|Type of paper:||Essay|
|Categories:||Surgery Nursing care|
The clinical reasoning cycle (CRC) as proposed by Levett-Jones (2018) refers to an approach that the clinicians view the problems they face in the clinical practice. The cycle fundamentally consists of if the two processes and includes clinical judgment and clinical decision-making. Fundamentally, the CRS is a logical process which the nurses utilize to gather the patient's cues through a consideration of the patient situation, process available signals to establish an assessment, identification of the illness or issues (Levett-Jones, 2018). The information collected, therefore, helps the nurses to treat different ailments through an application of the clinical reasoning. This essay, therefore, aims to integrate the clinical reasoning cycle to assess the 49 years Old Italian lady presented at outpatient department at the hospital following complications from a right foot ulcer. Also, the essay critically analyses the underlying pathophysiology and causes of the patient's post-operative wound status, the nursing priorities of care, and management for the patient.
Underlying Pathophysiology and Causes of the Patient's Post-Operative Wound Status
The patient presented in the case study is called Mrs Gina Bacci and aged 49 years. The patient shows a history of Diabetes Type II which diagnosed six years ago. She also presents the symptoms of Peripheral disease (PVD), the Obesity (BMI 40.4m2, Height of 165cm and the weight of 110 kilograms). She has been further admitted to the Insulin medication as part of her admission in the hospital. As a result of her surgery, she experiences a post-operative surgical that has tremendously affected her body (Tjeertes et al. 2015)
According to Harrison, Khansa & Janis (2016), the creation of surgical incision through subcutaneous creates five primary critical responses that constitute to the pathophysiology of the postoperative wound. This is due to the human inflammatory response. The first process involved in the wound development as in the case of Mrs. Bacci is the activation of the coagulation proteins and platelets. Notably, this kind of activation forms an integral component of the haemostatic mechanism but also acts as a herald to the onset of the inflammation. This is further followed by the activation of the Mast cells and the complement proteins (Bryan et al. 2019). The five factors when combined, pose a considerable effect that include; the vasodilation and increased local blood flow at the surgical incision site. It is important to note that while the intensity of the flow is increased in such circumstances, its speed is tremendously lowered as a mechanism of preparing for the phagocytes margination (LeMone et al. 2016). The increased vascular permeability and the vasodilation at the site of the surgical incision cause the vasodilation, which further enhances the edema fluid formation and this also contributes to the increase in the space between the endothelial cells (Martini, Nath, & Bartholomew, 2018). Such an increase in the permeability offers the phagocytic access to the surgical incision area. The oedema fluid, on the other hand, provides a concentrated conduit necessary for phagocytic movements through highly condensed extracellular tissue.
Chemoattractant signals which constitute a critical product of the issue injury products of tissue injury coordinate the phagocytes' movements into the wound. The process further involves the binding of the local vascular endothelial cells (Mone et al. 2016). All these results to the rolling of the neutrophil on the endothelial surface and this happen within the post-capillary venule. Further interaction between the endothelial cells and the neutrophil contributes the anchoring of the neutrophil to the surface of the latter, and this allows the chemoattractant to act as a natural motivator and therefore encourages the movement of the neutrophil into the surface or the surgical area. The reduction in the microbial contamination and the early arrival of the neutrophils sufficiently controls the available bacteria. The consequent production of chemicals enhances the regulation and wound healing process (Martini, Nath & Bartholomew, 2018).
Two Main Nursing Priorities for the Patient in the Case Study
A close look at the patient's wound would reveal the presence of an island film dressing along with the surgical incision area, and it is considerably wet from the serous exudate output. The presence of the dehiscence along the suture line shows the presence of a sloughy tissue (Shanmugam et al. 2015). These conditions call for two major nursing priorities which revolve around management of the surgical would. The priorities include keeping the wound clean and dressing.
1. Keeping the would clean and Dressing
Regardless of the mechanism of the wound healing process, the objective of the post-operative would care to remain the same, and this entails allowing the wound to heal rapidly without the possibility of complications and with the best functional and aesthetic outcome. The patient in the case study presents a wound that healed through tertiary means or healing process. Ideally, this includes the staged closure of the wound of the varying etiologies and which are surgically created. As a nursing priority, the dressing will involve a period of debridement and surveillance to ensure that the tissue is viable before the final closure (Anderson et al. 2014). The surgical wound of the patient should, therefore, be kept as clean as possible to prevent the development of further SSIs. According to LeMone et al. (2016), post-operative wound management should involve the use of dressing and cleaning of wounds, the antibiotic treatments, debridement, and specialist care services among others. The use of antiseptic and the non-touch technique will play a critical role in helping the patient go through a quick healing process (Daeschlein, 2013). The tissue viability nurse must advise on the appropriate dressing designs for the surgical site wound because the patients would heal by a curative intention.
