NRSG 258 Case Study: Diabetes, PVD and Post-operative Wound Care

This case study analyzes the post-operative wound status of a 49-year-old diabetic patient, Mrs. Gina Bacci, who underwent partial amputation. It delves into the pathophysiology and causes of her infected wound, highlighting the role of diabetes and peripheral vascular disease in impaired healing. The essay identifies key nursing priorities, including wound swabs for culture and sensitivity testing and empirical antibiotic therapy, emphasizing the importance of accurate pathogen identification and appropriate antibiotic administration. Safe nursing management strategies, such as proper wound cleansing, specimen collection techniques, and pain management, are outlined. The conclusion stresses the significance of these interventions in preventing superficial infections from progressing into deeper, more serious complications and promoting effective wound healing. Desklib offers a wealth of similar case studies and solved assignments for nursing students.

Running head: NURSING ASSIGNMENT 1
Nursing Assignment
Student’s Name
Institutional Affiliation

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Introduction
The essay focuses on a 49-year-old Italian lady whose name is Mrs. Gina Bacci who was
admitted to hospital for surgery of the right foot. From the information gathered, Gina has a
history of type 2 diabetes, Peripheral Vascular Disease together with obesity. Seven days after
the surgery, Gina visited the hospital for further wound assessment and management. Using the
clinical reason cycle, the essay will discuss the underlying pathophysiology and causes of Gina’s
wound status, and the main nursing priorities of care along with the appropriate and safe nursing
management for Gina’s wound status.
Based on the case study, critically analyze and discuss the underlying pathophysiology and
causes of the patient’s post-operative wound status.
1. Considering the patient condition:
Pathophysiology is the abnormal processes related to an injury or a disease (Taeb,
Hooper & Marik, 2017). Considering the patient condition in the case scenario the status of the
wound indicates an infection. This is because when her wound is examined, it shows signs of a
disease such as the surrounding skin being warm, dark pink and painful. Also, her temperatures
read high indicating fever which is a sign of infection. Therefore, the exposure of subcutaneous
tissue following a wound produces a humid, warm and a nourishing surrounding which is useful
to microorganism’s colonization and proliferation. Consequently, the diversity together with the
abundance of these microbes in a wound is determined by the type of a wound, its depth, quality,
and location along with the level of tissue intromission and the antimicrobial efficiency of the
host immune response.
Infection of a wound after surgery happens when bacterial out-competes the patient’s
natural immune system resulting in a sequence of local and systemic inflammatory reactions.
The infection starts when a microbe successfully enters the body, grows and multiplies which is

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called colonization (Stacy, McNally, Darch, Brown & Whiteley, 2016). People who have a
suppressed immune system are especially vulnerable to opportunistic infections. Entrance to the
host-pathogen interface occurs typically through the mucosa in orifices, or the organisms can
enter the body via open wounds.
All multicellular microbes are colonized to some level by extrinsic bacteria, and the vast
majority of these exist in either a commensal or mutualistic relationship with the host. An
example of mutualistic is the anaerobic microbe species which colonizes the mammalian colon,
and the case of the commensal relationship are the several species of staphylococcus which
reside on human skin (Krismer, Weidenmaier, Zipperer & Peschel, 2017).
2. Gathering information and cues.
According to the information gathered, the patient is diabetic and her blood glucose level
is high which means that diabetes made it harder for the body to manage her blood glucose level
and when it remained chronically high it impaired the white blood cells functioning leading to
the inability to fight bacteria (Walsh, Shaw, Sachdev, Anstey & Cherbuin, 2018). The most
common microbial source of postoperative wound infection is the patient’s skin and the most
common inoculating microbes for clear surgical cases are gram-positive cocci from the skin.
3. Process information.
After the information is processed, it is evident that Methicillin-sensitive Staphylococcus
aureus (MSSA) along with drug-resistant microbes including vancomycin-resistant enterococci
and Methicillin-resistant Staphylococcus aureus (MRSA) colonized on the skin. These MSSA
and MRSA are transmitted by contact, and the microorganisms reside with other microbes on an
individual's surface and when an individual contacts things or other people he or she can spread
the organisms (Boswihi & Udo, 2018). All surgical wounds can condone some level of host

