NRSG 258 Assessment case study Solution | Case Study Sample

Title: Post surgery wound assessment and safe nursing management practice in Diabetic patients.

Introduction:

Post-operative Surgical care is an essential component of nursing. The strategies of care are unique to every individual patient and determined by the rate of wound infection which varies from one to nine per cent, depending on the surgical procedure(Perl & Roy, 1995). The comorbidities and cost of treatment increase with every surgical wound and they demand significant nursing intervention. Risk factors in developing a surgical site infection (SSI) include Host factors, surgical and environmental factors. Diabetes is a metabolic disorder where the body is unable to synthesize the hormone insulin for the uptake of glucose into the cells. According to The World Health Organization Diabetes mellitus is rising to an alarming epidemic level with a highest prevalence in Western countries at 37.5% (Kharroubi & Darwish, 2015). Diabetes mellitus belongs to a group of metabolic diseases with a characteristic feature of chronic hyperglycaemia. The individuals suffering from Diabetes are prone to various pathological consequences such as foot ulcerations sometimes leading to foot amputations, recurrent infections due to low immunity. In the current case study, the potential risks and management of a surgical wound in a Diabetes patient into developing a wound infection post-surgery are discussed.

Clinical history:

Mrs. Gina Bacci is a 49-year-old Italian female. Medical history of Gina reveals that she was consistently obese with a BMI 40.4. She was diagnosed with Type 2 Diabetes six years ago, insulin doses were recommended to control the blood glucose levels. A history of Peripheral vascular disease involving the weakened vasculature in the extremities and insufficient blood circulation has been noted. She developed a diabetic foot ulceration and required the forefoot amputation along with the great and first toes. Post-surgery the prescribed medication included NovoRapid an insulin analogue to substitute the lack of insulin production. Pain in surgical patients is addressed through a multifaceted approach using analgesics Paracetamol 1g QID, and neuropathic pain due to the damaged nerves is treated with Pregabalin, Lantus a long-acting insulin analogue with an improved glycaemic control in adults is included as a part of treatment regime. It is considerably safer as the glucose levels are consistent(Delgado & investigators, 2012)

Diagnosis of post-operative condition:

Biological indicators of diabetes included HbA1C, blood pressure, Body-mass index, lipid profile, with a special focus on the peripheral vasculature; the laboratory findings indicated hyperglycaemia –high blood glucose levels > 12.6 mmols/L.

Her blood pressure is normal 120/70mmHg with a slightly lower diastolic pressure. Pulse 88 bpm regular; Respiratory Rate is 18 bpm and a partial pressure of oxygen SpO2 at 97% on RA, Body temperature recorded is 37.8ºC. The peripheral arteries showed low pulse rate with a delayed capillary refill at 2-3 seconds and the extremities were cold to touch indicating venous insufficiency. The patient reported this to be a normal finding. The patient is currently moving with the aid of offloading boot and a walking stick.

Pathophysiology of the patient:

A closer examination of the patient reveals an Island film dressing along the incisional wound, which is wet from serous exudate output. Island dressings consist of an absorbent pad with a soft and conformable fixative layer for simple and effective management of sutured post-operative wounds. The air-permeable covers with low allergy adhesives are ideal. These are skin-friendly and cause least interruption to surrounding or healing skin tissue. The surgical wound shows dehiscence along the suture line and there is some sloughy tissue. Surgical wounds usually cause minimal damage as the trained medical personnel make them with precision. If the wound is deeper, the penetrating trauma may cause the damage to the connective tissue, nerves, and internal organs. Wound dehiscence is a surgical complication where the sutures rupture along the incision and internal organs are exposed. The aetiology of the wound dehiscence has diverse factors. Localised factors responsible for dehiscence are inadequate blood supply, increased skin tension, localised bacterial or fungal infection. Systemically, many factors are indirectly responsible such as malnutrition, advanced age, presence of malignancy; nutritional deficiencies play a significant role in the healing of the wound.

In the current case, patient has a clinical history of peripheral vascular disease and maybe the probable cause of impeded wound healing. The surrounding skin of the surgical wound is warm indicative of perfusion, and dark pink representing the proliferative phase of wound healing and painful to touch.

Nursing priorities:

The process of damaged tissue repair and healing is an extremely complex process; presence of comorbidities negatively influences the process. In the case of a post-operative patient, the major nursing goals include prevention of wound dehiscence. Despite advances in postoperative care, the rate of surgical wound dehiscence is 1%-3% among the operated patients. (Hahler, 2006) There is a relatively higher risk of wound dehiscence in the cases of vascular surgery(Shanmugam et al., 2015).

Early identification of risk factors is essential to manage the symptoms and further degradation of the wound. Another crucial parameter is the prevention of wound infection.

Management of mechanical stress on the surgical incision assists in holding the sutures together. Extreme cases of dehisced wounds may include immediate surgery. Moist wound environment is essential for healing, reduction of bioburden and pain, and promotion of granulation tissue.

Management of diabetes is also a concern in this current case. Continuous assessment of blood sugar levels and HBA1c is essential to keep the diabetes in check.

