Wound Management

This document discusses the wound management process for a patient with a diabetic foot ulcer. It includes the client's presentation, significant clinical history, holistic assessment, evidence-based management plan, and consultation pathway.

Running head: WOUND MANAGEMENT
Wound Management
Name of the Student
Name of the University
Author Note

1
WOUND MANAGEMENT
Client presentation and significant clinical history
Mrs Y was an aboriginal man who is 55 years old. He was admitted to hospital in the
surgical unit 2 weeks ago in order to treat the complications in his left foot ulcer. The
presentation of wound of Mr. X with the diabetic foot ulcer in the right leg occurred with
swelling and discoloration of the skin at the site of the wound. The wound was warm to touch
with pungent smell coming from wound. Discharge was seeping from the wound. Mr. X was
reporting pain at the wound site along with fever and chills. There was formation of callused
or thickened skin surrounding the wound. At the time of admission it was found that his nails
were large and filled with dirt. He underwent surgery of his right foot ulcer under normal
anaesthesia for partial amputation of the forefoot, great and toes. He was diagnosed with type
2 diabetes mellitus (T2DM) 5 years ago. He is also suffering from peripheral vascular disease
(PVD) and obesity (BMI 44.4 m2 and height 172 cm and weight 115 kilograms). In order to
manage his high blood glucose level (hyperglycemia), he has been on insulin upon her
admission to hospital.
On the next day post surgery (24 hours), her blood pressure was 120/70 mmHg, pulse
rate was 88 bpm, with respiratory rate 18 bpm and level of oxygen saturation within the body
is 97% RA. Body temperature is 37.8. Both her feet, right and left was cool to tough with a
capillary refill time 3 to 4 seconds. Mr. X states that he normally has cold feet and used to
wear socks at home. His blood glucose level (BGL) is 12.6 mmol/L (normal: 4.0 to 5.4
mmol/L). Upon examination of the wound, during replacement of the Island film dressing
along the incisional wound, it was found that the wound site is wet with sight redness along
with yellow or greenish colour pus or cloudy drainage. The wound has dehiscence along the
suture line. There was presence of some sloughy tissue at the site of the wound. The skin
surrounding the wound is warm to touch and painful to tough and dark pink.

2
WOUND MANAGEMENT
The medication list reported by Mr. X include novorapid ( a modern analogue of
insulin that has rapid acting effect), lantus (insulin glargine that is used as long acting insulin)
and pregabalin (used for the treatment of the generalised anxiety disorder and neuropathic
pain and restless leg syndrome) (Bryant et al. 2019). Mr. X reported that he feed on whatever
food he gets and mainly leads to sedentary life and lives alone.
Mr. X English was poor and he was found comfortable in communicating in
Aboriginal language. He stated that after surgery was completed he was lying and was
anxious about his health. He was becoming restless due to his addiction towards alcohol and
smoking and was feeling homesick. Mr. X used to work as a truck driver at present he is
jobless because he has developed problem in his eye sight (dual vision: diabetic retinopathy).
Results of holistic assessment
The wound presentation of Mr. X during the time of hospital admission showed that it
is an acute wound that is the wound and the formation of callus tissues surrounding the has
generated during a considerable period of time. Unmanaged T2DM leads to persistent high
blood glucose level (BGL). Increased blood glucose leads to micro and macro-vascular
complication of diabetes. Diabetic foot ulcer is a macro-vascular complication of diabetes.
High BGL for a considerable period of time hampers neurotransmission (peripheral
neuropathy) and hampering the flow of the blood, oxygen and other nutrients at the periphery
of body (Pop-Busui et al. 2017). The damage in the blood vessels at the peripheral region of
the body (peripheral neuropathy) along with poor supply of oxygen leads to development of
diabetic neuropathy. Pain and encountered by Mr. X at the time of hospital admission is due
to damage in veins. The formation of callus and wound increase the tendency of bacterial
infection leading to formation of fever. The restless in leg might be due to tingling sensation
of pain (Pop-Busui et al. 2017).

