Explore the Underlying Principles of a Specified Caring Situation, Incorporating Reflection from Your Practice Placements.
The aim of this essay is to explore the underlying theory of wound care. This will be broken down and looked at in terms of comfort, safety, and status and assessment of the nursing model - activities of daily living concerning wound care. Under examination will be definitions of care and comfort, and biological theories of wound care. In addition, I will examine holistic care (looking at the whole person, not just the wound) and the skills required by the nurse in order to fulfill this. Reflection from practice experience will be included.
The concept of care has wide-ranging definitions and theoretical perspectives, and can sometimes be taken for granted (McKenna, 1993). McFarlane (1976, cited in McKenna, 1993) points out that nursing is the same as caring and Leininger (1986, cited in McKenna, 1993) defines caring as "the essence of nursing". McFarlane and Leininger share a consensus here, however, there is a lack of agreement between nurses and patients on the concept of care. Nurses tend to consider trusting and comforting types of behaviour essential to care whereas patients prefer behaviours associated with competency and physical care (McKenna, 1993).
Morse (1992, cited in McKenna, 1993) asserts that the concept of caring does not encompass the nature of nursing and suggests that the main aim of nursing is to promote ‘comfort’. The concept of comfort is also quite complex and diverse and researchers and theorists have offered a variety of descriptions of comfort (Morse et al, 1994). Kolcaba (1994) defines comfort for nursing as
the satisfaction (actively, passively or co-operatively) of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful.
Other descriptions of comfort offered by theorists include comfort as a state of ‘physical or mental well-being’ (Flaherty and Fitzpatrick, 1978, cited in Morse et al, 1994) and by degrees on a discomfort – comfort continuum (Patterson and Zderad, 1976, cited in Morse et al, 1994).
The whole wound healing process is an intricate sequence of events that commences at the time of injury and can continue for months and even years. Wound healing is an exceptional example of how a part of the body (specifically the skin) contributes to homeostasis (how the body maintains stability). When damaged skin begins to heal, specific mechanisms go into action in order to return it to its normal or near normal structure and functions (Tortora and Grabowski, 1996).
The initial phase of wound healing involves an inflammatory, vascular, and cellular response, the purpose of which is to dispose of micro-organisms, foreign substances, and dying tissue in preparation for repair. Produced during this phase is wound exudate, which contains proteins and a variety of nutrients, growth factors, and enzymes, which cleanse the wound surface and assist healing. Wound exudate also has anti-microbial properties (Hutchinson, 1989, cited in Miller and Glover, 1999). This phase can last from the moment damage to the skin has occurred and can last for two to five days (Wound Expert, 2001).
The next stage of wound healing is the proliferative phase when the formation of new connective tissue occurs. The proliferative phase lasts from two days to three weeks (Wound Expert, 2001).
The final phase of wound healing is the maturation stage, in which restoration of the epidermis to normal thickness occurs when the scab sloughs off (Tortora and Grabowski, 1996). New collagen (protein of the white fibres of the skin) forms, which increases the tensile strength of the wound, however, scar tissue, is only eighty per cent as strong as original tissue. The maturation phase can last from three weeks to two years (Wound Expert, 2001).
Morse (1992, cited in McKenna, 1993) asserts that the main aim of nursing is to promote comfort and Kolcaba (1992, cited in Kolcaba, 1994) argues that comfort is a preferable, holistic outcome that is relevant to the nursing profession.
Pain is a common and often underestimated problem for patients with wounds. Incompetently managed pain can lead to a difficult situation of sleep disturbance, irritability, anxiety, depression and increased pain (Seers, 1994, cited in Morison et al, 1999), therefore compromising patient comfort. Patient’s today experience unnecessary wound pain. This is because of inadequate assessment, the use of unsuitable practices in wound cleansing and the inappropriate use of wound management products that cause trauma to the wound and surrounding tissues (Hollinworth, 2001).
Pain is an individual response to a stimulus and is a different experience for every patient (Morison et al, 1999). McCaffery and Beebe (1989 cited in Morison et al, 1999) define pain as ‘whatever the patient says it is and exists wherever he says it does’.
