Read the following case study scenario and submit your responses to the questions below
Case Study Scenario:John Jones, age 32, is admitted to your ward after post-surgical lancing of a cutaneous abscess located on his perineum. The abscess was caused by MRSA bacteria. The abscess required excision and
drainage to remove pus and debris. Mr. Jones is under police guard as he has been on remand at the nearby Correctional Centre for the past 2 days awaiting trial related to holding an illegal drug. Mr. Jones has a history of IV
heroin use and homelessness. He states that he last used heroin “about 4 days ago”.
Mr. Jones’s medical history reveals that he was diagnosed with Diabetes type 2 two years ago and when homeless lives off left overs found in bins from fast food shops. Mr. Jones has been a heavy
smoker for over 10 years. He has previously been admitted to hospital for depression and a suicide attempt. His blood tests returned positive for Hepatitis C. Blood glucose levels are within
normal range at 7.8mmol/L and chest x ray returned clear. His BMI is 30.2 kg/m2, weight is 98kg and height 180cm.You read the surgeon’s post-operative instructions:“Wound cavity to be dressed daily with Betadine-soaked gauze packing”Mr. Jones is visited by the wound management nurse who documented the following in his notes:“Nursing: Wound to heal by secondary intention. Wound cavity measures 12mm long x 11mm wide and 10mm deep, extending to the subcutaneous tissue layer. Wound bed consists of 100% granulation tissue;
is malodorous and is oozing large amounts of haemoserous exudate. “
Based on this assessment, the wound management nurse disagreed with the surgeon’s post-operative wound management strategy.
Short answer questions: Each question must have no less than 150 words and be referenced. Read each question carefully and ensure you answer each part.
Answer the following questions in relation to the information provided in the above case study:
1. Mr. Jones has MRSA within his wound:
a) Define MRSA and discuss its microbiology and what type of bacteria it is? (150 WORDS, reference)
Methicillin-resistant Staphylococcus aureus (MRSA) infection is responsible for several difficult to treat infections in the human body. It is also called oxacillin-resistant Staphylococcus aureus
(ORSA). MRSA is any strain of Staphylococcus aureus that has developed, through the process of natural selection, resistance to beta-lactam antibiotics, which include the penicillins (methicillin,
dicloxacillin, nafcillin, oxacillin, etc.) and the cephalosporin’s. These bacteria naturally live in the nose, throat and on the skin and generally don’t cause any harm. However, when they begin to
multiply uncontrollably, a MRSA infection can occur. These infections typically occur when there’s a cut or break in your skin. MRSA is very contagious and can be spread through direct contact with
an infected person. It can also be contracted by coming into contact with an object or surface that an infected person has touched. In the community, most MRSA infections are skin infections. In
medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections. Though a MRSA infection can be serious, it may be treated effectively with
antibiotics.
b) Explain why MRSA is antibiotic resistant? Discuss this in terms of its genetic structure and ability to mutate.(150 WORDS, Reference)
Bacteria use chemical-based processes to live, grow, and replicate. At the heart of these processes are protein molecules. Proteins perform a range of specific functions, from destroying/changing
other molecules, to forming physical structures and barriers, to helping build new molecules by joining other smaller molecules together. When a living cell replicates its genetic code in
preparation for division, there is the possibility of mistakes occurring that will lead to the formation of abnormal proteins also known as mutations which is the basis for diseases which evolve
overtime. Bacteria can multiply in hours and, genetic mutations are passed on so quickly that an entire population of bacterial cells with the same mutation can be created in the span of a couple
days. Sometimes a mutation is immediately lethal to the original bacterium in which it occurs. Other times the mutation results in a protein that is changed just enough to remain functional for
survival, but is no longer recognizable as an antibiotic target. When this one in a million event occurs, you now have a bacterial cell that can no longer be killed by antibiotic treatment.