3
WOUND MANAGEMENT
The management stage of diabetes along with the development of diabetic foot ulcer
is due to long unmanaged health condition. The unhygienic condition of his feet further
highlighted his lack of self-management skills. One social indicator of the aboriginals in
Australia is lack of proper hygienic status and poor sanitization. This is the reason why
majority of the Aboriginals suffer from poor oral health with unmanaged nails. The direct
present in the nails along with long and sharp nails might have been the reason behind wound
formation and infection in the wound (Gray and Tesfaghiorghis 2018). Aboriginal culture
mainly gives importance to the use of the traditional medicine. Mr. X reported during the
time of hospital admission that he do not believe in taking medications and prefers to rely on
traditional medicine. This is the reason why he did not seek help during the initial phase of
the infection development (Oliver 2013). Traditional medicine fails to improve the chronic
stage of the diabetic wound and high BGL increases the severity of the wound further leading
to the formation of callus tissue at the site of wound (Armstrong, Boulton and Bus 2017).
His obesity and high BMI is the reason behind his disability and loss of job has further
impose a state of sedentary life. The social status of the aboriginal people is poor as they
belong to poor socio-economic background. Social exclusion, lack of proper employment
opportunity along with substance abuse hampers their social status further leading to the
developing of depression and anxiety. Mr. X was also suffering from anxiety lack of
employment and psychological distress leads to increased BGL (Hackett and Steptoe 2017).
The aboriginals in Australia suffer from poor health care awareness and this is the reason
why they follow unhealthy diet. Mr. X lives alone and feed on whatever food he gets handy.
Uncontrolled intake to food increase fat deposition in the body and thus increasing the BGL.
Mr. X lost is job and at the age of 50 with dual vision, he is unlikely to get any new job. In
relation to this, it can be said that avenue for getting a fixed salary at the end of every month
is less for Mr. X. Lack of employment opportunity and financial unrest increase stress and

4
WOUND MANAGEMENT
inability to avail healthcare services and thus causing increased BMI, obesity and high BGL
(Pearson et al. 2016).
Evidence-based management plan
First nursing priority that can be highlight from the presentation of the patients is
effective management of the wound at the surgical site. According to the study conducted by
Forrester and Griffiths (2015) it is the duty of the nurses in the surgical ward to take active
measures for management and healing of the wound. Wound management by promoting
faster healing helps to decreases surgical wound dehiscence and chances of sepsis at the
wound site. Mr. X was suffering from unmanaged T2DM with high BGL. High BGL
promotes functional and structural chance in the hyaluronan causing delayed wound healing
at the surgical site. To promote faster healing of wound and formation of new tissues at the
wound site, periodic replacement of dressing is important along with the use of the
natispectic ointment and ointment rich in iodine. The presence of iodine will help in faster
wound healing. The faster healing of wound reduces the chances of sepsis and severity of
diabetic foot ulcer (Brown et al. 2015).
Second priority for Mr. X is reduction in his high BGL and this will promote faster
wound healing and decreased severity of diabetic foot ulcer (Martini, Nath and Bartholomew
2018). The formation of wound or incision over skin following injury or cut, the first step
taken by the body is the trigger of type 1 hypersensitivity reaction. Type 1 hypersensitivity
reaction prevents the chances of infection at the wound site by triggering the infiltration of
the macrophages and neutrophills at the site of the wound. The second step of wound healing
is generation of tissues or formation of new cells at the site of the wound. The third step
involves formation of scar tissue at wound site. However, an individual with diabetes the
process of wound healing in a step wise manner is delayed due to high BGL. The presence of

5
WOUND MANAGEMENT
high glucose in blood hampers the normal signalling pathways involved in wound healing.
Delayed healing increases the chances of the microbial infection at the site of the wound and
increases the chances of sepsis. The sight redness along with yellow or greenish colour pus or
cloudy drainage of wound of Mr. X is signs of microbial infection (Hall 2016). Keeping BGL
under normal range helps to promote normal process of wound healing and this in turn helps
to secrease the chance of peripheral neuropathy. Decrease in peripheral neuropathy helps to
decrease the chances of cold feet at night. This will help to ensure sound sleep at night and
helping to reduce the level of anxiety and restless in leg (Hamlin et al. 2016).
The first nursing management plan for Mr. X as per the evidence based guidelines
will involve education of the patients for developing self-management skills of diabetes.
According to the Professional code of conduct of Nursing and Midwifery Board of Australia
(2018), a nurse must educate the patients about the underlying concept of disease progression
for increasing clinical governance. Improvement in the clinical governance helps to increase
the rate of participation of the patients in the therapy plan and thus helping to improve rate of
therapy adherence and improvement in the self management skills (Powers et al. 2017). For
Mr. X gap in the diabetes management is leading to un-managed diabetes. He do not have a
proper diet plan for diabetes and is leads to sedentary life. The ignorance towards healthy
lifestyle further indicates gap in the self-management skills of diabetes. The health education
for promoting self-management skills for diabetes will initiate with the education of the
factors leading to diabetes and its outcomes. Mr. X must be educated that his dual vision is a
result of diabetic retinopathy (Chawla, Chawla and Jaggi 2016). He must be educated further
that foot ulcer is an outcome of diabetic neuropathy. This education will be followed by the
self-management skills of diabetes like controlling lifestyle factors. As per the evidence-
based practice, Mackey et al. (2016) stated that diabetes is a lifestyle disease can be
effectively controlled through managing lifestyle factor (modifiable risk factors) like diet,