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harm locally and a particular amount of bacterial flora. Consequently, the state of the wound and
the microbial flora are reticular and if either of these outpaces an endurable threshold, an
infection may thrive. This threshold may be influenced by host factors like the existence of
comorbid situation like type 2 diabetes as in the case of Gina.
Skin is a natural barrier against infection, and any surgery which results in a break in the
skin can result in an infection. Infection to wounds after a surgical operation is caused by germs
and the most common being Gram-negative bacilli, Staphylococcus, and Streptococcus
(Mundhada & Tenpe, 2015). One form in which these germs could infect a surgical wound is by
contacts like germs in the surrounding around a person like hands of the health professional or
contaminated surgical instruments. From the case scenario, Gina underwent a partial amputation
which was performed by a surgeon and bacteria might have spread from the surgeon's hands or
the instruments used hence the infection. Moreover, they are caused by microbes which are
already on the skin that extend to the surgical wound or bacteria which are inside the body or
from the organ on which the medical procedure was carried out (Mundhada & Tenpe, 2015).
Identify two main nursing priorities of care for this patient and provide justification and
rationale for each.
4. Identify Problems.
The two nursing priorities of care are wound swabs for culture and sensitivity along with
empirical antibiotic therapy. To identify the problems with the wound like the pathogen
responsible, a sampling of the wound surface is performed first to isolate and identify
microorganisms in the wound and determine the antibiotic sensitivity of the bacteria to prevent
the spread of the infection (Yaqub et al., 2018). Before the sampling, the healthcare giver deep

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cleans the wound site to remove the dead or the infected tissue which is referred to as
debridement.
A sterile swab is then used to collect pus or cells from the external wound site. The
sample is added to a substance that promotes the germs growth, and if enough bacteria are found
in the sample, it means that the infection is bacterial. Therefore, other additional tests will be
ordered to confirm a diagnosis or determine the severity of the infection Furthermore; a sensitive
test will be requested to assist in determining the antibiotic which will be most effective in
treating the disease.
Antibiotic therapy must aim the most probable bacteria responsible for the infection. To
select the antibiotic, considerations such as the bacteriostatic or bactericidal action under the
existing tissue situation should be acquired. Also, the pathogen’s sensitivity, in vitro
susceptibility of the pathogen, cost, and safety along with drug distribution to the infection site
should be obtained (Bessa, Fazii, Di Giulio & Cellini, 2015).
5. Establish goals.
Cytologic assessment such as a Gram stain may be of help in directing the initial therapy
(Samuel, Balada-Llasat, Harrington & Cavagnolo, 2016). To establish the goal of treating the
infection and fasten its healing specific antibiotics are administered. For instance, Amoxicillin is
an antibiotic that belongs to the penicillin group of beta-lactam antibiotics, and it’s only useful
on the bacterial population. It does not kill the bacteria directly, but it destroys the cell wall
preventing the bacteria from making proteins which are needed for them to survive and thrive.
This antibiotic is prescribed for infections caused by gram-positive microbes like Streptococcus
and for penicillin-resistant strains of bacteria; Augmentin antibiotic is prescribed to fight them.

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From your identified priorities, outline and justify the appropriate and safe nursing
management of the patient during this time.
6. Take action.
To obtain the accurate results from wound swabs for culture and sensitivity nurses should
take action by getting the specimen before the patient commences the antimicrobial treatment
which interrupts the growth of the bacteria (Yaqub et al., 2018). The clinical nurse should wash
hands before obtaining the specimen and remove jewelry before handling the wound along with
using gloves to remove the old dressing to avoid further transfer of germs. After that, the wound
swab is cleansed thoroughly for it to gather the bacteria in the wound bed and not the harmless
skin flora or contamination from the previous primary dressing. The recommended cleansing
agent is water or normal saline.
For proper management of the wound swab, the nurse should assemble the equipment,
perform hand hygiene, put on unsterile gloves and irrigate the wound with 0.9 percent of sodium
chloride and swab smoothly using the gauze pad. The moist swab provides more accurate
information when compared to a dry swab since it elevates the chance of recovering bacteria
from the wound bed (Ramsay, Cowan, Davidson, Nanney & Schultz, 2016). The health
professional should identify a small region of unstained, feasible tissue and turn the swab on it
averting any necrotic tissue. This wound culture must be obtained from a clean tissue since
necrotic tissue or pus will not give the correct profile of the microflora in the tissue.
The health caregiver must insert the swab in a sterile container, redress the wound and
perform hand hygiene. He or she should evaluate the patient and make sure that any type of pain
in the wound has been managed (Ramsay et al., 2016). The lab slip and the electronic document