c) Discuss the major complications of MRSA and their impact on other body systems.(150 WORDS, reference)
MRSA infections are often the cause of serious complications and widespread infection. MRSA can sometimes get into the bloodstream and travel to internal parts of the body to cause more serious
infections. In severe cases, skin infections can result in tissue death (necrosis). Other MRSA complications can include blood poisoning (septicaemia), brain or spinal cord abscess (nervous system
infections), cellulitis (connective tissue infection), Endocarditis (heart valve infection), organ failure, Osteomyelitis (bone marrow infection), Pharyngitis (throat infection), Pneumonia
(respiratory infection that affects the lungs), Septic arthritis and septic bursitis (joint infections), Septicaemia (also called blood poisoning), Sinusitis (sinus infection), Thrombophlebitis
(inflammation of a vein and formation of a blood clot), Toxic shock syndrome (acute infection that involves multiple organ systems) and Urinary tract infections (UTI). These serious infections are
more likely to occur in people who are already unwell or physically weak (debilitated), or who have a poor immune system.
2. . In regard to infection control and wound care answer the following questions:
b) the chain of infection – discuss each step in the chain eg. Reservoir/ host, portal of entry/exit, transmission and link each step back to Mr. Jones. For example, identify what Mr. Jones’
portal of entry might be?. (150 WORDS)
The first link in the chain of infection is the pathogen itself. This is the disease-causing organism. For many illnesses and diseases this is a virus or bacterium.
The second link is the reservoir. This is the natural environment that the pathogen requires for survival. Reserviors can be a person, an email, or an environmental component, such as soil or
water.
The third link is the portal of exit. This link is needed for the pathogen to leave the reservoir. If the reservoir is a human, then the portal of exit may be saliva, mucous membranes, feces,
blood, or nose or throat discharges.
The fourth link is the means of transmission. The pathogen can be transmitted either directly or indirectly. Direct transmission requires close association with the infected host but not
necessarily physical contact. Indirect transmission requires a vector, such as an animal or insect.
The fifth link is the new host. Once in the new host, various factors influence the severity of infection, including the strength of the immune system and the reproductive rate of the pathogen.
b) standard/additional precautions – put each one under a heading and identify the differences between them. Explain how you would apply them in your care of Mr. Jones (150 WORDS)
Standard: Using standard precautions is essential as the primary strategy for the successful minimisation of transmission of healthcare-associated infection such as a patient with MRSA. This is
because infectious patients may not show any signs or symptoms of infection that may be detected in a routine history or medical assessment, or a patient’s infectious status is often determined by
laboratory tests that may not be completed in time to provide emergency care.
Additional precautions: Additional precautions are used for patients known or suspected to be infected or colonised with epidemiologically important or highly transmissible pathogens that can
transmit or cause infection by airborne, droplet or contact transmission, being inherently resistant to standard sterilisation procedures or disease specific means of transmission where standard
precautions are not sufficient or any combination of these routes. Additional precautions are designed to interrupt transmission for infection by these routes and should be used, in addition to
standard precautions, when standard precautions alone might not contain transmission of infection.
c) Provide an education session to the client on wound care and how to prevent infection.(150 WORDS)
3. Compare and contrast the differences between a primary, secondary and tertiary intention wound. (150 WORDS)Primary Closure – Wound closure happens in one of three ways. Primary wound closure is the fastest type of closure, and is also known as healing by primary intention. Wounds that heal by primary
closure have a small, clean defect that minimizes the risk of infection and requires new blood vessels and keratinocytes to migrate only a small distance. Surgical incisions, paper cuts and small
cutaneous wounds usually heal by primary closure. These wounds do not usually trouble the wound care specialist.Secondary Closure – Secondary wound closure, also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated. Secondary closure
requires a granulation tissue matrix to be built to fill the wound defect. This type of closure requires more time and energy than primary wound closure, and creates more scar tissue. The majority
of wounds close by secondary wound closure.Delayed Primary Closure – Occasionally, wounds are closed by delayed primary closure, also known as healing by tertiary intention. Delayed primary closure is a combination of healing by primary and
secondary intention and is usually instigated by the wound care specialist to reduce the risk of infection. In delayed primary closure, the wound is first cleaned and observed for a few days to
ensure no infection is apparent, before it is surgically closed. Examples of wounds that are closed in this way include traumatic injuries such as dog bites or lacerations involving foreign bodies.
