Running Head: CONCEPT MAP SCHOLARLY ASSIGNMENT

Submission B: Concept Map Scholarly Assignment

Submitted by: Hayley Ann Nolan
Student Number: N00616959
Date Submitted: Monday, March, 14th, 2016
NURS 252: Complex Issues and Patient Safety
Professor: John Stone (Eva Hearn)
Humber College ITAL

CONCEPT MAP SCHOLARLY ASSIGNMENT

2
Introduction

According to Introduction to Medical-Surgical Nursing, the post-operative patient is at risk for a

multitude of complications depending on: the type of surgical procedure performed, medications used
before and/or during the procedure and the length of time elapsed since surgery (Linton, 2016, p. 269).
However, this does not include the potential myriad of patient specific variables such as age, sex, weight,
past medical history and existing medical conditions which heavily influence outcomes for post-operative
patients. As patients continue to present to hospital units with increasing and more complex comorbidities, it is imperative that nurses are able to consider multiple independent patient factors when
prioritizing and planning care.
In the assigned case study, the patient presented with many coexisting conditions such as diabetes
mellitus type two, hypothyroidism and hypertension. Since the aforementioned conditions affect multiple
body systems, the nurse must consider how these conditions influence expected outcomes such as
effective wound healing. However, when prioritizing care, it is paramount to use critical thinking to
decide which conditions and/or complaints present the most serious and immediate threat to safety. The
priority information identified from the case study relates to the patients chief complaint of severe
abdominal pain rated seven-out-of-ten at incisional site three days post total hysterectomy. Further, the
incisional wound is not approximated at midline and inferior aspect with moderate purulent drainage.
These symptoms are also accompanied by a febrile response and decreased blood pressure. Based on the
information provided, the patient appears to be present with concurrent wound dehiscence and infection.
The possible dehiscence is as evidenced by incision site infection, pain and separated wound edges. The
possible infection is as evidenced by elevated body temperature, purulent drainage from incision site, pain
and compromised wound healing.
Priority Pathway: Wound Infection vs. Wound Dehiscence
It is imperative that early interventions are initiated if wound dehiscence and/or infection is
identified to prevent short-term and long-term complications such as increased length of hospitalization

CONCEPT MAP SCHOLARLY ASSIGNMENT

and patient mortality (Graham, D., & et. al., 1998, p. 669). According to The American Surgeon, when
infection is concurrent with wound dehiscence rate of mortality increased by nine to twenty percent when
compared to wound dehiscence or infection alone (1998, p.662). Therefore, identification and early
treatment of potential infection and/or dehiscence is imperative to patient safety.
Simply, wound dehiscence is the re-opening of a surgical wound caused by increased strain to
incision site which may be the result of various factors such as obesity, dehydration and wound infection
(Linton, 2016, p. 271). When a surgical incision is re-opened outside of the sterile surgical environment,
it leaves underlying organs and tissue vulnerable to foreign organisms which can lead to infection. Thus,
wound dehiscence can be the cause and/or result of wound infection. However, wound dehiscence cannot
be corrected until the wound infection has been treated by mechanical cleansing, debridement and/or
antibiotic therapy. Further, since infection is the most common and severe complication of dehiscence, it
is imperative and expected that infection prevention measures are implemented once dehiscence is
identified (Schilling McCann, J., & et. al., 2004, p.261). This is especially significant in patients with one
or more conditions such as hypothyroidism and diabetes mellitus which impair wound healing and
infection fighting mechanisms such as in the assigned case study. Therefore, wound infection is the
highest priority because of impaired patient infection defense mechanisms related to comorbidities,
increased threat to patient well-being due to risk of severe complications and influence on treatment of
other priorities such as dehiscence.
Priority Clinical Manifestation: Risk for Systemic Infection
According to the Nursing Times, sepsis is the leading cause of death in hospital patients
worldwide. Unfortunately, this is highly associated with delayed interventions and poor identification of
symptoms by healthcare professionals (2014, p. 14). As aforementioned, infection is the most common
and severe complication of wound dehiscence. This is related to wound infection complications such as
systemic infection (Schilling McCann, J., & et. al., 2004, p.261). The patient background in the provided
scenario lists many comorbidities which may impede immune system function such as diabetes,

