Pathophysiology and causes of postoperative wound status

Care process of patients suffering from post- operative aspects include proper evaluation, diagnosis and effective interventions so that management of the surgical wounds and incisions could be achieved (Yazdanpanah, Nasiri & Adarvishi, 2015). This paper discusses about the pathophysiology and causes of Mrs. Bacci’s post-operative wound status. Further, after identifying the causes, it would present the two primary nursing management priorities so that effective management of her wound could be achieved. Finally, depending on the identified health care priorities, the nursing management and handling strategies would be included in this discussion, so that through effective strategies the adverse condition of Mrs. Bacci’s wounds could be improved.

In this case of Mrs. Bacci, who undergone a surgery for foot ulcer and was treated with partial amputation of her forefoot and visited the outpatient service after 2 weeks of her discharge, infection in her wound condition was noticed. While examination, her wound appeared warm, dark pink and painful to touch. As per Noor, Zubair and Ahmad (2015), wound healing is the process, which progresses through three phases such as inflammation phase, proliferative phase, and the maturation phase. Redness and swelling around the wound area is a general sign of healing and this redness determine that the human immune system is providing red blood cells, macrophages and other fibrin proteins to the wound site. However, in case of the Mrs. Bacci, her sutures were broken and dehiscence along with presence of sloughy tissue around the wound was observed, that indicated towards severe risk of infection (Amin & Doupis, 2016). Further, her wound sutures appeared broken, which could cause by several manual issues performed during surgery. Tight sutures, improper type of sutures used for the surgery or external forces applied on the wound by coughing, sneezing, as well as bowel movement could also lead to dehiscence of the wound sutures (Baltzis, Eleftheriadou & Veves, 2014).

Besides these, physical reasons, such dehiscence could occur due to the bacterial or viral infection as Bertesteanu et al. (2014) mentioned in his research that patients, who are malnourished, undergone radiotherapy or suffering trauma could lead to adverse postoperative wound conditions. Further, with dehiscence, serous exudates was also observed leaking from the wound and it was seen that this exudates, was spread over the incision line. As per Alavi et al. (2014), excretion of exudates is the mechanism of the human body to fill the wound with inflammatory agents, blood, as well as wound healing compounds that help it to heal rapidly. However, if the serous fluids excrete in large amount, it could lead to harmful bacterial infection in the wound area (Baltzis, Eleftheriadou & Veves, 2014). Further, upon bacterial infection, the consistency, amount and colour of the wound changes, that indicated bacterial or fungal infection around the wound (Wang et al., 2017). The pathophysiology of wound related pain is associated to the severe bacterial infection, to withstand that body raises the inflammation response in the surrounding tissues of wound. This process eventually causes the white blood cells to release enzymes and free radicals, due to which, the surrounding tissue becomes prone to damage and the patient feel pain in the surrounding tissue area (Bertesteanu et al., 2014). 

Two primary nursing management priorities for effective wound management

Further, the proliferative phase and maturation phase should also be mentioned in the pathophysiology of the disease. In this phase, epithelial cells, fibroblasts and vascular endothelial cells starts increasing its number around the site of wound, due to which the cellularity of the increases (Baltzis, Eleftheriadou & Veves, 2014). This is the process, which occurs when the wound physiology progresses towards effective healing and maturation phase occurs. Moreover, bacterial contamination, virulence as well as the microenvironment of the surrounding skin of the disease causes this adverse condition and hence, as per Noor, Zubair and Ahmad (2015), the surgical site infection and their own flora becomes responsible for the patient contamination. The majority of bacterial infection is caused by the gram positive cocci and gram negative aerobes that colonize under the skin and mucosal surfaces. Therefore, in this case of Mrs. Bacci, these are the pathophysiological changes that affected the condition of the wound and increased the complication associated to it (Bertesteanu et al., 2014).

As Mrs. Bacci is suffering from severe risk of wound infection and dehiscence, while preparing her care plan and optimizing the intervention, several nursing priorities would be developed for effective treatment. The first priority for the care plan of Mrs. Bacci would be maintaining the aseptic condition of her wound and proper management and handing of the incision site so that improved and quick healing of the wounds could be achieved (Yazdanpanah, Nasiri & Adarvishi, 2015). This is an important aspect for management of wound infection as aseptic techniques of the wound management process decreases the spreading of infection and pathogens in the wound or around the surgical site. Further, it was also seen through research of Guffanti (2014) that maintaining personal hygiene and cleanliness around the surgical site would decreases the rate of pathogenic spread in the wound and hence, her acute wound infection would be the priority of her care plan.

