Assessment Task: Case Study 1 - Nursing Priorities for Wound Infection

This case study centers on Mrs. Gina Bacci, a 49-year-old Italian woman with type 2 diabetes, PVD, and obesity, who experienced complications from a right foot ulcer leading to partial amputation. The assignment delves into the pathophysiology of her post-operative wound infection, identifying bact...Read More

Running head: ASSESSMENT TASK: CASE STUDY 1 1
Assessment Task: Case Study 1
Student’s Name
Institutional Affiliation

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Introduction
The essay is based on an Italian lady of 49 years old called Mrs. Gina Bacci. Gina visited
the hospital two weeks ago for partial amputation following complications from a right foot
ulcer. She has a history of type 2 diabetes diagnosed six years ago, Peripheral Vascular Disease
(PVD) and obesity. Seven days later after being discharged from the hospital, she visits the
hospital for further wound assessment and management. The essay will discuss the
pathophysiology and causes of her wound status and identify the main nursing priorities for
wound care. Also, it will 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.
Pathophysiology is defined as the scientific study of abnormal processes which cause an
infection (McCance & Huether, 2018). After close examination of Gina's wound and the vital
signs, there is an indication that the surgical wound was in the process of healing at the
inflammatory phase, but it seems to have been invaded by some bacteria which leads to an
infection. The wound shows the sign of infection since the surrounding skin is warm, dark pink
and painful to touch. Also, her temperature is very high indicating fever.
The wound disarrayed the tissue integrity that commenced the coagulation cascade to
desist bleeding. The cellular components which are the platelets aggregated to the wound and
because of the platelet’s reaction they released several cytokines. These cytokines entail the
Insulin-Like Growth Factor-1 (IGF-1), Epidermal Growth Factor (EGF), and Platelet Derived
Growth Factor (PDGF) along with the Fibroblast Growth Factor (FGF) (Park, Hwang & Yoon,
2017). Furthermore, serotonin was dispensed and working jointly with histamine which is
released by mast cells kindled an adjustable opening of the junctions amid the endothelial cells.

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Serotonin and histamine allow the monocytes along with neutrophils to pass which become
macrophages to the site of the wound.
The huge cellular movement to the site of the wound is triggered by the cytokines
generated by the platelets and by an added chemotactic cytokines made by the macrophages at
the wound site (Zhao, Liang, Clarke, Jackson & Xue, 2016). They entail the Transforming
Growth Factor alpha (TGF-α) and the Transforming Growth Factor beta (TGF-β).
Correspondingly, the inflammatory exudate that comprises of macrophages, red blood cells,
plasma proteins together with neutrophils including coagulation cascade proteins as well as fibrin
strands fill the wound (De Oliveira, Rosowski & Huttenlocher, 2016). Not only does the
macrophages scavenge but are also predominant to the process of wound healing because of the
production of their cytokines.
When Gina Bacci's vital signs are taken, the blood pressure, pulse rate, and the
respiratory rate are standard except the temperature and the blood glucose level. Since Gina has a
history of type 2 diabetes, it is clear that diabetes made it difficult for her body to control her
blood glucose level. When the blood glucose level remained habitually very high, it impaired the
operation of the white blood cells resulting in the inability to fight microorganisms (Sorisky,
2017). For a post-operative surgical wound infection to occur the person’s skin is the most
common bacterial source.
Looking at Gina, there are triggers which resulted in her present condition. The infection
of the wound was caused by germs either from the skin or from her operational instruments.
Most of the surgical wound infections are as a result of the individual’s bacterial flora and the
most common bacterial causing surgical wound infection are Staphylococcus, Streptococcus
along with Pseudomonas (Brook, 2016). The skin is the body’s first line of defense that is