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including the time the specimen was collected and the site of the wound along with any
antimicrobials received by the patient should be completed by the health professional.
Since there is some dehiscence along the suture line, the suture line should be treated
with a dressing which will control a small amount of expected, early inflammatory exudate and
provide a waterproof covering (Bollero, Malvasio, Catalano & Stella, 2015). This is done to
reduce edema and ensure the comfort of a patient. The health professionals need to thoroughly
assess the structures or the cavities of the dehisced surgical wound and the presence of foreign
bodies.
Another nursing management is pain management. Gina's surrounding skin to the wound
is painful to touch, and nurses should make sure that the pain is reduced to make her
comfortable. After the dressing health professionals should make sure the pain is managed
effectively. These assessments allow the nurses to identify any triggers which can be avoided or
modified to reduce the pain (Tan, Law & Gan, 2015).
Once the causative pathogens along with their antibiotic susceptibility have been
identified, the health caregiver should document the clinical severity of the infection. Moreover,
he should record the classification of the wound, and any diagnostic uncertainties along with
further diagnostic tests planned (Bessa et al., 2015). Before starting antibiotic therapy, the
treating clinician should obtain appropriate samples for the culture which is vitally essential and
then select the antibiotic regimen including the route of administration and the dose.
7. Evaluating outcomes
For acute and severe wound infections the most appropriate therapy is the intravenous
therapy frequently with a composition of bactericidal agents. Evaluation of the findings of the

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empirical antibiotic treatment is done once the infection clinically responds and microbiological
results are accessible (Morency-Potvin, Schwartz & Weinstein, 2017). Here, the clinical nurse
should consider simplification which is narrowing the spectrum therapy by changing from
intravenous to oral treatment with an agent with good orally bioavailability or topping treatment
if a different source has been confirmed.
Conclusion
The most common microbial source of postoperative wound infection is the patient's skin
and the most common inoculating microbes for clear surgical cases are gram-positive cocci from
the skin. To manage a post-operative infected wound, wound swabs for culture and sensitivity
and empirical antibiotic therapy are the nursing priorities to fasten the wound healing. Safe
nursing management in these nursing priorities is vital in making sure that the responsible
bacteria to the infection is identified by obtaining accurate data from the culture and the correct
antibiotic to the bacteria is administered to prevent the superficial infection from becoming a
deep infection.

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References
Bessa, L. J., Fazii, P., Di Giulio, M., & Cellini, L. (2015). Bacterial isolates from infected
wounds and their antibiotic susceptibility pattern: some remarks about wound
infection. International wound journal, 12(1), 47-52.
Bollero, D., Malvasio, V., Catalano, F., & Stella, M. (2015). Negative pressure surgical
management after pathological scar surgical excision: a first report. International wound
journal, 12(1), 17-21.
Boswihi, S. S., & Udo, E. E. (2018). Methicillin-resistant Staphylococcus aureus: An update on
the epidemiology, treatment options, and infection control. Current Medicine Research
and Practice, 8(1), 18-24.
Krismer, B., Weidenmaier, C., Zipperer, A., & Peschel, A. (2017). The commensal lifestyle of
Staphylococcus aureus and its interactions with the nasal microbiota. Nature reviews
microbiology, 15(11), 675.
Morency-Potvin, P., Schwartz, D. N., & Weinstein, R. A. (2017). Antimicrobial stewardship:
how the microbiology laboratory can right the ship. Clinical microbiology reviews, 30(1),
381-407.
Mundhada, A. S., & Tenpe, S. (2015). A study of organisms causing surgical site infections and
their antimicrobial susceptibility in a tertiary care government hospital. Indian Journal of
Pathology and Microbiology, 58(2), 195.

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Ramsay, S., Cowan, L., Davidson, J. M., Nanney, L., & Schultz, G. (2016). Wound samples:
moving towards a standardized method of collection and analysis. International wound
journal, 13(5), 880-891.
Samuel, L. P., Balada-Llasat, J. M., Harrington, A., & Cavagnolo, R. (2016). Multicenter
assessment of gram stain error rates. Journal of clinical microbiology, 54(6), 1442-1447.
Stacy, A., McNally, L., Darch, S. E., Brown, S. P., & Whiteley, M. (2016). The biogeography of
polymicrobial infection. Nature Reviews Microbiology, 14(2), 93.
Taeb, A. M., Hooper, M. H., & Marik, P. E. (2017). Sepsis: current definition, pathophysiology,
diagnosis, and management. Nutrition in Clinical Practice, 32(3), 296-308.
Tan, M., Law, L. S. C., & Gan, T. J. (2015). Optimizing pain management to facilitate enhanced
recovery after surgery pathways. Canadian Journal of Anesthesia/Journal canadien
d'anesthésie, 62(2), 203-218.
Walsh, E. I., Shaw, M., Sachdev, P., Anstey, K. J., & Cherbuin, N. (2018). Brain atrophy in
ageing: Estimating the effects of blood glucose levels vs. other type 2 diabetes effects.
Diabetes & Metabolism, 44(1), 80-83.
Yaqub, S., Ahmed, K., Nafees, M. A., Imran, R., Hussain, I., & Shuja, N. (2018). 39. Etiological
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Gilgit-Pakistan. Pure and Applied Biology (PAB), 7(2), 736-744.