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Identification of the Care of Patient

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    Case Study One Identification of the Care that Mr Jones will require in relation to the safe management and promotion of wound healing This essay will focus on the holistic care of Mr Jones, with particular attention to the management of his wound. The points that will be discussed and analysed are the role of the skin, wound assessment, the nutritional status of Mr Jones and the problem of his obesity. Added to this, an analytical discussion of the involvement of the multi-disciplinary team, the way that Mr Jones’ wound should be managed including the problem of infection and pain plus the suitable dressings, which could be used.

    Lastly, health promotion for Mr Jones will be addressed. It is important that the role and functions of the skin are identified in order to realise the importance of appropriate wound care. The skin is the largest organ in the body (Worley 2004), and has an array of functions. According to Gunnewicht and Dunford (2004), there are seven main functions that the skin performs. These are the regulation of body temperature, protection, sensation, excretion, immunity, blood reservoir, and finally synthesis of vitamin D. Gunnewicht and Dunford (2004) mention that the skin is the body’s first line of defence against infection.

    It provides a physical barrier to protect from bacterial invasion. Mr Jones’ wound is a surgical wound so it can be classified as mechanical because it was caused by a laparotomy performed 10 days earlier. Mechanical wounds can be caused by either surgery, friction or shearing. Other types of mechanical wounds could be bites, penetrating wounds and lacerations. (Dougherty and Lister, 2004) According to Gunnewicht and Dunford (2004), most surgical wounds heal by primary intention, which means that the wound will heal from the skin downwards, the edges are brought together in direct opposition and are closed using sutures or clips.

    In Mr Jones’ case, his wound will have to heal by secondary intention because it is not suitable to be resutured due to his obesity problem. Gunnewicht and Dunford (2004) state that wounds that are left to heal by secondary intention heal from the bottom upwards; the wound is not closed but left to heal by granulation. “Accurate wound assessment forms the basis of any clinical decision making and is a sound investment in time. Effective wound management depends on the appropriate selections of dressings and treatments, which can only be determined by a thorough and knowledgeable wound assessment” (Gunnewicht and Dunford 2004 pp6).

    It is important that when nurses are faced with a new patient who has a wound, that it is assessed within the context of the history, investigation results, and overall medical status of the patient. The assessment should focus on the “whole patient and not just the hole in the patient” (Gray and Cooper 2005 pp1). This statement is supported by Fletcher cited in Hoban (2005) who maintains that holistic care is essential in wound management and that the wound should be looked at last and the patient first.

    However, it is noted that this rarely happens in practice because of factors such as nurses particularly liking a certain wound care product and tending to use it a lot of the time without properly assessing the wound, the availability of wound care products, and the tendency to get caught up in just the wound that the patient has instead of looking at the patient as a whole (Gunnewicht and Dunford 2005). The nutritional status of Mr Jones is of great importance to consider concerning the healing of his wound. The case study mentions that Mr Jones is obese with a weight of 120 Kilograms and a height of 5 feet and 8 inches tall.

    This would mean that his body mass index is 40, which is classified by the World Health Organisation as just into grade 3 obesity. According to Williams and Young (1998), it is a common myth that nutritional supplements will only aid healing if the patient is underweight. It is an extremely important point to note that obese patients need nutritional support for optimum wound healing as well as underweight patients. (Pinchcofsky-Devin, 1994) Hoban (2005) supports the idea that nutrition can be overlooked especially concerning surgical wounds.

    The case study states that Mr Jones has spent the last six months on a diet that mostly consisted of junk food. This is an indicator that Mr Jones could be malnourished. It is very likely that the junk food he was consuming had low nutritional value yet high fat hence the 10 kilogram weight gain. The nutritional status of Mr Jones is detrimental to the healing of his wound. Manley and Bellman (2000) states “Tissue breakdown occurs when adverse factors such as malnutrition combine with the predisposing condition.

    It is then that healing may be impaired”. It can also be noted from the case study that Mr Jones has a very poor appetite, added to this the fact that he has undergone major surgery and may be having a high exudate loss from his wound indicates that he is at high risk of poor nutrition anyway irrespective of the fact that he could have been malnourished prior to admission (Gunnewicht and Dunford 2004). In order for Mr Jones’ wound to heal, his nutritional status would need to be improved as part of his nursing care.

    An array of authors have noted that protein in particular is essential in wound healing. Lewis and Harding (1993), state that protein is like a building block in the process of constructing the wound bed. They also note that malnourishment of protein prolongs the inflammatory phase of wound healing and makes wounds weak. This is supported by Russel (2001) who agrees that protein deficiency prolongs the inflammatory process plus results in decreased collagen synthesis and puts the patient at risk of wound dehiscence.