CONCEPT MAP SCHOLARLY ASSIGNMENT

hypothyroidism, hypertension and advanced age (Lewis, S., & et. al., 2014, p. 291). These coexisting
factors can also influence the bodys ability to regulate temperature and blood glucose which may result
in increasing difficulty to identify early indicators of systemic infection. For example, a patient with
diabetes is generally anticipated to have elevated glucose levels. However, elevated glucose may be a
symptom of systemic infection (McClelland, H., & Moxon, A., 2014, p. 15). As a result, subtle indicators
of systemic infection may go unnoticed resulting in delayed identification of changes in patient condition.
Therefore, early identification of sepsis and sepsis screening is a priority with wound infections due to
high risk for patient morbidity and mortality in post-operative patients.
Nursing Interventions: Risk for Systemic Infection
Assess Vital Signs Q2-4H and PRN
According to The Nursing Times early identification of sepsis is key to survival (2014, p.17).
Fortunately, vital signs provide valuable insight to the progression of infection and identification of
sepsis. Systemic Inflammatory Response Syndrome (SIRS) is a minimum of two alterations in various
vital signs which is helpful in early identification of sepsis including: increased respirations, elevated or
decreased temperature, increased heart rate and/or decreased systolic blood pressure. This is based on the
bodys natural reaction to injury or illness (McClelland, H., & Moxon, A. 2014, p. 15). By monitoring
vital signs every two to four hours, nurses can quickly identify any changes which may be indicative of
SIRS.
Assess Laboratory Studies QD and PRN
According to SIRS identification tool criteria, blood studies such as white blood cell count
(WBC) less than 4 or greater than 12 grams per liter can be an indicator of SIRS. Further, elevated levels
of lactate can potentially indicate development of sepsis. Further, blood cultures obtained from two
different sites simultaneously including intravenous devices in situ for over 48 hours promote improved

CONCEPT MAP SCHOLARLY ASSIGNMENT

identification of microbial and antibiotic selection. Cultures are not limited to blood but can include
sputum and urine specimens (McClelland, H., & Moxon, A., 2014, p.16).
Strictly Adhere to Prescribed Therapeutic Antibiotic Regimen
A recent study revealed that every hour antimicrobials are delayed in treatment of sepsis rate of
survival decreases by almost eight percent (Moore, L., & et. al., 2013, p. 79). Therefore, adherence to
antibiotic regimen as prescribed by the physician is imperative to positive outcomes in the event of
systemic infection. The nurse should educate the patient about their antibiotic regimen and importance of
compliance with prescriber instructions.
Measure Input and Output Q6H
Assessment and measurement of oral fluid intake is imperative to management of fever and
patients at risk for sepsis. The nurse should encourage three to four liters of water per day to replace lost
fluid (Lewis, S., & et. al., 2014, p. 291).
If oral intake is inadequate, intravenous fluid replacement should be investigated.
Assess for S/S of Wound Healing QD

Conclusion

CONCEPT MAP SCHOLARLY ASSIGNMENT

References
Fundamentals of Nursing Made Incredibly Easy! (2009). Lipincott Williams and Wikins.
Retrieved from:https://books.google.ca/books?id=TrOtmsKNR8C&printsec=frontcoover
&dq=fundamentals+of_nursing&hl+en&sa=X&ved=0ahUKEwjTjJuT39_KAhWHIx4KheTDCM
kq6AEILTAD#v=onepage&q=fever&f=false
Graham, D., Mchenry, C., & Stevenson, J. (1998). The Association of Intra-Abdominal Infection and
Abdominal Wound Dehiscence. The American Surgeon. Vol 64:7
Linton, A. (2016). Introduction to Medical-Surgical Nursing. St. Louis, Missouri: Elsevier.
Lewis, S.L., Dirsken, S. R., Heitkemper, M. M., Bucher, L., Camera, I. M. (Eds.). (2014).
Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (3rd
Cdn. Ed.). Toronto: Elsevier
Lorig, K. (1992). Patient Education: A Practical Approach. St. Louis, MO: Mosby Year Book.
McClelland, H., & Moxon, A. (2014). Early Identification and Treatment of Sepsis. Nursing
Times. Vol 110:4.
Moore, L., Turner, K., & Todd, R. (2013). Common Problems in Acute Care Surgery. New
York: Springer.
Schilling McCann, J., Holmes, N., & Robinson, J. (2004). Lipinicotts Nursing Procedures (5th

CONCEPT MAP SCHOLARLY ASSIGNMENT

Ed). Ambler, PA: Lipincott Williams and Wilkins.