6
WOUND MANAGEMENT
physical activities. Education must be given in regular monitoring of the blood glucose level
in order to adjust the insulin dosage accordingly (Mackey et al. 2016).
The second nursing management plan will include proper dressing of wound and
replacement of the wound in a timely manner to prevent the chance of infection and control
the secretion of serous exudates. Mr. X wound was wet from serous exudates. Replacement
of the wound with Island dressing along the use of ointment will promote faster healing of
wound (Weller and Team 2019). According to the evidence-based practice, Island film is the
most suitable wound dressing for the management of the wound dehiscence at the surgical
site because it is made of absorbent pad and is associated with adhesive backing. It helps in
absorb the additional fluid (serous exudates) of wound, and keeping the wound dry and free
from moisture (Weller and Team 2019). Wound free from moisture is less likely to become
affected with microbial infection.
Consultation and Referral pathway
In order to optimize the patient outcome and to implement patient centered
interventions proper consultation and referral to the members of multidisciplinary team will
be important. The first member of multidisciplinary team that will be helpful for promoting
comprehensive health and well-being of Mr. X is dietician. The role of the dietician will be
frame the anti-diabetic diet plan for Mr. X depending on his weight, BMI level, height and
BGL. The will be followed by physical trainer. The role of the physical trainer is to frame
person-centred physical activity of Mr. X depending on his calorie intake and body weight.
At present Mr. X is suffering from diabetic foot ulcer with surgical wound in his right feet.
Rigorous physical activity at current time is not feasible. The intensity of physical activity
will depend on the stage of his recovery from diabetic foot ulcer and management of wound.
Bancks et al. (2017) stated that proper observance of anti-diabetic diet and physical activity

7
WOUND MANAGEMENT
helps to reduce the blood glucose and thus reducing severity of diabetes mellitus. Another
multidisciplinary team member includes a culturally competent aboriginals nurse. The role of
the aboriginal nurse will be make Mr. X understand the process of disease prognosis and the
disease propagation in aboriginal language in which he is comfortable. Villalba et al. (2018)
stated that educating the Aboriginals and Torres Strait Islander in their colloquial language is
a part of trans-cultural nursing. It helps to implement culturally competent care plan while
increasing patients’ interest to take part in care plan. Mr. X lives alone thus referrals must be
made to residential care nurses in the discharge planning. The presence of residential care
nurse will help in periodic monitoring of BGL, adherence of diet plan and medications. The
residential care nurse will also assist Mr. X in activities of daily living till complete recovery
from wound. Consultation must be done with the doctor about yellow exudates coming from
wound for eradicating threats of bacterial or fungal infection and wound site. Proper
administration of antibiotic helps to reduce the chance of bacterial infection (Hurley et al.
2017). People suffering from diabetes develop psychological stress that hampers the disease
propagation by increasing the secretion of glucose in blood. Mr. X has high anxiety levels
and in order medication for the management of anxiety. However, pharmacological
interventions for anxiety management can lead to negative health outcome in long run like
development of cardiovascular disease. Consultation must be done with psychological
counselor and mental health nurses in order to uncover the reasons underlying his anxiety and
framing non-pharmacological mental health nursing interventions accordingly. Mental health
counseling will help to overcome Mr. X addiction to smoking and drinking (Hackett and
Steptoe 2017). Consultation must be done with ophthalmologist for recovery of his dual
vision (diabetes neuropathy) (Villalba et al. 2019).

