Principles of Nursing: Surgical

This article discusses the nursing priorities of care for post-operative foot ulcers in diabetic patients. It covers the causes and pathophysiology of such wounds, and identifies surgical debridement and non-removable total contact cast offloading as the most effective nursing management techniques. The article also recommends the use of removable cast walkers.

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Principles of Nursing: Surgical
Name
Institution

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Principles of Nursing: Surgical
Bacci is a 49-year-old Italian female who was admitted to the facility about two weeks
ago for surgery after she had faced right foot ulcer complications. Ginna underwent a partial
amputation of her forefoot under general anesthetic. In this process, Ginna's great and first toes
were amputated. The patient was diagnosed with Type II diabetes about six years ago. The client
is obese and suffers from Peripheral Vascular Disease (PVD). Ginna was put on insulin as her
diabetes condition was worsening. Upon examination, the incision wound had a wet island film
dressing with serious exudates outputs. The injury depicted dehiscence on the suture line with a
slough tissue.
There is a need for an in-depth analysis of the state of diabetes when underscoring the
pathophysiology of wounds that emerge from post-operative foot ulcers. Game et al. (2016)
explain that patients infected with diabetes mellitus face more significant risks of acquiring foot
ulcers. Such risks include peripheral neuropathy, infection disruption responses, and peripheral
vascular ailments. Fernandez, Ellman, and Jackson (2017) reveal that diabetic patients present
wound healing disorders that increase the risk of infections. In Mrs. Bacci’s case, there are
tendencies that the postoperative wound complications would be s a result of neuropathy.
According to Brüggenjürgen, Eberlein, and Hunt (2017), the damages caused to the leg
muscles' innervations may lead to imbalances in the extension and flexion processes. As a result,
the affected region of the postoperative wound may experience deformities and changes in
pressure points.
As deformities and changes in pressure points develop, the wound manifests gradual skin
alterations that lead to the development of foot ulcers. Mrs. Bacci revealed that she makes use of
a walking stick and an offloading boot for mobilization purposes even though her left foot and

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toes were cold and depicted a capillary refill ranging between 2 and 3 seconds. The patient
confesses that she at times bears with cold feet and puts on bed socks. According to Game et al.
(2016), autonomic neuropathy is one of the critical causes of postoperative wounds among
diabetic patients. The condition may impose great negative consequences such as lowering the
levels of activity of sweat and oil glands. The affected area is exposed to the susceptibilities of
mechanical injuries as a result of the associated reductions in the content of foot moisture.
Hyperglycemia is one of the critical causes of postoperative wounds among diabetic patients.
Worley et al. (2017) reveal that hyperglycemia leads to endothelial dysfunctions in peripheral
arteries and the muscles contained in blood vessels. The researchers showed that high blood
pressure leads to a decrease in the levels of vasodilator production of the endothelium. As a
result, the patient is forced to experience constrictions.
On the other hand, Chu et al. (2018) demystify that hyperglycemia in diabetes leads to a
significant increase in the levels of thromboxane A2, which increases the risks of acquiring
plasma hypercoagulability. Brüggenjürgen, Eberlein, and Hunt (2017) also consider
dyslipidemia and hypertension as critical contributors to the emergence of external arterial
conditions. The condition results in occlusive arterial diseases that lead to the development of
ischemia of the lower extremities coupled with increased risk of preoperative foot ulcers.
Mannan et al. (2017) explain that after formation, foot ulcers face the vulnerabilities of being
infected with other forms of bacteria that develop into gangrenes which call for adoption of
lower leg amputations.
Diabetic patients such as Mrs. Bacci face the vulnerabilities associated with decreased healing
of the peripheral soft tissues. Such a state increases the chances of acquiring post-operative
complications in the wound healing process. Because Bacci's diabetes is at its advanced stage

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(diagnosed about six years ago), there are tendencies that essential organs such as skin tissues,
support tissues, nerves, and blood vessels have been destroyed. Mujeeb and Mutha (2017)
explain that the control of blood sugar among these patients is not adequate to initiate effective
healing. The researchers demonstrated that reduced rates of wound healing among diabetic
patients exposes them to the vulnerabilities associated with wound complications that in turn
slow down the healing mechanism. Finestone et al. (2018) enumerate cellulitis, gangrene,
septicemia, osteomyelitis, and abscesses as the complications that increase a patient's levels of
vulnerability to postoperative wound complications.
Debridement and off-loading is adopted as the primary nursing priorities of care for Mrs.
Bacci. Prasad et al. (2017) reveal that the causal management practices adopted for patients who
present post-operative foot ulcers must be accorded higher priority. The researchers further
demystify that there is a need for proper inclusion of comprehensive diagnostic assessments
when choosing the nursing priorities of care among these patients. Debridement and off-loading
present caregivers with an ample opportunity to initiate effective post-surgical interventions,
promote efficient circulation, and enhance venous return enhances their levels of operational
effectiveness when managing the conditions presented with Mrs. Bacci. Debridement is
conducted among patients depicting postoperative wound conditions as a technique of removing
all forms of surface debris and necrotic tissues. A critical analysis of the patient under
consideration reveals that the incision wound had a wet island film dressing with serious
exudates outputs. Such descriptions out rightly reveal that Mrs. Bacci's injury had debris and
narcotic tissues. Nonremovable total-contact cast (TCC) is adopted as the most effective
technique of conducting the offloading exercise. According to Götz et al. (2017), TCC is
undertaken by the use of fast setting fiberglasses and cast materials or plaster. The researchers

