Mrs Bacci has a previous history of a foot ulcer which has now resulted in a partial amputation of her forefoot and great and first toes. This was performed under general anaesthetic with an acute wound. As Mrs Bacci has a complicated history of obesity, type 2 diabetes mellitus and peripheral vascular disease, she is at risk of the wound not healing in the clinical sense. Mrs baccis history leaves her susceptible to infection.Q1According to the world health organisation, overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health.
(Lenzi, Migliaccio & Donini, 2015). To test whether a person is overweight or obese, the nation-wide test is body mass index (BMI), this is a person’s weight (in kilograms) divided by the square of her height (in metres). The average body mass index is 18.5-24.9, in Mrs Bacci’s case she is in the obese range at 40.4. (Holt, Cockram, Flyvbjerg & Goldstein, 2016)Mrs Bacci’s obesity has hindered her wound healing.
Obesity has many different complications that affect wound healing such as, poor nutrition, wound dehiscence and susceptibility to infection. Wound dehiscence in obese patients is frequent as there is increased tension on the facial edges at the time of wound closure. (Wilson & Clark, 2004) It is important to eat a healthy and balanced diet for effective wound healing as newly forming tissue needs proteins, glucose and vitamins to recover appropriately. This also effects the immune system negatively therefore leaving the body more susceptible to infection. (Holt, Cockram, Flyvbjerg & Goldstein, 2016) Obesity leads to multiple complications and diseases, most commonly diabetes mellitus type 2.
In this case Mrs Bacci was unfortunate and diagnosed 6 years ago with type two diabetes mellitus. Diabetes mellitus is a metabolic disorder characterised by the abnormal secretion and/or action of the pancreatic hormone insulin, which is essential for the cellular uptake of glucose. The pancreas, in type two diabetes, can make and release insulin, but the release is dysfunctional. (Bullock & Hales, 2018) There is a change in sensitivity of the body’s muscles, adipose tissue and the liver, to the insulin signal, this can therefore lead to defects in glucose transportation. (Holt, Cockram, Flyvbjerg & Goldstein, 2016) Without appropriate blood glucose control and hyperglycemia, overtime, this can lead to damage of the body’s blood vessels and nerves, the heart, eyes, kidneys and nerve damage in the feet. (Bullock & Hales, 2018) Peripheral vascular disease is a macrovascular complication of uncontrolled diabetes.Peripheral vascular disease is the presence of obstruction or narrowing in the arteries that reduce the circulation of blood to parts of the body, especially the lower limbs. The aetiology of peripheral vascular disease is atherosclerosis, in 90% of cases. The lack of adequate arterial blood supply to certain organs or parts of the body can result in reduced tissue viability or tissue death. (de Souza Pereira da Silva, de Moura Vergara, Procіpio & MourЈo, 2017)Lower limb ulcers are the most common type of chronic wound, as many will either be very slow to heal or will not heal at all due to varying degrees of reduced or no blood supply to the limb, or parts of the limb. (Peate & Glencross, 2015)Ischemia, trauma and neuropathy are three main abnormalities which lead to the disruption of the healing process in wounds. Infection risk with diabetes, immunity and immune system lowered. Ischemia is an obstruction in the arteries which reduce blood flow to the lower limbs. Cutaneous signs of ischemia in the lower limbs include cold or cyanosed feet, erythema, hair loss and atrophy. (Holt, Cockram, Flyvbjerg & Goldstein, 2016) Poor blood flow cannot sustain the supply of oxygen and nutrients needed for growth and to facilitate waste removal. Healing wounds need adequate blood flow and oxygen delivery. Mrs Bacci’s case she previously had a foot ulcer on the right foot and now the left foot is cool to touch, with a capillary refill of 2-3 seconds. The characteristics of neuropathy are the loss of sensation and/or motor function. The loss of sensation affects wound healing as the wound may become infected and the patient may not feel the wound worsening. (Holt, Cockram, Flyvbjerg & Goldstein, 2016)Q2The two main nursing priorities in Mrs Bacci’s case is her diabetes and wound care. Her diabetes is uncontrolled, and she is non-compliant with her medication. Mrs Bacci has been readmitted, 7 days post op, her wound has some dehiscence, sloughy tissue, exudate and the surrounding skin is warm, erythemic and painful to touch. As a nurse we must provide a duty of care to our patients. It is our duty to educate our patients on the best practice to avoid harm for them. The main goal of treatment for Mrs Bacci is to normalise blood glucose levels, minimise risk of further acute