8
WOUND MANAGEMENT
References
Armstrong, D.G., Boulton, A.J. and Bus, S.A., 2017. Diabetic foot ulcers and their
recurrence. New England Journal of Medicine, 376(24), pp.2367-2375.
Bancks, M.P., Kershaw, K., Carson, A.P., Gordon-Larsen, P., Schreiner, P.J. and Carnethon,
M.R., 2017. Association of modifiable risk factors in young adulthood with racial disparity in
incident type 2 diabetes during middle adulthood. Jama, 318(24), pp.2457-2465.
Bryant, B., Knights, K., Rowland, A and Darroch, S. 2019. Pharmacology for health
professionals (5th ed.). Chatswood, NSW: Elsevier Australia.
Chawla, A., Chawla, R. and Jaggi, S., 2016. Microvasular and macrovascular complications
in diabetes mellitus: distinct or continuum?. Indian journal of endocrinology and
metabolism, 20(4), p.546.
Forrester, K., and Griffiths, D. 2015. Essentials of law for health professionals (4th ed.).
Sydney: Elsevier.
Gray, A. and Tesfaghiorghis, H., 2018. Social indicators of the Aboriginal population of
Australia.
Hackett, R.A. and Steptoe, A., 2017. Type 2 diabetes mellitus and psychological stress—a
modifiable risk factor. Nature Reviews Endocrinology, 13(9), p.547.
Hall, J.E. 2016. Guyton and Hall Textbook of medical physiology (13th ed.). Philadelphia:
Elsevier.
Hamlin, L., Davies, M., Richardson-Tench, M. and Sutherland-Fraser, S. (Eds.). 2016.
Perioperative nursing: An introduction. (2nd ed.) Chatswood: Elsevier Australia.

9
WOUND MANAGEMENT
Hurley, L., O'Donnell, M., O'Caoimh, R. and Dinneen, S.F., 2017. Investigating the
management of diabetes in nursing homes using a mixed methods approach. Diabetes
research and clinical practice, 127, pp.156-162.
Mackey, L. M., Doody, C., Werner, E. L., and Fullen, B. 2016. Self-management skills in
chronic disease management: what role does health literacy have?. Medical Decision
Making, 36(6), 741-759.
Martini, F. H., Nath, J. L. and Bartholomew, E. F. 2018. Fundamentals of anatomy &
physiology (11th ed.). New Jersey: Pearson.
Nursing and Midwifery Board of Australia (2018). Professional code of conduct of the nurses
and midwives. Access date: 14th June. 2019. Retrieved from:
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-
standards.aspx
Oliver, S.J., 2013. The role of traditional medicine practice in primary health care within
Aboriginal Australia: a review of the literature. Journal of ethnobiology and
ethnomedicine, 9(1), p.46.
Pearson, O., Eltridge, F., Luz, Z., Stewart, H., Westhead, S., Zimmet, P. and Brown, A.,
2016. The South Australian Aboriginal Diabetes Strategy 2017–2021.
Pop-Busui, R., Boulton, A.J., Feldman, E.L., Bril, V., Freeman, R., Malik, R.A., Sosenko,
J.M. and Ziegler, D., 2017. Diabetic neuropathy: a position statement by the American
Diabetes Association. Diabetes care, 40(1), pp.136-154.
Powers, M.A., Bardsley, J., Cypress, M., Duker, P., Funnell, M.M., Fischl, A.H., Maryniuk,
M.D., Siminerio, L. and Vivian, E., 2017. Diabetes self-management education and support
in type 2 diabetes: a joint position statement of the American Diabetes Association, the

10
WOUND MANAGEMENT
American Association of Diabetes Educators, and the Academy of Nutrition and
Dietetics. The Diabetes Educator, 43(1), pp.40-53.
Villalba, C., Askew, D., Jaiprakash, A., Donovan, J., Roberts, J., Russell, A., Crawford, R.
and Hayman, N., 2019. A mixed-methods retrospective study: 10 years of diabetic
retinopathy screening in urban Aboriginal and Torres Strait Islander primary care. Australian
journal of primary health, 25(1), pp.24-30.
Weller, C., and Team, V. 2019. Interactive dressings and their role in moist wound
management. In Advanced Textiles for Wound Care (pp. 105-134). Woodhead Publishing

11
WOUND MANAGEMENT
Appendix
Hi Mr. X how are you feeling now? I am the surgical nurse in this unit. I would like to
know few things related to your health. Please remain rest assured that your name and other
identification details will be kept strictly confidential. There is not compulsion for your take
part in this conversation but I would still like to tell you that taking part in this conversation
will help to improve your stage of recovery.
I will mainly ask questions related to your current health status like time of disease
development and your symptoms. We will also ask questions related to your lifestyle
management and activities daily living. This are the part of the routine check-up procedure.
Why I am telling you all these because, I need your consent or approval in order to
progress with the conversation process. If you’re the conversation you feel uncomfortable or
unwell, you are free to end the process of conversation.
This process of conversation will occur in the presence of aboriginal nurse who will act as in
interpreter.