It has seen through researches that patients with past history of diabetes and obesity could affect the healing process of wound by decreasing the healing process (Phillips et al., 2016). Further it was also observed that people with excessive weight puts extra pressure in their skin due to which the healing process of wound decreases and the patient suffer from infections in the surgical site (Avishai, Yeghiazaryan & Golubnitschaja, 2017). Therefore, the second nursing priority for the nursing intervention of Mrs. Bacci would be controlling her blood sugar level and maintaining her weight through implementation of low carbohydrate diets (Rondas et al., 2015). Further, it was seen that for healing of the wound, blood should reach to the surgical site so that the nerves around the surgical site could be relieved. However, in patients affected with diabetes, excessive level of blood sugar hinders the blood to reach to the surgical site and affects the process of skin repair, thereby affecting the wound healing process (Yazdanpanah, Nasiri & Adarvishi, 2015). Therefore, this would be selected as the care priority for Mrs. Bacci in this care plan developmental process. 

Nursing management and handling strategies

To comply with the first nursing priority selected for the case study of Mrs. Bacci, the patient would be provided with asepsis dressing change and wound care processes. It is an effective process, for nursing management of the patient and hence, the nursing management would include patient education (Phillips et al., 2016). This would help the patient while maintaining the wound in her home, so that she could understand the wound management, suture and dressing handling and effective hygiene technique. As per Guffanti (2014), it is an important factor to include patient education in nursing intervention management so that patient could herself interrupt the infection spreading associated condition  and prevent it for the efficiency of wound healing process. Further, the patient would be asked to limit her movement so that her wound could not affect due to her over weight and diabetic conditions (Rondas et al., 2015). Besides this, from this case study, it was seen that the patient tends to forget to consume her medications as well as does not consume few medications deliberately. Hence, in the patient education and training sessions, she would be provided with education related medication administration and important of the prescribed medications to maintain her health and hygiene condition (Serra et al., 2015). 

The second nursing management would focus the enhanced blood sugar level of the patient. The blood sugar level of Mrs., Bacci was 12mmol/L, which is much higher than the optimum blood glucose level of the patient (Alam et al., 2014). Hence, this could be one of the primary reasons for the wound infection and improper healing of the foot ulcer surgical wound, as Schaper et al. (2016) mentions that due to excessive sugar, blood could not reach to the surgical site, increasing the delay of healing process. Further, to maintain the healing process, the blood glucose level of the patient would be managed and in the course her diet and nutrition should be modified as per the need of the patient (Powers et al., 2017). In this management of patient’s diet and nutrition, carbohydrate would be eliminated for her diet and protein rich food would be provided to increase the rate of wound healing as well as increases the immune system responsiveness (Yazdanpanah, Nasiri & Adarvishi, 2015). The patient would be provided with intra venous insulin and regarding that a medication administration education session would be included in the nursing management process. This would eventually help to maintain her obesity and decrease her body weight condition (Schaper et al., 2016). The patient would be assessed for her fluid intake and output so that her blood glucose level could be balanced and risk of infection around the wound could be decreased (Yazdanpanah, Nasiri & Adarvishi, 2015). 

Importance of maintaining aseptic conditions for wound management

Besides this, she would be provided with proper dressing and suture management education so that her dehiscence and disrupted sutures could be treated again and her secretion of serous exudates could be controlled (Childs & Murthy, 2017). This intervention would help to manage her wound condition and protect her incision site from external pollutions, bacterial infection and other severe wound infection risk factors (Schaper et al., 2016). Further, in the process of patient education, she would be provided with detailed education about wet or patch dressing technique so that she can maintain the hygiene and health of the surgical site or the incision site (Yazdanpanah, Nasiri & Adarvishi, 2015). Hence, the primary focus of the nursing intervention would be undertaking patient education, improving her diet and nutrition, managing her blood glucose level and maintaining her water intake condition for the patient’s health improvement (Schaper et al., 2016).

Conclusion

While concluding this case study analysis of Mrs. Bacci, it was seen that patient was affected with diabetic foot ulcer and to treat the infection, she undergone surgery and amputation of her front foot was undertaken. This assessment helped to understand the pathophysiology associated with wound infection. Further, two nursing priorities such as management of wound hygiene and management of diabetic and overweight condition were selected for the nursing intervention. Further, in the care process, intervention related to patient education, addressing patient’s diet and nutrition, and her medication error was also included in the case study analysis. Finally, through the management of diabetes, overweight and excessive blood glucose level, preventive measure would also be taken so that further infection of the wound could be avoided and health and hygiene could be retained.   

References

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