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shielded by a thin, acid film secreted by the sebaceous glands known as the acid mantle. The acid
mantle adjusts the skin’s pH and keeps the normal flora which aids prevent bacteria from
entering the body. When the skin is ruptured, the protection is no longer there, and any bacteria
are colonizing the skin cause infection.
Another cause of surgical wound infections is the bacteria found in the environment
around the person (Streeter & Katouli, 2016). Whenever these germs come in contact with the
person, they are introduced to the site of the wound, and it colonizes it causing an infection.
Finally, bacteria from the hospital setting cause post-operative infections (Deshpande,
Someshwaran & Gnanaprakash, 2016). For instance, during the time of Gina’s surgery, the
instruments used might have had bacteria and might have been transferred to the wound site.
Also, the surgeon's body has bacteria, and if he did not perform hand hygiene before operating
the germs might have been spread to the surgical site hence causing an infection.
Identify two main nursing priorities of care for this patient and provide justification and
rationale for each.
The reason behind Gina’s present situation at the hospital is the bacteria which has
colonized her wound causing an infection. Also, the sloughy tissue seen on the wound bed must
be harboring some bacteria which might have contributed to the epidemic. Gina’s wound has
some dehiscence along the suture line which is a complication as a result of an infection. The
primary nursing priorities are the removal of the sloughy tissue and confirming the species of
bacteria present in the wound bed through taking wound swabs for culture and sensitivity so that
the correct treatment can be identified (Chhugani, Jacob & James, 2017).
The sloughy tissue can act as a focal point for microorganisms and the peri-wound
protected as the exudate can be high. The sloughy tissue can delay the process of wound healing,

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and it is frequently necessary for the devitalized tissue to be removed before any progress
towards cure can be made. This removal of the sloughy tissue is known as debridement and can
be performed surgically or using non-surgical methods like utilizing enzymes to eat up the dead
tissue.
To make sure that Gina’s problem is solved, the treatment goals must be ascertained, and
steps are taken to obtain the desired results. The accurate information about the species of
bacteria present in the wound bed must be confirmed, and then the correct antibiotic is given to
fasten the healing process. Antibiotics work in two ways; they either eliminate the microbes by
ceasing the mechanism accountable for building their cell walls or they block the breeding of the
bacteria.
If bacteria such as streptococcus are present and responsible for the infection Amoxicillin
antibiotics will be appropriate for dealing with them (Surahio, Talpur, SalamMemon, Junejo &
Laghari, 2017). Amoxicillin will not kill the microbe directly, but it will destroy the cell wall
hence preventing the bacteria from making proteins which are necessary for them to grow and
survive hence the goal of avoiding the infection will have been met.
From your identified priorities, outline and justify the appropriate and safe nursing
management of the patient during this time.
To meet the patient’s treatment goals, actions need to be implemented. The clinical nurse
has to take care of the wound complication, that is, the dehiscence. He should wash out the
wound using saline and then do simple wound care like packing the wound with absorbent
ribbon gauze. Since the dehiscence is along the suture line, the nurse should treat the suture line
with a dressing that will control the anticipated early inflammatory exudate, and it will also
provide a waterproof covering (Smart & Acton, 2016). Here, a thorough assessment should be

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done on the structures of the dehisced wound and the presence of any foreign bodies. Since the
surrounding skin is painful to touch, the health care professional should make sure that adequate
measures are taken to make the patient comfortable. This will be achievable if the nurses
administer the correct drugs to reduce the pain.
The removal of the sloughy tissue can be performed either mechanically through a
surgical incision, sharp debridement, and bio-surgery or non-mechanically via enzymatic,
autolytic and through the use of polysaccharide dressings (Percival & Suleman, 2015). If the
nurse is performing autolytic debridement and the wound is too wet or too dry, he should use the
appropriate dressing such as hydrogels along with occlusive dressings to rehydrate dry slough to
create a moist environment. This is appropriate since autolysis relies on a humid environment.
Moreover, he should utilize hydrofibres, calcium alginates together with semi-permeable
dressings to absorb excess exudate in wetter wounds (Percival & Suleman, 2015).
If surgical debridement is done, the surgeon must visually inspect the tissue, ascertain
what tissue is viable and then remove the tissue which is not salvageable. Using a sharp
instrument, the surgeon should cut away the bad tissue and try to preserve as much good tissue as
possible (Percival & Suleman, 2015). On the other hand, if the health professional chooses the
type of debridement using enzymes, he should use the enzyme solutions and combine with a
dressing which is changed frequently that softens the tissue and enables for the lousy tissue to be
removed when the dressing is removed.
When confirming the type of bacteria, wound swabs are taken for culture and sensitivity, and it
needs some nursing management. The health professional should perform hand hygiene,
assemble the instruments, wear sterile gloves and irrigate the wound site using sodium chloride

