Clinical Reasoning Cycle Based on Highlighting Clinical Priority

This essay analyzes the clinical priorities of Mrs Gina Bacci, a patient with diabetic foot ulcer, using the Levette Jones Clinical Reasoning Cycle. The clinical priorities identified are effective wound management and effective management of uncontrolled diabetes mellitus. The essay discusses the factors contributing to these priorities and proposes nursing interventions to address them. The importance of patient education and multidisciplinary team collaboration is also highlighted.

Running head: NURSING
Clinical Reasoning Cycle Based on Highlighting Clinical Priority
Name of the Student
Name of the University
Author Note

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Introduction
The development of the nursing care plan is guided by several factors. However, the
principal focus of the nursing care plan mainly depends on the proper identification of the
clinical priority based on the patient’s needs. The determination of the clinical priority and
devising nursing intervention based on the clinical priority helps to improve the overall
health-related outcome of the patient’s care (Levett-Jones, 2018). The following essay aims
to analyse two main clinical priorities of Mrs Gina Bacci, a 49 year old Italian lady who is
suffering from diabetic foot ulcer. The identification of the clinical priorities will be done
based on the framework of the Levette Jones Clinical Reasoning Cycle followed by the
development of the nursing gaols and subsequent interventions in order to address the clinical
priorities.
Answer 1
Mrs Ginal Bacci’s wound site in the left foot is cold to touch with a capillary refill
time of 2 to 3 seconds (normal capillary refill time is less than 2 seconds). This high capillary
refill time and decrease of the body temperature at site of wound indicates that decrease in
overall flow of the oxygen at the wound site that is decreased peripheral perfusion. Decrease
in the blood flow at the site of the wound mainly results from the decreased rate of
oxygenation and rate of wound healing (Brown et al., 2015). According to Bullock and Hales
(2019), decrease in the overall rate of blood flow at the site of the wound indicates that there
is reduction in the infiltration of the blood plasma and blood platelets. This reduced in-
filtration of the blood corpuscles like platelets or white blood cells delays the overall process
of wound healing. The reduced temperature at the site of the wound is an indicator of
increased oxidative stress results from the generation of reactive oxygen species (O3-) and

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thereby increasing the severity of the foot ulcer and thereby delaying the overall process of
wound healing (J.A. & Gordon, 2019).
The unmanaged state of left foot wound of Mrs Gina Bacci is attributed to her
unmanaged diabetes. Mrs. Gina Bacci is suffering from type 2 diabetes mellitus (T2DM) for
the past 6 years. High level BGL (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) indicate that she state of T2DM (Bullock & Hales, 2019). According to the
Diabetes Australia (2019) high blood glucose level (BGL) indicates the direct signs of
unmanaged T2DM. Mrs Gina Bacci medication indicates regular dosage of Novorapid TDS
and Lantus, artificial insulin medication however; her blood parameter shows high BGL.
Thus it indicates that Mrs Bina Bacci has poor lifestyle habits. Uncontrolled diabetes for a
prolong period of time leads to the development of micro and macrovascular complications
of diabetes and diabetic foot ulcer is a form of microvascular complications of diabetes. High
BGL for a prolong period of time leads to disruption of neurotransmission (peripheral
diabetic neuropathy) and thus hampering the process of healing leading the development of
diabetic foot ulcer (Bryant et al., 2019).
High blood glucose level for a prolong period of time hinders proper breakdown of
fats. The fatty acids or triglycerides are converted in LDL or low density lipo-protein or bad
cholesterol and this extra cholesterol gets deposited in the arteries leading to the development
of arthrosclerosis (macro-vascular complications of diabetes). Arthrosclerosis lead to the
narrowing of the arteries and hampering the flow of the blood at the wound site and delaying
the process of wound healing. The delayed process of wound healing is reflected in the signs
of dehiscence along the suture line and presence of sloughy tissue (Farrell, 2017).

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The post-operative wound status of Mrs Gina Bacci also indicates the presence of
serous exudates output. Serous exudate is thin clear and watery fluid and is different from
purulent exudates, which is viscous, thick and opaque. During the course of wound healing,
the first phase is the type1 hypersensitivity phase characterized by mild to moderate
inflammation. This mild inflammatory phase is associated with mast cell degranulation and
infiltration of leucocyte leading to the formation of serous exudates. The outbreak of
microbial infections at the wound site leads to transformation of serous exudates into purulent
exudates (Forbes & Watt, 2016). Thus, serous exudate at the wound site of Mrs Gina Bacci
indicates that her wound site is still not infected with microbes. However, Mrs Gina Bacci
has visited the outpatient department seven days post her right foot ulcer surgery. Presence of
serous exudates after 7 days of post-operative wound indicates delayed wound healing as
serous exudate decreases after two to three days post surgery at wound site. The surrounding
skin is warm, dark pink and is painful to touch and this further indicates the initial stage of
wound healing. The increased temperature at the site of the wound helps to prevent bacterial
infection (Forbes & Watt, 2016).
Answer 2
Nursing Priority 1: Effective wound management at the surgical site
Forrester and Griffiths (2015) stated that it is the duty of the nursing professionals to
take active initiatives in the wound management. Effective wound management by
application of the proper nursing interventions helps to reduce the chances of post-surgical
wound dehiscence and the chances of sepsis initiated at the wound site. Mrs Gina Bacci is
suffering from unmanaged T2DM has high BGL or hyperglycemia. High BGL leads to
structural and functional changes in the hyaluronan leading impaired healing of the tissue at
the wound site. Thus, in order to promote faster wound healing and in order promote

