Nursing Management: Wound Care - Term Paper Example

Title: Nursing management: Wound care Student name: Student ID: Institution: Date: 05/05/2013 Nursing management: Wound care Introduction Pressure ulcer is a type of skin injury that is normally localized in a tissue that develops because of pressure being placed on an area of skin (Wake 2010). Pressure ulcers can sometimes be called bed sores, pressure sores or decubitus ulcers. According to Wake (2010), the incidence of pressure ulcers in more or the risk is high with the patients that have reduced mobility. It can also be associated by poor nutrition, increased moisture, friction and altered sensory perception. Pressure ulcers are caused by unrelieved compression of blood vessels and tissues which result in failure of the lymphatic system to filter waste products. According to Wake (2010), nurses are mostly the people under the treatment and care of pressure ulcer patients as per the tradition in the health sector, while the physicians are only involved partially through giving instructions. However, there is an increase in the involvement of physicians in pressure ulcers treatment and care recently due to an increase in the cost of the treatment. Search strategy The search about was on journal articles and written books that are related to nursing management, pressure ulcers and dressing management and nutritional management. The main search engine used was Google. The materials identified were also dated 2009 to date. Five of the references addressed the pressure ulcer management while the other five addressed the nutritional management. After identifying the relevant books and journal articles, the next was to read through and understand the material, and then write a brief summary of my own words about the topic which is pressure ulcers and their management in accordance with the given objective of the study. Findings: dressing options of pressure ulcers A dressing is a sterile covering that is applied directly on a wound1. An ideal dressing should have certain characteristics which include: maintaining optimum moisture; remove excess exudates; allow gaseous exchange; impermeable to bacteria and fungi; free of toxic materials and allow removal without causing trauma. Dressings are used in the care, treatment and prevention of pressure ulcers. There is a wide range of dressings that are available hence the practitioner is able to make choices based on several factors. These factors include: ability of the dressing to absorb exudates, adhesiveness and the patient’s comfort (EPUAP & NPUAP 2009). The choice of dressing is a preventive factor for trauma and infection. For some health care practitioners, there is a dressing for each stage of pressure ulcers while for others; innovative features have been developed to assist in difficult characteristics of the pressure ulcer. The choice of the dressing however, is the domain of nurses and physicians who have the relevant skills to know the best dressing to use for a particular case of pressure ulcers. Dressing of wounds helps maintain moist environment and a favorable microclimate. There are many different modern wound dressings available to manage pressure ulcers. The wide range of pressure ulcers dressings are classified as: transparent films, soft silicone foam islands, hydrocolloids, petroleum-based non-adherents, alginates, hydrogels, and gauze (Wright 2009). According to Wright (2009), dressing wounds in pressure ulcers care is a central component. The selection of the dressing however is based on the tissue in the ulcer bed, the goals of the patient and the skin condition around the wound. Maintaining a moist ulcer bed is ideal when the wound is clean to promote healing. The type of dressing also changes over time depending with the ulcer condition (Heyneman, Beele, Vanderwee & Defloor 2009). Gauze dressings are available in forms of sponges or wraps with varying degree of absorbency (Wright 2009). Gauze dressings are in most cases used in surgical dressings due to the need to change frequently and this can be expensive professionally. They are however highly impermeable to bacteria and fungi. The use of moistened gauze dressing is highly recommended as it helps in protecting the wound and desiccation of the ulcer hence quick healing of the pressure ulcer. Hydrocolloid dressings have a long wear time and are best for stage two of ulcer treatment. They are known to speed up the healing process of pressure ulcers as they require fewer dressing changes compared to the gauze dressing. They are recommended for stage 1 of pressure ulcers since their major function is to protect the vulnerable area from friction, moisture or shear force (Wright 2009). Silver-impregnated dressings can also be used although there is little research done on their use in human pressure ulcers. The evidence is only shown in burnt wounds, animal ulcers and leg ulcers. They can however be used in highly infected pressure ulcers (Heynerman et al 2009). Transparent film dressings are another type of dressing made from polythene and are transparent just as the name suggests. They vary in thickness and have an adhesive coating on one side to adhere the skin. They are impermeable to bacteria and fungi. Besides, Alginates are another type of dressing which are non-adhesive and good for heavy exudating wounds. Alginates dressings are non-woven rope-like sheets and are composed of natural polysaccharide fibers which are derived from seaweeds. They are fit for heavy exudating wounds due to their heaviness. They should not be used on wounds/pressure ulcers which are not producing a lot of fluid as this can lead to the wound being dry (Wright 2009). There are some recent studies that have been done of pressure ulcers dressings. They have indicated that the use of