and chronic complications and overall improve the quality of life. Majority of the chronic complications associated with diabetes is hyperglycemia. Hyperglycemia can lead to blood vessel and nerve damage, immune dysfunction, and diabetic ketoacidosis. It would be a good idea to get Mrs Bacci’s family involved in her care as she is poor with her English. Mrs Bacci needs further education regarding the risk factors, disease process and management, this is essential in achieving the goals we have in place. Mrs Bacci needs a thorough and personalised care plan as she has multiple co-morbidities that will affect the wound healing process. These co-morbidities lead to immune dysfunction which can trigger infection. A wound swab and blood test are needed upon admission to determine which antibiotics is appropriate. As Mrs Bacci has pain at the wound site which can affect her mobility, not being mobile can then lead to respiratory complications. It is our job to reassure Mrs Bacci that she is well looked after, she may be struggling with self-esteem issues, emotional stress, anxiety and depression. Our goals are to care for the wound appropriately, reduce Mrs Bacci’s pain and provide constant reassurance and education. Q3Whilst Mrs Bacci needs further education about her diabetes it is important to get the multidisciplinary team involved, such as, dietician, endocrinologist, diabetes educator and physiotherapist. As a nurse using the teach-back method with Mrs Bacci is helpful, we can therefore gauge how much she understands about her disease.The main goal of treatment for Mrs Bacci is normal glucose levels. Blood glucose levels are monitored and measured by a blood glucose meter and test strips. Mrs Bacci should have an endocrinologist to monitor her blood sugar levels and determine how often she should be testing her blood sugar, pre meals and before bed is ideal. A glucose level record sheet or diary should be kept, to monitor the variations in Mrs Bacci’s sugar levels.Mrs Bacci was prescribed insulin on which she has not been compliant in taking. Diabetes educator should be involved in re-educating Mrs Bacci on taking her insulin. We also will be supervising Mrs Bacci on self-administration of her insulin. Whilst in hospital the multidisciplinary team will gauge Mrs Bacci’s blood glucose levels and amount of insulin that she will receive. Dietician involvement is important as they will give a guide on a healthy and balanced diet. It is our responsibility as nurses to order a diabetic diet for Mrs Bacci and give constant education on healthy choices whilst she is in hospital. Exercise is important for many reasons with diabetes such as, helps insulin work more efficiently, weight management and reduce the risk of further cardiac complications. A physiotherapist involvement would be ideal as they can guide Mrs Bacci into exercises fit for her condition and wound status. A wound care plan and wound assessment is a top priority. As nurses we need to evaluate the healing process and plan appropriate wound management. A wound assessment, evaluation and documentation is necessary on patient’s admission to hospital. A wound swab is important to get admission to hospital, this will check for any infections, such as methicillin resistant staphylococcus aureus (MRSA). Depending on hospital, a stomal therapy nurse or wound care nurse may be appropriate for advice on how to treat Mrs Bacci’s wound. A thorough wound assessment should be documented on the wound assessment and treatment chart and signed for after every dressing change. The wound assessment includes.Wound type: what type of wound are we treatingSite of the wound: document the location of the wound.Size of the wound: length, width and depth of wound.Stage and Colour: wound bed description and wound colour.Exudate amount and type: the amount of wound exudate or drainage and what the exudate looks like.Odour: document if there is an odour or not.Peri wound skin condition/surrounding skin: assess for colour and temperature. Inflammation or erythema may indicate wound infection or dermatitis.Pain: the presence, absence, or type of pain may indicate infection, underlying tissue destruction, neuropathy, or vascular insufficiency.Dressing regime: a moist wound-healing environment requires a proper dressing. Considerations for choosing proper primary and secondary dressings are based on wound characteristics, including size, undermining or tunnelling, and amount of exudate. Aim of treatment: manage exudate, debridement, control infection as a few. (Hess, 2013)Discharge planning is in the works from when the patient gets admitted to hospital. Mrs Bacci will need to have conversations with an occupational therapist to arrange nurse to comes into her home to ensure the patients wound is well looked after.
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