Case study Case Study Scenario 3 – Infected Surgical Wound:…

 

Case study

Case Study Scenario 3 – Infected Surgical Wound: Ms Maggie Malone is an obese 52-year-old female, who was admitted to the orthopaedic ward for a total left knee replacement.  Staples were the method of wound closure.  Ms Malones’ medical history reveals that she is a heavy smoker, smoking at least 30 cigarettes / day and was diagnosed with Diabetes type 2 around 4 years ago, but has not been following a recommended diet.  Day 5 post-op: Maggie is complaining of pain in her left knee, she is febrile 38.7C and an increase in discharge from her wound on her dressings is apparent.  On removal of the wound dressings, the wound appeared reddened and inflamed; staples are insitu; an open 1.3cm gap at the lower end of the wound was obvious and is oozing purulent fluid.  A wound swab is taken and results show a Methicillin-resistant Staphylococcus aureus (MRSA) infection  On reading the surgeons’ instructions: “Antibiotics to be commenced; Wound cavity to be dressed daily with Dressing as per directed by wound specialist  Ms Malone is reviewed by the wound management nurse who documented the following:  “Nursing: Wound to heal by secondary intention. Wound cavity measures 13mm long x 10mm wide and 8mm deep, extending to the subcutaneous tissue layer. Wound bed consists of 100% granulation tissue; is malodorous and is oozing a moderate amount of haemopurulent exudate. Staples to remain insitu until day 10 post-op”.   74838715 / jsouthby / shutterstock.com

 

 

 

Case Study 3- Short answer questions:  word count and referencing stated where required 

Read each question carefully and ensure you answer each part. 

1a.    Maggie’s Husband comes to visit and he has asked you to explain Maggie’s infection, how she got it and how long will she have it for. To be able to explain to Maggie’s husband you need to understand the chain of infection

Listed below are the 6 elements required for a disease to be spread (starting with infectious agent). 

1. Re-arrange the elements below in the in the correct order. Beside each element state how it applies to Maggie’s wound.

• Infection Agent
• Susceptible host
• Portal of exit
• Reservoir
• Mode of transmission
• Portal of entry

 

95425765/ billdayone/ Shutterstock.com. Modified by TAFE Queensland.

 

 

1b.    Using the above model, it could be suggested that this is a healthcare-associated infection (HAI). 

Provide an example of a brief discussion on how you would explain this type of infection and its development to Maggie’s husband. Provide this education as though you were speaking to the client’s husband using appropriate terminology. 

 

1c.    Tick true or false for the following in regards to the bodies defence mechanisms against wound infections 

	True	False
The body has normal defenses against infection.
Each organ system has defense mechanisms to protect against exposure of infectious microorganisms.
Normal flora, body system defences and inflammation are non-specific defences that protect against microorganisms, regardless of previous exposure.
Separate cells and molecules of the immune system don’t help the body resist disease.
Immune-system responses are either pathogen-specific or non-pathogen-specific defenses. If any of the body’s defenses fail, an infection can quickly progress into a serious health problem.

 

 

 

1d.    Explain in terms that you can understand – the immune response in regards to infections.

 

2.      Standard and Additional precautions – Using the word bank complete the sentences in regards to precautions. (fill in the blanks)

Word bank: Mucosa, airborne, fluids, single, all, contact, suspected, infection, skin, known, droplet, cohorted

 

Maggie requires both standard and additional precautions.  Standard precautions are infection

control practices used for …………………………………… patients, regardless of their known 

……………………………………  status.

 

Standard Precautions dictate that personal protective equipment (PPE) must be worn when there 

is a risk of contact with body ………………………………. , non-intact ………………….  or …………………………………………………………………….. 

 

Infection may be transmitted in various ways. The 3 transmission categories are ………………………………………………………………………………………………………………. ,

……………………………………….  and ……………………………………….. 

 

Maggie’s type of transmission is…………………………………………… 

 

Transmission-Based Precautions are infection control practices used for patients with 

……………………………………  or …………………………………..  conditions.

 

As Maggie has MRSA (an infectious condition) she would require additional precautions and should be nursed in a ..  room or …………………………..  in a room with a patient with 

the same infectious condition.

3.      As stated in the case study Maggie had a wound specimen taken. Which of the following are correct in regards to obtaining a wound specimen and interpreting laboratory results (Tick 4 correct answers)

• Always collect a wound culture sample from viable granulation tissue near the centre of the wound that has just been cleansed or irrigated with 0.9% sodium chloride solution.
• Evaluation findings and laboratory results must be communicated to the clinical team leader per the organization’s practice
• Cleanse the wound and surrounding skin with 0.9% sodium chloride solution from the most to least contaminated area.
• If there is more than one wound, obtain only one culture from each wound. Perform hand hygiene and change gloves between wounds.
• Determine when a dressing change is scheduled. If possible, plan the specimen collection and wound evaluation during the next scheduled dressing change.

 

4.      What impact will the following issues have on Ms Malones’ wound healing and her activities of daily living? (including psychological impact).

Put each of the above issues under a heading and discuss each in detail. Support each issue with research and a clear rationale (reason) for why it will affect her healing. This question is looking for your ability to problem solve and critically think.