soft silicone foam dressing can help in reducing the incidence of pressure ulcers. The use of multi layer of soft silicone dressing can also help in impacting on the local microclimate between the bed linen, the support surface and the skin2. Findings: nutritional management Under nutrition is one of the risk factors of pressure ulcer development. Therefore individuals should undergo a nutritional screening to know their status. Nutritional screening is done on patients using a tool that is valid, reliable and practical. The tool used should be convenient to both the patient and the health worker. Individuals with a high risk of pressure ulcers should be referred to a dietician and other multidisciplinary team of nutritionists who include a physician, a language therapist and an occupational therapist among others (Wake 2010). Wake (2010) further argues that, a more comprehensive nutritional assessment should be carried out in case the multidisciplinary nutritional team identifies the individual being prone to pressure ulcers and nutritional support offered to him/her. This support include: nutritional assessment; estimating the nutritional requirements; providing appropriate interventions and monitoring and evaluating the outcome. There should also be re-assessments at frequent intervals in case the individual is at risk. Oral nutrition in very crucial to all patients who are prone to pressure ulcers or whose risk of getting pressure ulcers is high. This is because most of the pressure ulcer patients never meet their nutritional requirement through the normal food intake. This helps in reducing pressure ulcer development when compared to the routine care (Riordan & Voegeli 2009). Several nutrients are essential in the healing process of pressure ulcers. These nutrients include but are not limited to: energy, protein and vitamins with special emphasis on vitamins A and C and zinc). Though the optimal nutritional requirements are still unknown, there is particular emphasis on these nutrients and are highly recommended (Gelis, Dupeyron, Legros, Benaim, Pelissier J & Fattal 2009). According to European Pressure Ulcer Advisory Panel (EPUAP), patients suffering from pressure ulcers require with a minimum of 30-35kcal per kg body weight per day and 1-1.5g protein per kg body weight per day (Gelis et al 2009). However, there are few trials that have been done to support these recommendations, these nutrients are essential and are required for all the stages of the process of pressure ulcer healing. There is limited evidence based research but the general information is still that nutrition is an important aspect for prevention and treatment of pressure ulcers. Plenty of proteins, energy, vitamins, minerals and fluids are essential for tissue repair and prevention of tissue breakdown (Dorner, Posthauer & Thomas 2009). Dorner et al (2009) further states that the incidences of pressure ulcers can increase with age, history of pressure ulcers within families, weight loss and eating difficulties. Therefore under nutrition, occurrence of pressure ulcers within other family members, low basal metabolic rates, the elderly and significant weight loss are some of the risk factors of pressure ulcers development. Under nutrition may lead to increased rates of morbidity and mortality and impacts negatively the process of pressure healing (Dorner et al 2009). Among the conditions that cause under nutrition is dependency in eating, swallowing problems, decreased oral intake, unintentional loss of weight and advanced age. This decreases the body’s ability to fight infections hence impact negatively on the healing process. Hyper metabolism is another risk factor of pressure ulcers infection (Dorner et al 2009). This is an increased metabolic rate in the body which can be triggered by trauma, severe illness, among other factors where the body utilizes the energy at a very high rate. Recommendations on practice: dressing options for pressure ulcers The ulcer should be dressed at every dressing stage with confirmation of the dressing regimen at every stage of dressing. There are different dressing recommendations from the manufacturer of the dressing and therefore these recommendations should be followed especially in relation to the frequency at which the dressing change should occur. There should also be plans provided for dressing changes as it is required. For example, the dressing change will be different in the condition of soilage, when the wound is healing and so on. Gauze dressings should not be used for clean, open pressure ulcers because they use a lot of labour and they cause pain during removal. In case other types of dressings are not available, the nurse is advised to use moistened gauze. They should also be used as secondary dressing to contain the ulcer drainage, should be woven loosely for highly exudative ulcers and tightly woven for less exudative ulcers. The health care assistants are also advised to use a single gauze roll and avoid multiple rolls as they cause more infection of the ulcer bed especially when retained on the ulcer bed. Silver-impregnated dressings should be used for those pressure ulcers that are highly infected, have high level of or heavy colonies or with high risk of infection. It is essential to select an appropriate dressing, not on the basis of the stage of the pressure ulcer, but rather on the amount of wound exudation maximizing the moist wound environment. Recommendations on practice: nutritional management All patients should undergo a thorough skin assessment before admission to the health centres to determine if they are being admitted for pressure ulcers infection or other conditions and proper records kept on the conditions of the patients. A diet high in protein and calorie should be encouraged with small and