Tula Stillwater is 36 years old and has had diabetes since age 26. Ms. Stillwater weighs 218 lb, is gravida 1 para 1, and delivered a 9 lb, 6 oz boy via cesarean section 3 days ago, resulting in a transverse abdominal incision with staples. She reports tenderness on the right side of the incision, but acute pain on the left side of the incision. Her 0800 vital signs are as follows: temperature, 101.6°F; pulse, 76 beats/min; respirations, 18 breaths/min; blood pressure, 134/78 mm Hg. Her blood glucose before breakfast is 185 mg/dL; her blood glucose on previous days had ranged from 90 to 124 mg/dL.On initial assessment, you note the dressing is intact on her incision. The staples are intact in the incision; the incision is well approximated and without erythema on the right side. However, the left side of the incision is pulling apart and is edematous and warm to the touch, with a scant amount of purulent drainage.
Prescribed Interventions
- Vital signs q4h
- Fingerstick blood glucose before meals and at bedtime
- Regular insulin per sliding scale
- Prescribed interventions:
- Remove staples before discharge.
- Discharge on third day, if stable.
Developing Clinical Reasoning and Clinical Judgment
- What is your interpretation of her vital signs? Who should be notified and when?
- How would you determine whether Ms. Stillwater meets the criteria for discharge?
- What is the relationship between Ms. Stillwater's diabetes and her postsurgical condition?
- What factors affect her staple removal?
- How should you respond to her fingerstick blood glucose level?
- What nursing interventions do you foresee performing?
- Describe the timing and the technique for administering her insulin.
Suggested Responses for Integrated Nursing Care
- Ms. Stillwater's vital signs and other symptoms should alert you to a potential complication. She may have an infection related to her incision, as evidenced by her increased temperature and her subjective report of acute pain at the incision. Her blood pressure could be a result of her pain, but you should compare it with her baseline and continue to monitor it. You assessed the incision carefully for signs of infection (refer to Chapter 8). Notify her health care team immediately of this potential complication.
- Wound healing may be impaired in people with diabetes, so any patient with diabetes requires vigilant wound assessment. In addition, the stress of surgery usually results in increased blood glucose levels. Ms. Stillwater's fingerstick blood sugar is elevated from her baseline, another symptom of a possible infection. When you see a dramatic increase in blood glucose in a patient with diabetes, consider the possible causes.
- Despite the urgency of this new complication of wound infection, Ms. Stillwater should receive her insulin and breakfast as she usually would. Administer her insulin in a subcutaneous site; she can help you identify the site where she should receive her insulin. Patients who are accustomed to managing their diabetes at home will have preferences when in the hospital, and you should honor these preferences when possible (refer to Chapter 5).
- Many patients who have had cesarean sections are discharged on the third day. One of the expected outcomes for discharge would include being free of infection. Ms. Stillwater is not free of infection; she has pain at her incision site, a fever, incision assessment findings indicating alterations in healing, and an elevated fingerstick blood sugar. When you notify the health care team of these symptoms, a complete blood count (Chapter 18), a wound culture (Chapter 8), incision site care (Chapter 8), and cancellation of the discharge are prescribed.
- Given the delayed discharge and impaired wound healing, you would not want to remove the staples from this incision because removing the staples at this time could place Ms. Stillwater at risk for dehiscence (Chapter 8). Another factor affecting the risk for dehiscence and impaired wound healing is Ms. Stillwater's increased subcutaneous fat.
- Did you foresee obtaining a complete blood count and a wound culture and performing incision site care? Did you also anticipate that this patient should not be discharged nor have her staples removed? In addition, although her physiologic care is very important, you will also need to relieve anxiety related to this infection and acknowledge her disappointment and potential concerns regarding the care of her son, since she cannot go home today.