Case Scenario:
Mr George McFarlane is a 53-year-old Caucasian Male, admitted to hospital after seeing his General Practitioner (GP) for an infected Left (L) toe, caused by a blister/ lesion, possibly from ill-fitting shoes. When Mr McFarlane realised there was a lesion present, he initially did not consider it serious and did not seek medical treatment straight away. After a week, the smell disturbed him and he sought advice from his General Practitioner (GP) who prescribed oral antibiotics and stressed the importance of cleansing and changing the dressing on his wound regularly. Due to Mr McFarlane’s job which required being on the road for long hours at a time, these regular dressing changes did not occur. Subsequently, due to irregular dressing changes, Mr McFarlane’s Methicillin-resistant Staphylococcus Aureus (MRSA) positive status and Type II diabetes, the lesion failed to heal and became larger and deeper. Mr McFarlane returned to his GP five (5) weeks later. The GP immediately referred him to a specialist wound clinic. Investigations included a full blood count (FBC). The white blood cell (WBC) count was 17x 10⁹/L, predominantly neutrophils. The erythrocyte sedimentation rate (ESR) was 75mm/hr. An x-ray showed changes consistent with osteomyelitis.
Mr George McFarlane was admitted to hospital for surgical debridement of his wound. A large amount of tissue was excised from his left foot, which resulted in amputation of all 5 toes. The wound was packed and placed on a suction wound dressing (negative-pressure wound therapy), to minimise the exudate at the wound surface and promote healing by granulation. Post-operatively, he initially did well. However, on the seventh day after surgery, he developed pyrexia and his diabetic control deteriorated. His left foot had swollen above the bandaging. The dressing was removed and there was tissue engorgement and cellulitis surrounding the wound and evidence of necrosis
Mr McFarlane has a Past Medical History (PMHx):
- Type ll Diabetes needing close management
- Osteoarthritis in L) Knee
- Peripheral Vascular Disease (PVD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Methicillin-resistant Staphylococcus Aureus (MRSA) positive
- peripheral neuropathy
Social History (SHx):
- Second marriage
- Occupation - Long Haul truck driver
- ETOH (Alcohol) usage on a regular basis
- Smoker, averages 15/20 cigarettes per day
- Often consumes take away/ fast food diet as away from home regularly Mr McFarlane’s current assessment consists of the following:
- BP 135/85
- RR 18
- SpO292% Room Air (RA)
- HR 89
- Temp 38.2oC
- BGL 13.8mmol
- U/A (Glucose ++, ketones+, protein +, SG 1010, PH 5)
- Pain score 7 at rest
- GCS 15
- Water low score of: 15 (High Risk)
Q1: Discuss the nursing strategies required to minimise cross infection whilst conducting a wound assessment and implementation of a wound dressing.
Discuss in your answer:
- The relevance of the client’s MRSA status, universal precautions and appropriate PPE to be considered for the client’s protection.
- Compliance with infection control practices and correct disposal of wound care products, including how hazardous waste are to be discussed.
- How Aseptic Non-Touch Technique (ANTT) and Hand Hygiene practices can prevent the introduction of new bacteria to the client.
Q2: Discuss how Mr McFarlane’s chronic illnesses could impact on wound healing and the cause of his wound.
- Include, in your answer, how the pathophysiologyof Type II Diabetes, Peripheral Vascular Disease and peripheral neuropathy could delay/ hinder wound healing.
- Discuss the differences in pathological terms between a venous ulcer, an arterial ulcer, a diabetic ulcer and a neuropathic ulcer.
- What type of ulcers may be treated with compression therapy, and what piece of equipment could you use to determine a pulse in a limb if you could not feel one?
Q3: What education should be provided to Mr McFarlane and his family in relation to his wound?
Your answer should be specific to Mr McFarlane.
Consider in your answer:
- Modes of transmission of infection, and what types of pathogens can cause infection.
- Strategies for the prevention of the development of other wounds.
- Wound care post discharge including evaluation of the condition of the wound and where to seek assistance if the wound deteriorates.
- Possible psychological impacts of a chronic wound.
Q4: Discuss appropriate pain management strategies for your client, Mr. McFarlane.
Who, within the multidisciplinary team, could provide you with assistance with planning a pain management strategy?
How could you relieve pressure from Mr. McFarlane’s foot for comfort and what equipment is available to relieve pressure?
Include, in your discussion, appropriate pain management for Mr. McFarlane and time frames to be considered prior to attending to the wound assessment and dressing. Discuss the role of the pain management team and the requirement to liaise with your RN/ Team leader as outlined in the Enrolled Nurse standards for practice.