2. Antibiotic Application for Wound Treatment
The nurses should also advise on the use of the appropriate antibiotic treatment method. Considering the situation of the patient, an antibiotic that covers the most likely causative organism should be used. The choice of the antimicrobial must further be taken into consideration in line with its local pattern and the results of accurate microbial tests.
Justification of the Appropriate and Safe Nursing Management of the Patient
The two nursing priorities identified for the patient in the case study involves keeping the wound clean and dressing and antibiotic for wound treatment. On a broader note, the keeping of the wound as management integrates various approaches such as the use of the antiseptic to clean the wound, the antibiotic treatment, debridement, and specialist wound care systems. A good dressing should play a crucial role in maintaining a moist environment and therefore promote healing. The dressing will help remove the excessive exudation as observed in the patient's current situation and which may otherwise lead to the wound maceration and provide an excellent barrier against bacterial or fluid contaminating. Additionally, the nurses will have to individualise the dressing regimens to ensure and meet the needs of each would at the surgical site (Procter et al. 2014). The factors to be taken into consideration on the decision of the dressing will include the position, size and the depth of the wound.
Regarding the conditions that the patient presents in the case study, the nurses should apply a standard infection control method. The treatment of the surgical site wound depends on the severity of the symptoms and the clinical status of the patient (Lall et al. 2015). The initial treatment in this case, therefore, will involve the pain management, body rest and IV hydration. According to Setiawan (2011), the benefits of the antibiotics remain unclear. However, the administration of the broad-spectrum antibiotics is generally used in patients with the postoperative surgical wound infections. The dressing is another critical nursing priority in this case.
The antibiotics used in this case, therefore, are aimed at reducing the rate of the surgical site infection. Regarding the conditions of the patient presented in the case, the antibiotic prophylaxis should be applied and has proven to be tremendously useful in reducing the incidences of the surgical site would and other relate infections perhaps after a contaminated or dirty operation (Setiawan, 2011). Studies have shown that the antimicrobial prophylaxis is recommended for clean surgical wounds as in the case of the patient under the case study. The nurses should adjust the dosing of a given antibiotic by the patient weight. For example, 2 grams of the Cefazolin should be used for patients weighing 80 kilograms or more and 3 grams for patient weighing 120kg or more. Because the patient weighs 110kg, about 2-3 grams of Cefazolin should be administered (Bullock & Manias, 2017). It is evident that the patient is a morbidity obese patient diagnosed with diabetes type II more than half a decade ago. As such, the nurses must ensure that the post-operative glucose of 180mg/dL or lower is maintained or achieved (Elgafy et al. 2018). Such regulation will help reduce any complications that may arise from her worsening diabetes.
Post-operative surgical site wound is a major complication that occurs after surgery. It manifests with critical symptoms that may be life-threatening. It can be managed through medical and nursing interventions. The clinical reasoning model provides an unequivocally and systematic guideline to the nurse as well as other medical disciplines aimed at ensuring effective management of such conditions. There might be various ways to approach a patient, and the above literature constitutes one of them. The idea behind this essay is to use the CRC to distinguish various possible sources of illnesses presented and identify the cause as well as the platforms for further evaluation. In this case, therefore, the two primary nursing priorities regarding Mrs Bacci's situation encompasses keeping the wound clean through dressing and treatment using anti-biotic such as the Cefazolin. The antibiotic will play a significant role in the patient's general health status, reduce the bacterial burden, facilitate the healing and reduce the risk of the cross-contamination or any other allergic reactions after the surgery.
Anderson, D. J., Podgorny, K., Berrios-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Greene, L., Kaye, K. S. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection control and hospital epidemiology, 35(6), 605-627. doi:10.1086/676022
Barnes, M. & Rowe, J. (2013). Child youth and family health. Strengthening communities (4th Ed). Sydney: Elsevier
Bryant, B., Knights, K., Rowland, A & Darroch, S. (2019). Pharmacology for health professionals (5th Ed.). Chatswood, NSW: Elsevier Australia.
Bullock, S., & Hales, M. (2019). Principles of pathophysiology. (2nd ed.) Australia: Pearson.
Bullock, S. & Manias, E. (2017). Fundamentals of pharmacology. (8th Ed.). Melbourne: Pearson Australia.
Daeschlein, G. (2013). Antimicrobial and antiseptic strategies in wound management. International wound journal, 10(s1), pp., 9-14
De Brouwer, M., Ongenae, F., Bonte, P., & De Turck, F. (2018). Towards a Cascading Reasoning Framework to Support Responsive Ambient-Intelligent Healthcare Interventions. Sensors (Basel, Switzerland), 18(10), 3514. doi:10.3390/s18103514
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