Poor nutrition

 

 

Smoking 

 

Diabetes 

 

 

5.      Develop a nursing plan of care for Ms Malone. Your care plan must follow a nursing problem solving approach using the table below 

Give one nursing intervention for each problem stated below i.e. a total of 5 nursing interventions that you would put into place to assist Ms Malone with the following problems. 

Support each intervention with a rationale/reason, evaluation and a reference 

 

PROBLEMS:

• the location of her wound
• activities of daily living
• reduced mobility
• Pain
• Referral needs – which other health team members both within and outside the hospital environment would be involved in the care of Ms Malone.

Problem	Intervention	Rationale	Evaluation (including how you would involve the patient?)
Location of Wound
Activities of Daily Living
Reduced Mobility
Pain
Referral Needs

 

General Questions 

1.      Refer to the National Safety and Quality Health Service (NSQHS) Standards – Second Edition[1] and identify and provide a brief description regarding the intention of the 2 standards that could relate specifically to wounds and infections (including pressure injuries) 

1.  

 

2.      Explain the difference between an acute wound and a chronic wound 

 

 

 

3.      Review the following case studies and underline if you think it is either an Acute or Chronic wound.

	Acute	Chronic
Sam had a motor bike accident 72 hours ago and sustained a leg wound that required stitches, there is serous discharge coming from the wound.
6 weeks later Sam’s leg wound has an area where there is thick yellowish drainage into the dressing
John is 66-years-old and has been a widower for 6 year. His neighbour has noticed that John has had no appetite, has lost weight, and has had a meaningful decline in function. She visits more frequently, bringing meals and trying to encourage him to eat. On her most recent visits she has noticed a foul odour in John’s home. He attributes it to his poor housekeeping and hygiene. She perceives the odour in his home to be fouler and notices that the front of his shirt over his abdomen is damp. She is very worried and after a lot of coaxing she convinces John to go to the hospital, and calls an ambulance.   An abdominal examination reveals an extensive open wound with copious discharge and a foul odour, which has permeated the whole area. The wound extends from about the midline of his abdomen to his left flank, measuring 22 cm by 16 cm. a biopsy of the wound is performed and confirms a malignant squamous cell carcinoma.
A 55-year-old woman was admitted to the surgical ward for exploration of a persistent sinus on the lower left leg. An ultrasound examination showed a cavity suspected to be an abscess, which was then explored and drained
Mrs Brown is a 65-year-old lady who is a diabetic with peripheral neuropathy. 8 weeks ago, she sustained a scape on her left leg while weeding some dense bush in her backyard.  She treated it herself but it is not healing and has gotten bigger and begun to ulcerate with some parts turning dark brown.  Finally, she went to her GP and he admitted her to hospital where she was facing cleaning and debridement of the wound which was diagnosed as a diabetic neuropathic ulcer.
A 65-year-old gentleman was operated with abdominoperineal rectal excision and a sigmoid ostomy. Ten days later total wound dehiscence and evisceration (bowel contents protruding through the abdominal wall). Abdomen had to be left open collecting small bowel contents in a specially designed fistula bag. The patient went home with ongoing wound dressings over a period of 3 months.

 

 

 

4a.    Jack Sparrow has a surgical wound with a Jackson Pratt drain. Which of the following are correct in regards to management of Jack’s drain (Tick 4 correct answers)

• Check for infection
• Maintain bulb patency as per Drs Orders
• Immediately remove if you think it is blocked
• Adhere to facility policy and procedures when caring for a Jackson Pratt Drain
• Document the amount of drainage
• No need to check the connections as this is a closed system

 

4b.    Mr Jones who has a history of chronic venous disease and leg ulcers has returned from theatre after hip surgery and is fitted with elastic compression stockings (TED) and sequential compression device (SCDs). 

Which of the following 2 points are NOT true when it comes to the management techniques of compression devices?

• The stockings are not to be rolled down, cut or otherwise altered
• Thigh-length stockings prevent proximal VTE better than knee-length stockings
• SCDs are not worn when a patient has an active VTE because of the risk of PE
• If the stockings are not fitted and worn correctly, venous return is impeded
• SCDs will still be effective if they are not applied correctly
• They apply external pressure to the lower extremities by means of an electric pump
• TED stockings are a part of VTE prevention in hospitalised patients
• SCDs are inflatable garments wrapped around the arms

 

 

 

5a.    Provide a brief outline in regards to the historical development of contemporary wound management strategies.

 

 

 

5b.    Visceral wounds often involve the internal organs of the body, specifically those within the chest (heart, lungs) or abdomen (as the liver, pancreas or intestines). Often injury is by gunshot or stabbing. 

Steven was involved in a fight late at night where he was stabbed and sustained a deep penetrating abdominal wound. He was transferred to the emergency department where he underwent a laparotomy to discover the extent of damage and a temporary closure to part of his wound was made with a vacuum dressing.  He was to have further surgery once stable.

Which of the following may NOT be included as wound management strategies for visceral wounds? 

• Pain control
• Keep wound area clean
• Daily wound dressing change
• Watch for bleeding

 

[1] https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

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