4. There are three overlapping phases in wound healing known as the inflammatory, proliferative and maturation phases. Explain in detail each of these physiological processes and how long
each stage takes. (150 WORDS)
Inflammation is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling.
Inflammation both controls bleeding and prevents infection. The fluid engorgement allows healing and repair cells to move to the site of the wound. During the inflammatory phase, damaged cells,
pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients and enzymes create the swelling, heat, pain and redness commonly seen during this stage
of wound healing. Inflammation is a natural part of the wound healing process and only problematic if prolonged or excessive.
The proliferative phase of wound healing is when the wound is rebuilt with new tissue made up of collagen and extracellular matrix. In the proliferative phase, the wound contracts as new tissues
are built. In addition, a new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient oxygen and nutrients. Myofibroblasts cause the wound
to contract by gripping the wound edges and pulling them together using a mechanism similar to that of smooth muscle cells. In healthy stages of wound healing, granulation tissue is pink or red and
uneven in texture. Moreover, healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection, ischemia, or poor perfusion. In the final phase of the
proliferative stage of wound healing, epithelial cells resurface the injury. It is important to remember that epithelialization happens faster when wounds are kept moist and hydrated. Generally,
when occlusive or semiocclusive dressings are applied within 48 hours after injury, they will maintain correct tissue humidity to optimize epithelialization.
Also called the remodelling stage of wound healing, the maturation phase is when collagen is remodelled from type III to type I and the wound fully closes. The cells that had been used to repair
the wound but which are no longer needed are removed by apoptosis, or programmed cell death. When collagen is laid down during the proliferative phase, it is disorganized and the wound is thick.
During the maturation phase, collagen is aligned along tension lines and water is reabsorbed so the collagen fibres can lie closer together and cross-link. Cross-linking of collagen reduces scar
thickness and also makes the skin area of the wound stronger. Generally, remodelling begins about 21 days after an injury and can continue for a year or more. Even with cross-linking, healed wound
areas continue to be weaker than uninjured skin, generally only having 80% of the tensile strength of unwounded skin.
5. Wound Bed Preparation uses four principles in the acronym T.I.M.E which provides a systematic approach to the management of wounds. Discuss what is meant by:a. Wound bed preparationb. T.I.M.E – Define each letter and explain what is involved in each stage of this wound assessment method. (150 WORDS)
6. Why do you think the wound management nurse disagrees with betadine-soaked gauze packing as a dressing choice for Mr Jones’s cavity wound? Support your answer with evidence-based research.
What dressing type would you select for Mr. Jones? (Check the journal article in “supplementary resources” on Healing by Secondary Intention as it discusses this scenario). (150 WORDS)
7. Choose one (1) contemporary (recent) wound management strategy for a client with a wound. Discuss this strategy, when it was introduced and give both the advantages and disadvantages of the
chosen therapy. Your answer should demonstrate why it is a contemporary (current/recent) therapy and be supported by evidence-based research. (150 WORDS)
8. What impact will the following issues have on Mr. Jones wound healing and his activities of daily living?b) poor nutritionc) smoking d) substance abusee) diabetes
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 his healing. In this question I am
looking for your ability to problem solve and critically think. 9. Develop a nursing plan of care for Mr. Jones. Your care plan must follow a nursing problem solving approach for example SOAPIE (see table below). Give one nursing intervention for each
problem stated below ie. A total of 6 nursing interventions that you would put into place to assist Mr. Jones with the following problems.
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