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effective formation of the tissue at the wound site proper nursing monitoring, change in the
dressing and use of ointment in order to promote faster wound healing is important. Faster
wound healing helps to reduce the severity of diabetic foot ulcers (Brown et al., 2015).
Nursing priority 2: Effective management of uncontrolled diabetes mellitus
Effective management of the high BGL is important to promote faster wound healing
while reducing the severity of diabetic foot ulcer (Martini, Nath & Bartholomew, 2018).
After the generation of wound or cut, the first step of the process of wound healing initiates
with generation of the effective immune response by triggering of the type 1 hypersensitivity
reaction. Type 1 hypersensitivity reaction helps to prevent the chances of infection at the site
of the wound. The second step of the process of wound healing is generation of new cells or
tissues at the site of the wound. This is followed by third step of wound healing that is
formation of scar tissue at the site of wound. However, among the diabetic patient, the overall
process of wound healing is delayed due to high BGL. The delayed wound healing increase
the chance of microbial infection at the wound site and at the same time increases the chance
of sepsis (Hall, 2016). Keeping the BGL under a permissible range helps to reduce the chance
of fluctuation of the glucose concentration in the blood and thereby helping to reduce the
chance of peripheral neuropathy. Decrease in the peripheral neuropathy ensures proper cell
signaling at the wound site in the extremities of the body. This leads to infiltration of the
proper blood platelets resulting in faster wound healing and formation of scar tissues.
Moreover, decrease in the peripheral neuropathy will help to reduce the chance of having
cold feet at night and preventing the tendency to wear socks that creates friction at wound site
(Hamlin et al., 2016). Having BGL under control also helps to reduce the chance of occurring
diabetic foot ulcer and thus helping to prevent disease recurrence (Hall, 2016).

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Answer 3
Nursing Management 1: Patient’s Education for Developing Diabetes Self-Management
Skills
According to the Nursing and Midwifery Board of Australia (2018), the nursing
professional must educate the patients about the process of disease progression in order to
increase the clinical governance. Increase in the clinical governance helps to increase
patient’s participation in the therapy plan and thereby helping to improve the therapy
adherence and at the same time increasing the self-management skills. In case of Mrs. Gina
Bacci, unmanaged diabetes indicates gap in her diabetes self-management skills. Moreover,
she at times forgets to take the requirement medications and also thinks that she needs not to
take medicines for her health. This ignorance and towards health and medicine intake
indicates her gap in knowledge about the disease progress and self-management skills.
Thus nursing care plan in order to promote health reduction for diabetes self-
management will include proper education of the health lifestyle habits in order reduce the
blood glucose level. For Mrs Gina Bacci, the healthy lifestyle activity will be healthy eating
(low calorie high protein diet) for reduction in the BMI and BGL. Regular observance of the
physical activities for reduction in BMI and BGL might not be suitable for her as at present
she is suffering from diabetic foot ulcer (Mackey et al., 2016). The education about the diet
plan will be done under the presence of the bilingual nurse as Mrs Gina Bacci is an Italian
lady with poor knowledge about English. The development of culturally competent diet plan
and use of the bilingual nurse will help her to understand the importance to taking medication
and proper diet plan in order to reduce the BGL and thus promoting self-management skills
of diabetes. The Gina Bacci will also be educated about the importance or regular monitoring
of BGL in order to bring changes in the diet plan and medication management (Mackey et al.,
2016).

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Nursing Management 2: Wound Dressing
Dressing of the wound done through timely replacement of the wound dressing and
use of proper medication will help in faster healing of wound. In the out-patient care Mrs
Gina Bacci wound was found wet from serous exudates. Replacement of Island dressing
along with the use of the ointment will help to promote faster wound healing (Weller &
Team, 2019). Island film dressing is made of absorbent pad that is fitted with an adhesive
backing that is known as island dressing and is used for the dressing and effective
management of the post surgical wound. The use of fresh Island dressing will help to soak
excess of serous exudates and thus helping to keep the wound site and moisture free (Weller
& Team, 2019.
Nursing Management 3: Multidisciplinary Team
The nursing management of Mrs Gina Bacci will include consultation with the
multidisciplinary team in order to generate person-centred care plan. The multidisciplinary
team members will include dietician in order to make a person-centred and culturally
competent diet plan, a community health nurse who will educate Mrs. Gina Bacci’s family
members in order to assist her to take the required medication as she frequently forgets to
take her medicine (Daly, Speedy & Jackson, 2017). An occupational therapist will help to
promote plan for easy manoeuvring while reducing the chance of injury at wound site (Toles
et al., 2016).
Conclusion
Thus from the above discussion, it can be concluded that main priorities of nursing
care for Mrs Gina Bacci is effective management of wound and effective management of
diabetes mellitus. The effective management of the wound for the foot ulcer will be done by
timely replacement of the wound dressing and use of proper ointment. The effective

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management of diabetes mellitus will be done by the use of patient education in the domain
of healthy diet plan under the presence of the bilingual nurse as she is Italian.

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