frequent meals given to stimulate the patient’s appetite (Wake 2010). Protein supplementation is important for pressure ulcers patients, but there should be ongoing assessment on the required levels since there has not been satisfactory research done on it. The high protein diet assists the wound to heal faster. The health practitioners should also be aware of the importance of good nutrition to the healing of the pressure ulcers and/or wounds and handle individuals with malnutrition with extra care (Riordan & Voegeli 2009). Riordan & Voegeli (2009) further explains that in addition to special nutritional advice being necessary when treating patients suffering from pressure ulcers, there is also evidence that it can also reduce development of new pressure ulcers. The nutritional status of every individual at risk of pressure ulcers should be screened and assessed in each health care setting. The condition can be reversed in case it is identified at an early stage and managed then. A nutritional screening policy should be put in place in all health care settings, along with recommended frequency of screening for implementation for better treatment management of pressure ulcers. Impact of education and socio economic status Pressure ulcers have an impact on both the patient and the health care system, especially in terms of cost on health care. Other than financial costs, pressure ulcers also impact on the social costs to the individual which include pain, discomfort, less mobility, loss of independence and isolation. There are also increased death rates which have been observed in elderly patients suffering from pressure ulcer. The economic effect of pressure ulcer treatment cannot be ignored considering the nursing time and loss of productivity for the patient and the family (Saladin, Krause & Adkins 2009). Some studies have shown a relationship between race and/or ethnicity and pressure ulcers occurrence. African American, for example have a higher risk of pressure ulcer infection and still stage three and four of pressure ulcers compared to the whites. Other social factors such as low level of income, type of occupation and education also have an effect of infection of pressure ulcers due to reduced access to quality health care. People with low level of income, no education and experiencing poverty (minority groups) have higher risk of infection (Saladin, Krause & Adkins 2009). Educational programs on pressure ulcer prevention provide knowledge and inform on the behaviors that are intended to reduce the risk factors of pressure ulcers incidences. In many cases, this education is given to in-patients during diagnosis. At this time the ability of the patients to appreciate the knowledge and information to prevent and manage the pressure ulcer is compromised (Saladin, Krause & Adkins 2009). There are therefore lesser chances of the patients benefiting in case the time stayed at the health centre is shorter hence they get discharged having not gained from the education on pressure ulcers. Conclusion Addressing both the macro and micro nutrients deficiencies arising from poor oral intake or decreased nutritional requirements related to wound healing process are the key mechanisms by which nutritional support can aid in treatment, prevention and healing of pressure ulcers. Research has also been done to show evidence that nutritional support through high protein, vitamins and energy nutritional supplement is effective in reduction of incidences of pressure ulcers. Collaboration between the nurses and the physicians at the health care centres is also very essential for the patients’ treatment and healing process. There is still a gap that needs to be filled to address the part on education to patients and also family members and friends. References Aquacel foam: The Role of Modern Wound Dressings in Stage I Pressure Ulcers and Patients at Risk of Pressure Ulcer Formation. Retrieved from http://www.convatec.com/media/4185549/aquacel-foam-dressing-shown-to-protect-against-ski-11546.pdf, on 09/05/2013. Dorner, B, Posthauer, M E & Thomas D 2009, The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Retrieved from www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf, on 05/05/2013. Dressing recommendations for stakeholder review. Retrieved from http://www.pressureulcerguidelines.org/therapy/docs/dressings.pdf, on 09/05/2013. European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) 2009, Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009 Gelis A, Dupeyron A, Legros P, Benaim C, Pelissier J & Fattal C 2009, Pressure ulcer risk factors in persons with SCI: part I: acute and rehabilitation stages 2009;47(2):99–107. Heyneman, A., Beele, H., Vanderwee, K., & Defloor,T. (2009). A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. Journal of Clinical Nursing, 17 (9), 1164-1173. Riordan, J & Voegeli, D 2009, Prevention and treatment of pressure ulcers, British journal of nursing 2009 (Tissue and viability supplement), vol 18. No 20. Retrieved from http://eprints.soton.ac.uk/71637/1/Riordan.pdf,on 04/05/2013. Saladin, L S, Krause, J S & Adkins, R H 2009, Pressure ulcer prevalence and barriers to treatment after spinal cord injury: comparisons of 4 groups based on race-ethnicity. Neuro rehabilitation. 2009; 24 (1):57–66 Wake, W T 2010, The permanente journal. Pressure ulcers: What clinicians need to know. A peer reviewed journal of medical science, social science in medicine and medical humanities, summer 2010 - Volume 14 Number 2. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912087/ on 04/05/2013. Wright, K 2009, A self help guide: pressure ulcers prevention and treatment. The doctors’ guide to pressure ulcers prevention and treatment. Retrieved from http://www.dmsystems.com/pdf/PUSelfHelpGuide.pdf, on 09/05/2013. Read More