    Vitamin C is also of great importance in wound healing. According to White (1990), research has shown that a deficiency in vitamin C can cause adverse effects on wound healing. Moreover, Zinc and Iron play a part in wound healing. Zinc helps with the immune response as well as the synthesis of RNA and DNA. Iron affects the transport of oxygen to the damaged tissue and for optimum healing there must be a good oxygen supply. Without iron the patient could also become anaemic (Manley and Bellman, 2000). The case study notes that there is dehiscence to the suture line.

    Dehiscence can be defined as the “ Separation of surgical incision or loss of approximation of wound edges” (Home Healthcare Nurse, 2003). Because Mr Jones’ wound is dehisced and he is obese, it can no longer heal by primary intention as most surgical wounds would, it will have to heal by secondary intention, which can take quite a while to heal. Wound infection can be defined as “…organisms present in the wound and surrounding soft tissue that result in a host response and lead to nonhealing or decline of the wound” (Robson 1997 pp642) .

    It is hinted within the case study that Mr Jones’ wound is infected. The pointers towards infection include Mr Jones’ ‘intense pain in his abdomen’, ‘dehiscence of the suture line’, and ‘the surrounding area is inflamed and the wound is discharging serous fluid’. According to Baxter and Ballard (2002), the main signs and symptoms of wound infection are erythema, localised heat, pain, odour, and increased exudate. This is supported by Emmerson et al (1993) who state that wound infection is indicated by tenderness, erythema, pain, and purulent discharge.

    White and Sibbald add that wounds that are green or blue in colour are almost certainly infected. This is not mentioned in the case study but it could be the case. Further authors support the above regarding signs and symptoms of infection in wounds but Gray and Cooper (2005) crucially add that another sign could be wound dehiscence, which certainly applies to Mr Jones. It is also noted that Manley and Bellman (2000), add that obese individuals are more at risk of infection because they may be lacking in the nutrients required for wound healing and also the blood supply to fatty tissue is poor.

    Another factor which applies to Mr Jones. One of the usual treatments for infection are antibiotics because it is a substance that is toxic for certain micro organisms (Manley and Bellman 2000). This could be used in the treatment of Mr Jones’ infection. Williams and Young (1998), identify that topical antibiotics are still in use in practice although there is no research or evidence that proves it is beneficial for infected wounds. This is something to keep in mind when managing Mr Jones’ treatment. A further point to note is Mr Jones’ pyrexia.

    The case study notes that he has a temperature of 37. 8(C, which has continued for a few days. According to Hoban (2005), pyrexia is a key sign of infection. This is yet another indicator that Mr Jones has an infection. If infection could be present, the wound would need to be swabbed. Manley and Bellman (2000 pp601) suggest that “A wound swab should be taken when two or more clinical signs of infection are evident, in order to confirm the diagnosis of the suspected wound infection and also to identify the drug sensitivity of the organism. Numerous authors support this statement. One in particular being Baxter and Ballard (2002). However, the reliability of swabbing has been questioned (Kelly 2003). The reasons for this is that the results can give a false positive because wound swabs can only detect bacteria from the surface of the wound and cannot identify infection within the deeper tissues (Gilchrist 1996). Infection Control is an issue, which must be addressed if Mr Jones has an infection. This would mean that universal precautions must be taken when nursing Mr Jones and coming into contact with his wound.

    The use of universal precautions will stop the transmission of infection from patient to patient and from nurse to patient and vice versa (Royal College of Nursing 1995). Therefore, it is essential that aprons and gloves are used and that the patient is put into a side room if possible. Hand washing is also of great importance (Manley and Bellman 2000). An essential part of wound healing is the dressing used. Many authors suggest that that moist wound healing for acute surgical wounds is the best practice. Baxter and Ballard (2002) state that wound exudate from an acute wound contains growth factors, which promote healing.

    Therefore, epithelialisation happens faster in a moist environment. Manley and Bellman (2000), adds that the ideal wound dressing would ensure that the wound is not macerated but is moist with exudate, stays at an optimum temperature for wound healing to take place, remains free from fibres or toxic particles which may be released from the dressing, and stays free from infection and slough. According to Dowsett (2004), a dressing, which would fill the above description of an ideal dressing, would be Aquacel( AG. It is a Hydrofiber( dressing which contains ionic silver. It is antimicrobial and absorbent.

    Demling and Desanti (2001), state that as well as being antimicrobial therefore excellent to use with infected wounds, it also has anti-inflammatory properties. Aquacel( AG comes as a non-woven ribbon or pad, which is soft and sterile. Further properties of it include that it can absorb a large amount of exudate and bacteria from the wound and it turns into a gel that maintains a moist environment and can also aid autolytic debridement if slough or necrotic tissue is present (ConvaTec 2004). Aquacel( AG seems an ideal and very suitable dressing for use on Mr Jones’ infected wound.