Pain assessment strategies and professional experience are important in monitoring wound pain, however, as McCaffery and Beebe’s definition points out, pain is ‘whatever the patient says it is and wherever he says it is, hence the patient is essential in any pain assessment (Hollinworth, 2001).
Patient assessment should be holistic and documented precisely and this should underpin care. The assessment should include whether the pain causes the patient disturbed sleep, whether it effects the patient’s ability to partake in activities and what eases or increases the wound pain.
Possible causes of increased pain could be changing the dressing, applying topical applications, compression therapy, and movement. If anything is found to increase pain, this should be clearly documented and any assessment and documentation should be consistent, and used to monitor existing pain and at times when wound pain may be increased. Pain assessment must be acted upon and plans for pain relief well documented (Hollinworth, 2001).
Various techniques have been adopted throughout time to cleanse wounds and promote healing. Topical treatments in the past have included the use of boiling oil, honey, diluted wine, and seawater. In clinical practice, the principles of wound cleansing have often been misunderstood, resulting in the unsuitable and ritualistic use of cleansing solutions (Morison et al, 1999). Nurses sometimes do not question as to why they are cleansing the wound (Bale and Jones, 1997).
Indications for wound cleansing are apparent if the nurse has an understanding of the underlying principles of wound healing and bacterial colonization. The purpose of wound cleansing should be to remove surplus exudate, slough, debris or necrotic tissue and remnants of dressing material, in order to promote patient comfort (Bale and Jones, 1997).
There are a wide variety of dressings and wound management products available today, however the appropriate use of these products is widely disputed. A dressing is defined as "a covering on a wound which is intended to promote healing and provide protection from further injury" (Dealey, 1994). Inappropriate use of dressings can delay and prevent healing. It is important when choosing a wound dressing that the nurse chooses the right type of dressing for the wound that is being dressed.
Wound care should provide the best possible environment for the natural wound healing process to occur. It is imperative that the nurse has an understanding of the underlying biological theory of the natural wound healing stages in order to gain a true awareness of the principles of wound care.
Whatever the wound, there are priorities in wound care: haemostasis; removal of foreign bodies, devitalized tissue, thick slough, and pus; provision of the optimum temperature, humidity, and pH; promotion of the formation of granulated tissue and epithelialisation; protection of the wound from further trauma and from the entry of pathogenic micro-organisms and promotion of patient comfort (Morison et al, 1999).
When planning and evaluating appropriate wound care, it is important to implement a holistic approach to patient care. A thorough patient assessment can assist the nurse in looking at the factors, which can affect the wound healing process, and perhaps alleviate some of the factors that could prolong the healing process. A nursing model can provide a useful framework for assessing patients. In order to implement a nursing model the nurse needs to understand the theory underpinning the model and its relevance to practice. The model should also be suited to the patient’s needs. The model chosen for this essay is the Activities of Daily Living Model devised by Roper et al (1980, cited in Bale and Jones, 1997).
The focal point of this model involves twelve activities of living: maintaining a safe environment; communicating; breathing; eating and drinking; eliminating; personal cleansing and dressing; controlling body temperature; mobilizing; working and playing; expressing sexuality; sleeping; and dying. According to Roper et al, (1980, cited in Bale and Jones, 1997) nursing intervention should follow three models of action: prevention strategies; providing physical and mental comfort; and enabling the patient to seek help to take responsibility for self-care.
Disruption of a safe environment can be a cause of wounds, for example accidents in the home or on the road. Factors within the environment can also affect healing, such as infection, the elderly and socio-economic problems (important if the patient is to be nursed in his or her own home, for example, badly lit stairs, damp, and rodent infestation). Nursing assessment should identify those at risk, a wound assessment and regular temperature monitoring (as a high temperature could be indicative of an infection) and evidence of relevant underlying disease. An evaluation of the patient, the environment, and the wound is essential (Dealey, 1994).
Communication is a vital component of nursing. This involves listening and identifying problems and anxieties. It is also important to give explanations of the wound care process and why particular treatments have been chosen. Failure to recognize stress or anxieties and failure to involve the patient in the decision-making process and ensure the patient understands the care, can all affect the wound healing process (Dealey, 1994).
The activity of daily living, ‘breathing’, is vital to the wound healing process. A good blood supply to the wound and a sufficient supply of oxygen, are essential to the healing of the wound. Factors that can affect this include age and cardiovascular disease.
