Identifying Priorities of Nursing Case

Running head: NURSING
Identifying Priorities of Nursing Case
According to Crisp et al. (2017), evidence-based practice, the formation of the
patient-centred care plan in the nursing profession helps to improve the health-outcome while
improving the quality of life and reducing the length of stay and cost of care in the hospital.
For the generation of the patient-centred care plan, the first and foremost requirement is
proper identification of the clinical priority based on the clinical needs of the patients (Crisp
et al., 2017). In nursing profession, Levette-Jones Clinical Reasoning Cycle provides an
excellent framework for work in a step-by-step format for the identification of the clinical
priority (Levett-Jones, 2018). The following essay aims of identify the clinical priority of Mrs
Gina Bacci who is suffering from right foot ulcer and is recently undergone a surgery, for
partial amputation of forefoot and the great and first toe.
Upon examination, it was found that Mrs Bacci’s right feet and toes are cool to touch
along with a capillary refill time of two to three seconds (normal capillary refill time is less
than 2 seconds) (Martin & Nunan, 2015). Thus examination of the capillary re-fill time of
Mrs Bacci highlighted that it is higher than the normal. This indicates decrease in the flow of
the oxygen at the lower extremities of the right foot and thus impending signs of delay in the
process of wound healing. The decrease flow of the oxygen is attributable to the peripheral
vascular disease that causes increased deposition of the cholesterol in the arteries leading to
narrowing of the arteries (arthrosclerosis). Narrowing of the arteries hampers the flow of the
blood at the peripheral region of the body leading to decrease in the temperature. This might
be the reason behind the cold feet that Mrs Bacci used to experience at night. The decrease in
the flow of the blood at the wound site decreases the infiltration of the thrombocytes or
platelets in the site of wound leading to delay in the process of wound healing (Martin &
Nunan, 2015).

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NURSING
Island film dressing along the incisional wound is wet from serous exudate output.
Serous drainage is clear, thin and watery plasma. It is regarded as normal stage during the
process of wound healing and smaller amount of exudate release is regarded as a standard
pathology behind wound healing. However, moderate to high amount of serous exudate in the
wound indicates the bioburden. Moreover, serous exudate disappears within 2 to 3 days post
wound formation. The presence of serous exudate 7 days post-surgery indicates delay in the
process of wound healing (Hall, 2015). The wound has some dehiscence along the suture line
and there is some sloughy tissue. It is a symptom of partial dehiscence and small amount of
tissues or the superficial layer that is re-opened is indicated as sloughy tissue. The main risk
factor of generation of dehiscence is weakened immune system, AIDs or renal disease
(Berke, 2015).
The complications like peripheral vascular disease and delay in wound healing is
attributed to unmanaged diabetes mellitus for Mrs. Gina Bacci. The blood glucose level
(BGL) of Mrs Bacci is much higher than the normal range (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) (Bullock & Hales, 2019). All these
parameters indicates the possible signs of unmanaged diabetes mellitus and thus leading to
delay in the process of wound healing and her foot ulcer is attributable to diabetic foot ulcer.
Diabetic foot ulcer is one of the several complications of un-managed diabetes status. The
main contributing factor of diabetic foot ulcer is peripheral arterial disease, peripheral
neuropathy and immunosuppression (Aumiller & Dollahite, 2015). Increase in the severity of
diabetic foot ulcer increase the risk of amputation. Under high blood sugar level or
hyperglycemic state, there occurs oxidative stress on the neuronal cells leading to neuropathy.
This damage of the nerve cells leads to glycosylation of nerve cell proteins leading to

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ischemia. Damage of motor neurons in the foot eventually leads to skin ulcerations leading to
the formation of diabetic foot ulcer. Damage of the autonomic neurons impairs the function
of the sweat gland. Decrease in the moisture quotient of the skin leading to epidermal crack
and dryness of skin that delays the process of wound healing (Aumiller & Dollahite, 2015).
The body temperature is Mrs Bacci is also high (37.8ºC; normal: 38-degree C) even
under the medication of paracetamol (Bullock & Hales, 2019). This indicates that her body is
might be suffering from bacterial invasion and taking her wound status into consideration
(pain, redness) it can be ascertained that bacterial invasion might have originated from the
wound site(Bullock & Hales, 2019).
Proper management of the wound is the first nursing priority. For the patients who are
suffering from diabetic foot ulcer and unmanaged state of diabetes, the nursing intervention
for wound care must encompass effective management of the wound. According to the
evidence-based practice, proper management of the wound deals with periodic change of the
wound dressing while maintaining proper aseptic condition (Coppola et al., 2016). The
wound management will also include proper use of the antibiotic ointment and lotion in order
to retain the moisture of the wound along with finding the possible signs of bacterial
infection. The administration of the antibiotic ointment must be done under the controlled
supervision of surgeon or post-operative care doctor. The dressing of the wound must be
done after the removal of the tissues at the suture (Coppola et al., 2016). Effective
management of wound will help to alleviate the pain and the same time will help to improve
the well-being of Mrs Bacci as at present she is mobilising with an offloading boot and
walking stick.
Promotion of the self-management skills for diabetes can be regarded as the second
nursing priority. This is because the main cause behind the development of diabetic foot ulcer