evident by the surrounding skin being warm and also the high fever. This is the
inflammatory phase of wound healing (Martin & Nunan, 2015).
Pathophysiology is the abnormal physiological processes associated with an infection
(McCance & Huether, 2018). At the inflammatory stage, the tissue integrity is disrupted by a
wound which initiates the coagulation cascade to refrain bleeding. Here, the first cellular
elements that accumulate to the wound are the platelets, and due to their reaction, many
cytokines are released which entail the platelet-derived growth factor, insulin-like growth factor-
1, epidermal growth factor, and fibroblast growth factor.
Histamine emancipated by mast cells together with serotonin prompts an unstable
opening of the junctions amid the endothelial cells enabling the monocytes together with
neutrophils to pass to the wound site. Once at the wound site, the vast cellular movement to the
location of the wound is then actuated by the cytokines produced by the platelets and additional
chemotactic cytokines produced by the macrophages (Mescher, 2017). The cytokines comprise
of the transforming growth factor alpha along with the transforming growth factor beta.

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Accordingly, the inflammatory exudate which comprises of neutrophils, macrophages,
plasma proteins, red blood cells including coagulation cascade proteins along with fibrin strands
fill the wound site. Because of the macrophages cytokine secretion, they are central to the
process of wound healing although they also scavenge the wound (Smigiel & Parks, 2018).
Most infected wounds are caused by bacterial colonization (Leaper, Assadian &
Edmiston, 2015). Infections after a medical procedure are caused by germs, and the most
common are the bacteria Streptococcus, Staphylococcus along with Pseudomonas. These germs
may originate either from the normal flora on the skin of the person or from outside the
environment (Thomas et al., 2017). Bacteria from outside the environment may come from either
the instruments used during the surgery or from the health care professional who conducted the
operation. The hospital obtained microorganisms like Methicillin-resistant Staphylococcus
Aureus (MRSA) frequently have elevated resistance to antibiotics.
Identify two main nursing priorities of care for this patient and provide justification and
rationale for each.
The reason why Gina is in this state is that her diabetes made it hard for the body to fight
invading germs to the site of the wound; hence an infection occurred. As with any disease, the
priority in addressing a post-operative infection is identifying the source of the infection and then
controlling the ongoing contamination through the appropriate use of antibiotics. The purpose of
determining the type of bacteria causing the infection is to make sure that the treatment to be
used works effectively by eradicating the infection and fastening wound healing.
To determine the type of strain that is responsible for the infection wound swabbing is
done for culture and sensitivity (Bessa, Fazii, Di Giulio & Cellini, 2015). This bacterial wound
culture is generally used along with a Gram stain to assist in determining whether the wound is

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infected and identify the bacteria causing the infection. If it is revealed that a wound is infected,
a susceptibility testing is performed to ascertain the antibiotic that will impede the growth of the
bacteria.
To achieve the treatment goals for the patient, the type of bacteria has to be identified
first and then the appropriate antibiotic is prescribed for the patient. Since the most common
bacteria that cause an infection after a surgical procedure is Staphylococcus (Mohamed et al.,
2017), the appropriate antibiotic is the dicloxacillin. This antibiotic binds to one or more
penicillin-binding proteins which in turn impedes synthesis of bacterial walls.
From your identified priorities, outline and justify the appropriate and safe nursing
management of the patient during this time.
To meet the patient’s treatment goals, health care nurses should follow some steps that
will enable them to deliver the best services for the safety of the patient. The proper technique
will refrain false-negatives and false-positives in a wound culture that might lead to either under
treatment or overtreatment with antimicrobials. The current best practice recommends the Levin
technique to obtain a wound culture (Joseph et al., 2016).
The nurses should make sure that the specimen is obtained before the patient commences
antimicrobial treatment because it interferes with the bacteria growth. They should assemble all
the instruments such as culture swab, appropriate wound dressing, unsterile gloves, 10-ml
syringe prefilled with 0.9 percent of sodium chloride, sterile swab container along with sterile
gauze pads (Lingaraj et al., 2015). After doing hand hygiene and wearing unsterile gloves, the
nurse should soak the wound using 0.9 percent of sodium chloride and then wipe smoothly using
a gauze pad.

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The swab should be moistened by the sodium chloride for it to provide more accurate
information. Then, a small region of viable tissue should be identified, and the swab rotated on it
averting any sloughy tissue (Lingaraj et al., 2015). Pressure should be applied to express as much
as wound fluid as possible, and a wound culture must be obtained from a clean tissue since
sloughy tissue cannot give an exact data about the flora incorporated in the tissue. The nurse
should now insert the swab into the sterile container and redress the wound and perform hand
hygiene.
Since the surrounding skin of the wound site is painful to touch, the health professional
should evaluate the patient and make sure that any wound pain is managed. This wound
management should be carried out before the procedure of obtaining the culture and also during
the process. An electronic document and a lab slip should be completed which should include the
site of the wound, the time in which the specimen was obtained along with the antimicrobials the
patient is receiving (Lingaraj et al., 2015). Finally, the sample should be sent to the lab
immediately so that the specimen can be kept stable.
To determine the correct antibiotic for the infection, the health professional has to
consider the type of bacteria involved (Bengtsson-Palme & Larsson, 2016). The bacteria might
be the Gram-positive bacteria that has a thick waxy external layer or Gram-negative bacteria
with an extra fatty layer that behaves like an impediment opposing specific antimicrobials. In
this case, he should select the one to penetrate the external wall or damage the structure enough
to avoid reproduction.
Moreover, the health professional should consider the action of the antibiotic. All
penicillin-class antibiotics such as amoxicillin and ampicillin act by blocking the development of
the external waxy layer of the microbes and the other classes attack the reproduction cycle of the

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microorganisms. Here, he should select the type of antibiotic by putting into consideration the
type of bacteria the action of the antimicrobial (Bengtsson-Palme & Larsson, 2016).
The effective antibiotics in this situation are the topical antibiotics for the control of the
wound infection and for pain management the pregabalin 75mg mane drug that was previously
prescribed should be continued. The topical antibiotics may include the cefazolin, dicloxacillin
or cephalexin.
Conclusion
Post-operative wound infections can occur at the inflammatory stage, and the infection can
develop if the patient has a history of diabetes. This is because diabetes results in high sugar
levels which help the bacteria to thrive and the body's immune system weakened to fight germs.
To control this infection what should be addressed first is the source of the infection and then
identifying the antibiotic appropriate for the bacteria causing the infection. Also, health
professionals should follow steps in determining the type of bacteria so that the antibiotic for the
specific microbe is recognized and also to avoid under treatment and overtreatment of the
antimicrobials.

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