The activities of daily living, ‘eating and drinking’, are necessary for health, well-being and wound healing. There is significant research that shows impaired wound healing in malnourished patients (Haydock and Hill, 1986 and 1987, Delmi et al, 1990, Paterson et al, 1992, Tkatch et al, 1992, cited in Dealey, 1994). An assessment should identify those at risk, the inclusion of a dietary history, observation of obvious signs of obesity, emaciation, or muscle wasting, and the patient weighed for comparison with ‘usual weight’ (Dealey, 1994).
Elimination can cause many problems to the wound healing process. Uraemia (excess urea in the blood, Weller, 1999) inhibits the activity of the fibroblasts (Lawrence and Payne, 1984, cited in Dealey, 1994), depresses epithelial cell division (MFDermott et al, 1971, cited in Dealey, 1994) and can delay granulation and epithelialisation (Barton and Barton, 1981, cited in Dealey, 1994). Urinary and faecal incontinence can contaminate wounds due to the constant soiling of the dressing. Nursing assessment should include the past and present medical history and an examination of blood urea.
Poor standards of personal hygiene (with regards to the activity of daily living number six: ‘personal cleansing and dressing’) can affect wound healing due to an increased risk of infection. This activity can also be related to ‘maintaining a safe environment’ and socio-economic problems. An assessment should include a nursing history and an observation of personal habits and the living accommodation of the patient.
Linked with ‘maintaining a safe environment' is ‘controlling body temperature’, as pyrexia (a body temperature between 37°C and 40°C) is indicative of infection. Hypothermia (a marked decrease in body temperature, Weller, 1999) can cause a shutdown of the blood supply to the periphery resulting in a severe reduction in the blood to wounds on the limbs. The surface of the wound could become necrotic as a result. Regularly temperature monitoring is essential, depending on the condition of the patient and the degree of risk of infection.
Patients with reduced mobility may have problems with wound healing. Reduced mobility can cause a stoppage in the peripheral circulation especially in the legs, which can result in odema and a delay in the removal of waste products. Steroids and rheumatoid drugs have an anti-inflammatory effect. A nursing assessment should include a nursing history (degree of mobility), a physical examination, looking for evidence of odema, deformity of joints and limbs, and a ‘Risk Assessment’.
Body image is the mental picture that people have of themselves. Sexuality is a vital part of this image. Strongly linked with self-esteem is body image. All patients with wounds have an altered body image, which can affect self-esteem and motivation and together with the anxiety about their prognosis, can be so overwhelming that patients may be unable to take in information, to share their feelings or to commence rehabilitation. This can all affect the wound healing process.
Shipes (1987, cited in Dealey, 1994) suggests that a nursing assessment should include the value attached to the altered or missing part by the patient (may be a cultural value), the meaning of altered body part to patient, support network (family and friends), and current activities and future plans. Is there evidence of negative self-esteem (refusal to look at, touch, or discuss wound, or the patient verbalizing feelings of worthlessness, and so on)? The patient may feel a sense of loss, loss of sexual function or withdrawal from relationships with partner or spouse, family and friends. The role of the nurse is to help the patient develop a re-integrated body image (Burgess, 1994, cited in Dealey, 1994). Good communication skills are vital.
Lack of sleep causes people to become increasingly irritable and irrational (Carter, 1985, cited in Dealey, 1994). During sleep, the release of growth hormone from the anterior pituitary gland stimulates protein synthesis and the proliferation of a variety of cells including fibroblasts and endothelial cells which assist wound healing (Lee and Stotts, 1990, cited in Dealey, 1994). Factors that can disturb sleep include anxiety, pain, uncomfortable beds, noise, and pyrexia (Closs, 1990, cited in Dealey, 1994). It should be possible to provide an environment, which is comfortable and conducive to sleep (Dealey, 1994).
The nursing of terminally ill patients with wounds should consider that there might not be sufficient time left to the patient to heal a large wound, and the disease process may affect the healing process. As with all patients, appropriate goals need to be set for patient care, incorporating the wishes of the patient. Often the formulation of goals is around what the nurse is trying to achieve and not what the patient may want. The primary goal should be patient comfort (Dealey, 1994).