Safe nursing management:

Active task handled by nurses with an intention and aimed at the patient better health outcome can be defined as nursing intervention. Nursing interventions are based on the nursing assessment i.e, diagnosis of the medical condition of a patient To establish effective wound management an extensive assessment reflecting the wound characteristics is required. With the clinical history in mind, the next stage is to ascertain the phase of the wound repair.

The parameters of wound assessment such as wound type, size, location and tissue type help in determining the nursing intervention. A gold standard for wound assessment is BATES-JENSEN WOUND ASSESSMENT TOOL. For a wound in proliferative phase, which is characterized by fragile granulation tissue care, should be taken while handling or dressing. Studies show that epithelialization is faster in a moist environment than under a dry environment which promotes scar formation (Junker, Kamel, Caterson, & Eriksson, 2013).

. Tissue damage and destruction of bone, indicative of osteomyelitis (bone infection) is only visible through imaging examination. Imaging in the suspected cases is vital, to realise the depth and extent of the infection to alter the type of treatment. Signs to be noted are the areas of decreased density on a scan indicating an abscess to interfere with incision and drainage, or soft tissue erythema with gas in the tissue is a medical emergency and needs immediate irrigation of the tissues.

The wound microenvironment is the immediate region of the wound closer to the surface. Based on the presence or absence of extracellular matrix it is categorized into dry or moist environment. Clinical studies show that exudate from the wound healing under moist conditions stimulates keratinocyte proliferation and fibroblast growth thereby forming muscular tissue.

Nursing interventions are primarily focused on treating wounds in a controlled wet environment, administration of antibiotics at the site of injury. The addition of growth factors improved the outcome of the treatment.

The features of an ideal wound dressing as a part of nursing interventions are:

a) Moisure environemnt

b) Promote angiogenesis through wet environment.

d) Allow gaseous exchange between wounded tissue and environment

e) Maintain appropriate tissue temperature to improve the blood flow to the wound bed and enhances epidermal cell migration thereby promoting re-epithelialization.

g) Promote the leukocyte migration

h) Sterilization is important to prevent further secondary infection, non-toxic and non-allergic(Dhivya, Padma, & Santhini, 2015).

Traditional methods had Gauze dressings made out of cotton, rayon, polyesters. They were not effective against the risk of infection. They absorb the exudate well and require constant change of the dressing. The major disadvantage of these dressings is that they become moistened and adhere to the wound rendering it difficult to remove. Xeroform (non-occlusive dressing) with 3% of Bismuth tribromophenate is a standard for non-exuding to slight exuding wounds.

Modern wound dressing facilitate the function of the wound into healing rather than just to cover it. Usage of transparent and adherent polyurethane allows the transmission of water and other gases from the wound and provides autolytic debridement of eschar (necrotic). These dressings are impermeable to bacteria and hence are reliable in preventing wound infection. Hydrogels can be used to manage the hydration and the temperature of cutaneous wounds as they provide soothing and cooling effect for the painful wounds. Most recent method for effective wound treatment include bioactive dressings known for their biocompatibility, biodegradability and non-toxic nature. These are extracted from natural tissues such as collagen , hyaluronic acid , chitosan.(Dhivya et al., 2015) For the current the case bioactive wound dressing is ideal.

Conclusion :

Wound healing is a complex process and is best managed by a multidisciplinary approach team that includes a wound care nurse, general and vascular surgeon, hyperbaric specialist, infectious disease consultant, dietitian, and physical therapist. The key to successful treatment is identification of the type and phase of the wound. Primary care is to prevent the exposure to the external environment while maintaining the balance of nutrients and air permeability.

References:

Delgado, E., & investigators, L. S. s. (2012). Outcomes with insulin glargine in patients with type 2 diabetes previously on NPH insulin: evidence from clinical practice in Spain. International journal of clinical practice, 66(3), 281-288. doi:10.1111/j.1742-1241.2011.02880.x

Dhivya, S., Padma, V. V., & Santhini, E. (2015). Wound dressings - a review. BioMedicine, 5(4), 22-22. doi:10.7603/s40681-015-0022-9

Hahler, B. (2006). Surgical wound dehiscence. Medsurg Nurs, 15(5), 296-300; quiz 301.

Junker, J. P. E., Kamel, R. A., Caterson, E. J., & Eriksson, E. (2013). Clinical Impact Upon Wound Healing and Inflammation in Moist, Wet, and Dry Environments. Advances in wound care, 2(7), 348-356. doi:10.1089/wound.2012.0412

Kharroubi, A. T., & Darwish, H. M. (2015). Diabetes mellitus: The epidemic of the century. World journal of diabetes, 6(6), 850-867. doi:10.4239/wjd.v6.i6.850

Perl, T. M., & Roy, M. C. (1995). Postoperative wound infections: risk factors and role of Staphylococcus aureus nasal carriage. J Chemother, 7 Suppl 3, 29-35.

Shanmugam, V. K., Fernandez, S. J., Evans, K. K., McNish, S., Banerjee, A. N., Couch, K. S., . . . Shara, N. (2015). Postoperative wound dehiscence: Predictors and associations. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society, 23 (2), 184-190. doi:10.1111/wrr.12268