Nursing-Medical Surgical

This essay discusses the case of a 49-year-old patient who underwent surgery for a foot ulcer. It explores the pathophysiology and causes of the patient's wound status, identifies nursing priorities for wound care, and explains safe nursing management. The patient's history of obesity, Peripheral Vascular Disease, and type II diabetes are considered. The essay also provides information on wound swabs, wound dressing, and pain management.

Running head: NURSING-MEDICAL SURGICAL 1
Nursing-Medical Surgical
Student’s Name
Institutional Affiliation

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Introduction
The essay focuses on a 49-year-old Italian lady, Mrs. Gina Bacci who was admitted to
hospital 14 days ago for surgery following complications from a right foot ulcer. She underwent
a partial amputation of the forefoot and the great and first toes. Gina had a history of obesity,
Peripheral Vascular Disease and type II diabetes diagnosed six years ago. After she was
discharged seven days ago, she visits the hospital for further wound assessment and
management. The discussion will focus on the pathophysiology and causes of her wound status,
identify the main nursing priorities for care of the wound and explain the appropriate and safe
nursing management of the patient.
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
Before Gina was discharged some drugs were prescribed for her to use such as
Paracetamol 1g QID, Novorapid TDS 12units, Pregabalin 75mg mane, and Lantus 30units nocte.
Although she was prescribed the medication, she admits that she sometimes forgets and does not
think she needs to take all of them. Concerning the wound, the island film dressing along the
incisional wound is found to be wet from a serous exudate output. Also, some dehiscence along
the suture line and some sloughy tissue are noticed. On further examination, the surrounding skin
of the wound is found to be warm, dark pink and painful to touch.
Gathering information and cues
After examination, her vital signs such as SpO2, blood pressure, respiratory rate, and pulse
rate are normal except the temperature which is high at 37.8°C along with her blood sugar level
which is also very high at 12.6mmol/L. As per her medical records, she has a history of Peripheral

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Vascular Disease (PVD), Type 2 Diabetes which was diagnosed six years ago and obesity.
Considering this data, diabetes that Mrs. Gina has led to the rise of the blood sugar level which
must have affected the effectiveness of the immune system of fighting germs. Also, the high
blood sugar level in the bloodstream enables the thriving of bacteria; hence the possibility of
infection is increased.
Process information
Upon processing of the data, the wound was in the process of healing but it might have
been colonized by some germs, and this is the inflammatory phase of wound healing which is
part of the body’s reaction to tissue damage or infection. The tissue integrity might have been
interrupted by injury which started the coagulation cascade to refrain bleeding. Platelets were the
first of the cellular elements which aggregated to the wound and due to their degranulation, that
is, platelet reaction, they released many cytokines. The cytokines consist of fibroblast growth
factor (FGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF) and insulin-
like growth factor-1 (IGF-1) (Shah & Amini-Nik, 2017).
Also, serotonin was dispensed which together with histamine released by mast cells,
induced a convertible opening of the junctions amidst the endothelial cells. They allowed the
passage of neutrophils and monocytes that became macrophages to the location of the wound.
The vast cellular movement to the wound section was actuated by cytokines produced by the
platelets and by additional chemotactic cytokines produced by the macrophages themselves at
the location of the wound (Shah & Amini-Nik, 2017). These consisted of transforming growth
factor beta (TGF-β) along with transforming growth factor alpha (TGF-α).
Accordingly, the inflammatory exudate which entails plasma proteins, red blood cells,
macrophages together with neutrophils inclusive of coagulation cascade proteins and fibrin

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strands filled the wound. Macrophages don’t only scavenge, but they are also predominant to the
process of wound healing due to the secretion of their cytokine. Therefore, these processes led to
wounding infection.
Skin protects the body from infection, but in case of an opening due to a surgical
procedure, diseases are caused by germs. The most common bacteria which cause infection
include Staphylococcus, Streptococcus along with Gram-negative bacilli (Takizawa,
Tsutsumimoto, Yui & Misawa, 2017). There are germs which are in the environment around a
person, and if they come in contact with the person, they are spread hence causing infection
(Manaia, 2017). Other germs are found in the instruments used to perform the surgery or from
the hands of the surgeon, and if they spread to the wound, they might cause an infection
(Chairman & JA, 2017). Finally, the skin contains bacteria which may extend to the surgical
wound hence colonizing the wound site causing infection (Sunderkötter & Becker, 2015).
Identify two main nursing priorities of care for this patient and provide justification
and rationale for each.
Identify problems
The problems that Gina is undergoing are as a result of diabetes because it makes it
difficult for the body to fight the penetrating microorganisms to the wound. Once these microbes
colonize the wound, it leads to an infection (Leaper, Assadian & Edmiston, 2015). To ensure that
the infection is controlled the two main nursing priorities of care are finding out if the wound is
infected by taking wound swabs for culture and sensitivity and then redressing the wound. The
first dressing has to be removed since it is wet from serous exudate and hand hygiene is much
considered to prevent any transfer of bacteria. The nurses here must adhere to principles for
patient safety by washing hands before undressing and before dressing the wound and even when