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and then by use of a gauze pad, swab the wound smoothly. When the swab is moist, it will be
possible to obtain the correct information concerning the bacteria (Assadian et al., 2018). Since
this wound culture must be collected from a clean tissue, the nurses should identify an unstained
area of a feasible tissue and turn the swab on it for better results.
The best and effective therapy for Gina is topical antibiotics since the infection is
localized. However, if the infection was systemic, the treatment could be changed to oral
antibiotics. Amoxicillin fights the bacteria and stops them from developing through preventing
them from forming cell walls (Lobanovska & Pilla, 2017). Through this mechanism, the bacteria
are killed, and the infection is eventually eradicated. The removal of the sloughy assists in the
effectiveness of the topical antibiotics.
Conclusion
A surgical wound can develop an infection at its inflammatory stage of healing and if a
slough tissue develops it can harbor some microbes leading to an infection. During this time, the
health professionals must make sure that the sloughy tissue is removed to prevent further
infection and then take a wound swab for culture to determine the bacteria present in the wound
bed that is causing the infection. When taking care of the wound, the nurses have to practice
hand hygiene, use the correct instruments for obtaining wound swabs and use the proper
dressings during debridement.

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References
Assadian, O., Kammerlander, G., Geyrhofer, C., Luch, G., Doppler, S., Tuchmann, F., & Leaper,
D. (2018). Use of wet-to-moist cleansing with different irrigation solutions to reduce
bacterial bioburden in chronic wounds. Journal of wound care, 27(Sup10), S10-S16.
Brook, I. (2016). Spectrum and treatment of anaerobic infections. Journal of Infection and
Chemotherapy, 22(1), 1-13.
Chhugani, M., Jacob, S. M., & James, M. M. (2017). Nursing Care: Making a Big Difference in
Stage 3 Bed Sore. Int. J. Nurs. Midwif. Res, 4(4), 4.
De Oliveira, S., Rosowski, E. E., & Huttenlocher, A. (2016). Neutrophil migration in infection
and wound repair: going forward in reverse. Nature Reviews Immunology, 16(6), 378.
Deshpande, S. A., Someshwaran, R., & Gnanaprakash, K. (2016). A Bacteriological Study of
Post-Operative Wound Infections and its Antibiotic Sensitivity Pattern from a Tertiary
Care Hospital, Coimbatore, India. International J. Current Microbiology and Applied
Sciences, 5(8), 629-634.
Lobanovska, M., & Pilla, G. (2017). Focus: Drug Development: Penicillin’s Discovery and
Antibiotic Resistance: Lessons for the Future?. The Yale journal of biology and
medicine, 90(1), 135.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in
adults and children. Elsevier Health Sciences.
Park, J., Hwang, S., & Yoon, I. S. (2017). Advanced growth factor delivery systems in wound
management and skin regeneration. Molecules, 22(8), 1259.

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Percival, S. L., & Suleman, L. (2015). Slough and biofilm: removal of barriers to wound healing
by desloughing. Journal of wound care, 24(11), 498-510.
Smart, L., & Acton, C. (2016). Wound dressings: surgical dressings. Dermatological
Nursing, 15(2), 36-40.
Sorisky, A. (2017). Effect of high glucose levels on white adipose cells and adipokines—Fuel for
the fire. International journal of molecular sciences, 18(5), 944.
Streeter, K., & Katouli, M. (2016). Pseudomonas aeruginosa: A review of their Pathogenesis and
Prevalence in Clinical Settings and the Environment. Infection, Epidemiology, and
Microbiology, 2(1), 25-32.
Surahio, A. R., Talpur, A. A., SalamMemon, A., Junejo, A., & Laghari, A. A. (2017). Surgical
site infections. The Professional Medical Journal, 24(01), 57-63.
Zhao, R., Liang, H., Clarke, E., Jackson, C., & Xue, M. (2016). Inflammation in chronic
wounds. International journal of molecular sciences, 17(12), 2085.