    It not only fulfils the criteria in the ‘ideal’ dressing description but it suits the needs of Mr Jones’ wound for optimum healing. Fletcher cited in Hoban (2005), states “Nurses make the most mistakes with dressings”. She notes that the main reason for this is lack of appropriate assessment. She states, “If you do a thorough assessment, the dressings should choose themselves”. Another issue that must be addressed in the holistic nursing care of Mr Jones is his pain management. It is mentioned in the case study that Mr Jones is experiencing intense pain in his abdomen.

    This could be due to his wound infection and the fact that his wound is dehisced. (Wulf and Baron 2002) support this by stating that when a patient has an infection, existing pain is compounded because nerve endings are repeatedly sensitised. Because of the increased sensitivity of neurones, even a small stimulus can be perceived by the patient as very painful. Because having a wound can cause anxiety, it can exacerbate the patient’s perception of pain. An insensitive attitude from a nurse could also greatly enhance the problem (Pasero and McCaffery 1998).

    Moffatt et al (2003), also adds that dressing removal can cause a lot of unnecessary pain for patients. Dried out dressings and sticky products can cause trauma at dressing changes. This is another advantage of using Aquacel( Ag as it forms a gel and does not stick to the patient’s skin. It will also not dry out. Although the dressing that has been suggested may not cause trauma to the patient during changing, analgesia still needs to be considered as Mr Jones is experiencing intense pain in his abdomen due to his wound dehiscence and infection. Therefore, the area will be extremely tender during dressing change.

    The type of pain that is experienced during medical procedures is known as ‘procedural’ pain (Williams 2003). Analgesia will not only ease the patient’s pain but it will also assist the practitioner as a comfortable and relaxed patient allows the practitioner to fully concentrate on the task in hand (Gunnewicht and Dunford 2004). It is mentioned in the case study that a dry dressing was applied to Mr Jones’ wound. This would cause unnecessary pain. According to Hollinworth (2005), traditional dry dressings such as gauze can dry out very quickly and adhere to the wound bed.

    Another factor to be considered is if it is not changed frequently, granulation tissue can grow into these products causing excruciating pain for the patient when it is removed and further injury to the wound which effects healing. Another very important aspect of Mr Jones’ care is the multidisciplinary approach. Kingsley (2005) in Gray and Cooper (2005) introduces the idea that doctors should be more involved in the diagnostic stage of wound management as their skills make them ideally placed to consider the wound in the context of the whole of the patient and their health.

    Gunnewicht and Dunford (2004) add that within wound care it is extremely useful to have a multidisciplinary approach as so many different disciplines can be involved in the wound care of one patient. There could be for example the involvement of physiotherapists, occupational therapists, dieticians as well as the nurses and doctors so it is essential that there is adequate communication and co-operation between them. According to Manley and Bellman (2000), in order to do this there must be a good team spirit and equal sharing of responsibilities.

    NHS trusts have reported that good multidisciplinary working gives outcomes such as reduced morbidity, higher patient and staff satisfaction, and increased cost effectiveness (Wilson 1997). As Mr Jones has just undergone surgery ten days ago and he is in quite a bit of pain and been feeling lethargic, his mobility will be impaired. It is important to get a physiotherapist involved into the multidisciplinary care of Mr Jones so that he can become mobilised as soon as possible.

    This is important because with immobility can come risk of more complications such as chest infections, pressure ulcers and deep vein thrombosis. Added to this, mobilisation will increase delivery of oxygen to Mr Jones’ wound so that optimum healing is possible (Manley and Bellman 2000). The last point, which is important to note concerning the care of Mr Jones, is health promotion. Gunnewicht and Dunford (2004), state, “In every shape of nursing activity, patient education is central to a successful outcome” (pp64).

    Particular attention needs to be paid to Mr Jones’ obesity problem with appropriate nutritional information and advice. As mentioned earlier, a dietician should be involved in the care of Mr Jones but it is also the role of the nurse to educate and inform patients and encourage them to take control of their lives and their health problems (Gunnewicht and Dunford 2004). The Department of Health have also put health promotion high on the agenda as they published ‘The Health of the Nation’ (1992).

    In conclusion, there is a lot to be considered in the holistic care of Mr Jones. Every aspect of his well-being must be addressed in order to provide sufficient care. The main focus of this essay is the management of Mr Jones’ wound but in order for the wound to be appropriately managed, many other aspects of care come into play. For example, if the only aspect being addressed was Mr Jones’ wound, he may well shortly find himself back in hospital because of problems caused by his obesity and nutritional problems.

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