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taking wound swabs. If the wound is found to be infected, they have to use the appropriate
antibiotic for the specific pathogen.
Establish goals
Goals will only be established if the type of species responsible for the infection will
have been recognized. This will happen after a wound culture has been tested in a lab and a
bacterium identified then the susceptibility test be done to determine the kind of antimicrobials
that will be effective for the specific pathogen. Since most of the postoperative wound infections
are caused by Streptococcus, the best antimicrobial that can be effective may be the penicillin.
Therefore, the use of this drug will control the disease and thus result in faster healing of the
wound.
In the process of establishing the goals which will lead to infection eradication, some
things need to be put in place to help the future care which can be possible by utilizing the
SMART goals. It is an abbreviation of specific, measurable, achievable, relevant and time-
bound. Specific:
The specific objective is for obese patients like Gina who have undergone a surgical
procedure to reduce a certain amount of weight. Throughout their admission to the hospital, they
would be involved in exercises until they are discharged.
 Measurable:
Moreover, for obese patients like Gina there will be put a particular room at the hospital
for exercises to help them reduce their weights.
 Achievable:

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To make this goal attainable, I will make sure I lead the exercises by introducing the type
of activities fit for everybody considering their state of health.
 Relevant:
Apart from educating them on how to take care of their health at home, the goal is to help
the patients reduce some weight which is aligning with the exercises that will be offered. Time-Bound:
To attain the goal, the exercises should be offered for two weeks by utilizing two hours
each day to make sure that at the end of the period patients will have lost a significant amount of
weight.
From your identified priorities, outline and justify the appropriate and safe nursing
management of the patient during this time.
Take action
For health professionals to manage the wound swab, they should follow some steps so
that quality health is delivered to the patient and that her safety is guaranteed. They should obtain
the specimen before the patient initiates the antimicrobial therapy because it disrupts the bacteria
development. The clinical nurse should identify a region at the wound site of unstained and
feasible tissue and turn the swab on it preventing any slough tissue (Bessa, Fazii, Di Giulio &
Cellini, 2015). They should thoroughly wash their hands before collecting the specimen using
soap and drying them with a clean towel and wear gloves to remove the dressing to prevent
further cross-infection. The wound swab should then be cleaned thoroughly using normal saline
or water so that the bacteria are gathered and not the harmless skin flora.
The clinical nurses should gather the instruments and then irrigate the wound using 0.9%
of sodium chloride followed by smooth swabbing by gauze pad (Bessa et al., 2015). This

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procedure helps in providing the correct information and increasing the recovery of bacteria from
the wound bed when the swab is moist. The wound swab should be inserted in a sterile container;
the wound redressed followed by hand hygiene. During this time, the pain around the wound
should be managed after dressing.
If no bacteria are present, the health professional should clean the wound site properly
and dress it, but if that is not the case, corrective measures should be taken. When the causative
bacteria and their antibiotic susceptibility is established the nurse should record the infection’s
clinical severity, wound classification along with any diagnostic uncertainties and other
diagnostic tests planned (Cerceo, Deitelzweig, Sherman & Amin, 2016). Moreover, to administer
the antibiotic treatment the nurse should acquire the correct samples of the culture and select the
regimen of the antibiotic including the dose along with its administration route.
While dressing the wound, the nurse should wash his or her hands using soap and make
sure that they are dry and ensure the surface is also clean. Then, they should wear gloves and use
any prescription or antibiotic cream to apply and place the fresh dressing over the wound site
with additional caution not to touch inside of it (Smart & Acton, 2016). Collagen dressings are
recommended for this type of wound because they act as scaffolding for new cells to grow and
could be highly effective during healing. They should also make sure that the wound is dried
before dressing (Borda, Macquhae & Kirsner, 2016).
According to the information gathered it was found that around the wound site was
painful and the pain needs to be managed. Through the evaluation of the wound, the health
professionals have to identify the triggers which could be modified or avoided to minimize the
pain. Also, they should provide opioid narcotics and combine them with non-steroidal anti-

NURSING-MEDICAL SURGICAL 8
inflammatory drugs to significantly reduce the required dosage of opioids for sufficient relief of
pain (Tan, Law & Gan, 2015).
Furthermore, due to the dehiscence along the suture line, the nurses should treat the
suture line with a dressing to control the expected and early inflammatory exudate and provide a
waterproof covering. They should also evaluate the cavities of the dehisced post-operative
wound and the presence of foreign bodies. Its goal is to minimize edema and make sure the
patient is comfortable (Muller-Sloof, de Laat, Hummelink, Peters & Ulrich, 2018).
Evaluating outcomes
Outcomes are reviewed through the antimicrobials prescribed to the patient. If the
penicillin is not working as expected another antibiotic is used for better results. For instance, to
manage the pain that Mrs. Gina Bacci is experiencing she should continue the prescription of the
pregabalin drug that was prescribed before. Although Gina is not taking the medications she was
given, Novorapid TDS 12units and Lantus 30units nocte will be helpful if continued and be
advised to take them seriously for her well-being. This is because her diabetes is seen to be
worsening.
Conclusion
In the process of wound healing, bacteria may colonize the wound and cause infection
which occurs at the inflammatory stage of wound healing. The first nursing priorities in caring
for a patient with an infected injury is finding out the pathogen responsible and administering an
antibiotic therapy along with dressing the wound. Moreover, to manage the surgical wound
proper measures are taken such as hand hygiene and wearing gloves when taking wound swabs
and even when dressing. The appropriate instruments should also be used to ensure accurate
information about the culture is obtained.

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References
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Borda, L. J., Macquhae, F. E., & Kirsner, R. S. (2016). Wound dressings: a comprehensive
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Cerceo, E., Deitelzweig, S. B., Sherman, B. M., & Amin, A. N. (2016). Multidrug-resistant
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