Consideration of the emotional and psychological needs of the patient is vital. Fear, for example, is a common human experience. Illness can release many fears and these can cause stress for the patient. Health care professionals failing to recognize when patients are experiencing fear and not allowing them to express their feelings can worsen this (Dealey, 1994).
Grief is a normal process, which allows adaptation to a major loss in a person’s life. The patient with a wound may have to come to terms with skin damage from burns, the loss of a limb or a breast and so on. Kubler-Ross (1969) identify six stages of grief: denial, isolation, anger, bargaining, depression and acceptance, and these can be applied to all types of grief. Each person progresses through some or all of these stages and at different rates. The nurse can assist in this process and reduce the amount of stress by listening to the patient and accepting without judgment (Dealey, 1994).
Patients can often feel powerless when placed in the ‘patient role’. Simple decisions are taken away from them in hospital, such as when to eat and sleep. Every patient has the right to be treated with respect. The implementation of patient education can allow the patient to participate in care and decisions, therefore giving the patient some degree of control (Dealey, 1994).
Everybody, whether they believe in God or not, has spiritual needs. The patient will seek to understand why he or she is suffering in a particular way. Until the patient finds meaning, they cannot cope with what will happen next. Simsen (1986, cited in Dealey, 1994) suggests that achievement of this is by the promotion of hope and trust, mediated by good relationships. Fish and Shelly (1985, cited in Dealey, 1994) suggest five characteristics necessary to giving effective spiritual care: listening, empathy, vulnerability, humility, and commitment.
During my practice in a nursing home, I had the opportunity to observe and carry out the dressing of a venous leg ulcer. Wound expert (2001) suggests treatment should consist of keeping the ulcer infection free, absorbing any excess discharge, maintaining a moist wound environment, supplying compression and promoting activity and managing the patient’s medical problems. The aim of the care plan was to promote healing.
Her original care plan was to renew the dressing every three days, administer antibiotics as prescribed and monitor wound for improvement, encourage the patient to drink one Entera (200mls) a day to boost protein intake and check full blood count for any sign of anaemia and discuss with General Practitioner.
The dressing consisted of a hydrogel called ‘nugel’ to promote a moist wound environment and to debride and deslough the wound used with ‘Tielle’, a hydropolymer adhesive with a polyurethane backing. The design of polyurethane dressings ensures absorption of large amounts of exudate. They do not stick to the wound and do not break down in the wound bed. Once enough exudate has been absorbed, these dressings provide a moist wound environment, however, it is not advised to use this dressing on low exudating wounds as they could cause scab formation. These dressings also protect against physical trauma due to the padding (Casey, 2000).
The use of this dressing regime was showing little improvement after three months. The majority of the wound surface was covered in slough, a small amount was necrotic, was quite odourous, and caused quite a lot of pain.
Reassessment of the wound care plan occurred due to the lack of improvement. The decision was to continue with the ‘nugel’ (applied directly in to the wound bed), to continue keeping the wound moist, then ‘Lyofoam’ is placed over the ulcer. ‘Lyofoam’ was chosen for its absorbent properties and can be left in place for several days. Then a ‘viscopaste’ bandage is applied to give a soothing effect, which is placed under ‘soft ban’. This is a bandage made of cotton wool and this provides padding to prevent further physical trauma. Then a crLpe bandage is placed over the ‘soft ban’. The crLpe bandage provides support and a low level of pressure to prevent swelling. Finally, a tubular retention bandage is placed over the leg, to hold everything in place. The overall effect is the wound is moist and occluded. Before the wound is redressed, painkillers are administered to the patient, to prevent unnecessary pain and promote her comfort.
When nursing any patient, for whatever reason, it is imperative that the nurse undertakes a thorough patient assessment. The assessment should be holistic, that is to say, assess the whole person not just the reason the patient has been placed under the nurses’ care. Any nursing assessment should include explanations of the diagnosis and the treatment available. The patient’s understanding and wishes should be ascertained. The patient should be involved in any decisions that are made. Good communication skills should be implemented and patient comfort should be the main priority. Before a nurse commences any care, he or she should have a good theoretical knowledge of the skill they are about to put into practice.
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