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further reveal that the technique is a bit cheap and allows for reduced activity. Considering Mrs.
Bacca's condition, the TCC exercise will be conducted to foster effective offloading of ulcers
situated in the forefoot. However, the scholars reveal that this technique could also be applied
among patients with ulcers in the midfoot. On the other hand, Mannan et al. (2017) demystify
that the method is used among patients who present deep abscess, poor skin quality, and
osteomyelitis.
Debridement will be adopted for this wound to improve the healing process by promoting
the processes associated with the production of granulation tissues. Comparatively, Van Bael et
al. (2016) demystify that offloading of the wound areas affected with the postoperative ulcer
plays a critical role in fostering proper healing of plantar cases. The researchers reveal that the
presence of elevated plantar pressures among these patients acts as vital contributors to the
advancement of plantar ulcers. According to Zgheib et al. (2017), the debridement exercise
should be conducted by the use of scalpel blades with tips pointed at an angle of 45 degrees to
remove all forms of nonviable tissues. The researchers explain that this process should be
repeated until a healthy ulcer is produced through saucerization of the edges of the wound under
consideration. The fact that Mrs. Bacci is presented with foot deformities exposes her foot to the
vulnerabilities of acquiring further ulcerations because she depicts diabetic peripheral neuropathy
and ineffective offloading. Worley et al. (2017) explain that inadequate offloading of foot ulcers
among diabetic patient is one of the critical contributors of healing delays particularly with the
manifestation of an adequately perfused foot.
Surgical debridement and non-removable total contact cast offloading will be considered
as the most appropriate and safest nursing management techniques for Mrs. Bacci in this period.
According to Tilliridou et al. (2016), surgical debridement is also referred to as the “sharp

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method” and is applied by the use of scalpels. The researchers further reveal that the technique
is of critical significance in fostering the removal of dead tissues and hyperkeratosis. However,
Kato et al. (2017) explain that nurses who are accorded the obligation of managing patients who
depict the associated conditions must take a lot of precautionary measures to ensure that they do
not cause damage to healthy tissues which present red or pink granulation appearances. Götz et
al. (2017) explain that the nurse in charge must suspend aggressive debridement in instances
where severe ischemia is suspected. The process is aimed at allowing for the useful undertaking
of vascular examinations and where necessary, the performance of a revascularization procedure.
On the other hand, the nurses given the role of managing Mrs. Bacca’s condition could
also take the option of initiating enzymatic debridement as an alternative for surgical
debridement. According to Kato et al. (2017), enzymatic debridement can be achieved through
proper inclusion of a more extensive array of enzymatic agents such as krill collagen, crab-
deprived collagenase, and a combination of dextrans, streptokinase, and streptodornase, the
scholars reveal that these agents are highly capable of removing necrotic tissues without
destroying the healthy tissues.
Finestone et al. (2018) explain that nonremovable TCC functions through the
distribution of plantar pressures presented in the mid and fore- regions of the patient’s foot. The
process will be applied for Mrs. Bacca to enhance the complete rest of the injured foot while
allowing her to engage in restricted activity. One of the most significant advantages of
nonremovable TCC is its inherent ability to foster the reduction of edema. However, considering
the fact that the patient was discharged from the facility about 7 days ago and was put under
medications such as paracetamol 1g QID, Novorapid TDS 12 units, Lantus 30 units note, and
Pregabalin 75 mg mane, there is need for the caregiver to insist on the importance of complying

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with the treatments administered. Apart from managing these remedies, there is a need for the
caregiver to recommend the use of removable cast walkers. According to Worley et al. (2017),
removable cast walkers are made up of lightweight semi-rigid shells that play a vital role in
supporting the affected limb while availing full cell protections.
In conclusion, the study proceeded with the aims of analyzing the underlying
pathophysiological and causes of the postoperative wound presented in Mrs. Bacca’s case,
identifying the most effective nursing priorities for this patient and justification of the nursing
management of the client. Based on the analysis, debridement and off-loading were adopted as
the primary nursing priorities of care for Mrs. Bacci. On the other hand, surgical debridement
and non-removable total contact cast offloading were considered as the most appropriate and
safest nursing management techniques for Mrs. Bacci in this period. Apart from administering
these remedies, the caregiver recommends the use of removable cast walkers.

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