ACTIVITY LOG
Background/
aetiology/incidence
It is estimated that 40-50 million people have surgery each year, and these will almost all have a surgical incision over which is placed a dressing (George, 2000). Between 8 and 10 million people are burned each year of whom and seek medical help. Burns are usually dressed to reduce pain, protect the burn from further injury and to contain and fluid escaping from the burn. Leg and foot ulcers and pressure ulcers are the commonest types of chronic wounds. They often take weeks or months to heal because there is substantial loss of the top layers of the skin, the epidermis and dermis. Furhter estimates suggest that 8-10 million people worldwide have leg ulcers and 7-8 million have pressure ulcers (George, 2000). These statisitcs are now 6 years old and with the rapidly changing NHS probably far greater than these estimated here. In the United Kingdom, venous leg ulceration alone has been estimated to cost the NHS £400m a year (Dunsdale, 2006). Much of this cost is accounted for by community nursing services, which can spend up to half of their time caring for patients with wounds (Smith et al. 2004). According to Rollins (1997) tackling malnutrition could save the NHS £266million pounds per year, a much debated statistic but a figure that cannot be ignored.
The first port of call for the majority of patients with wounds in the NHS is their general practitioners (GP’s) and nurses in primary care teams. Primary care is now at the centre of the NHS. This role is strengthened by the transfer of services closer to patients, and Practice Based Commissioning (Oldham et al. 2006). Front-line primary care professionals are well placed to modify the way that people seek help by addressing their beliefs about their health and condition. GPN’s subsequently more than often take the lead in wound assessment, management and patient education.
Understanding the phases and factors involved in wound healing can support a GPN’s practice (Casey, 2000). In this way, GPN’s can ensure that they have a sound knowledge base which they can use to inform and deliver evidence-based care
According to nursing assessments, particularly of wounds, can be inclined to concentrate on physical aspects of wound management, for example the use of appropriate dressing and infection control. This was also evident from observation and participation of practice nursing work experience. However, there is much research to show that nutrition is crucial in a holistic approach to wound healing . According to Bryant (2000) the importance of adequate nutrition for good wound healing should not be underestimated. Williams and Leaper (2000) concur stating that whereas good nutrition facilitates healing, malnutrition delays, inhibits and complicates the process. If a patients nutritional status is compromised, and they are unlikely to meet their requirements for recovery (Collier, J., 2006)
When injury occurs the whole body is affected. At the point of injury the hypothalamous is activated by stimuli such as pain or fear, and from autonmic stimuli such as changes to blood pressure or chemicals produced (cytokines) in response to tissue damage. Stress hormones, or catecholamines are realesed by the hypothalamus. The catecholamines increase the bodies levels of glucose (Morrison et. al, 1999). Glucose is the main substrate used by cells to produce energy for all cellular activities, including cell division, protein synthesis and secretion Increased energy demands are made by both inflammation and cellular activity in the healing wound . According to , the catabolic state induced by wounds will increase energy requirements. DeSanti (2000) states that wounds increase body metabolism, which, if left to progress, can precipitate profound weight loss, particularly of lean body mass. Body fat is also broken down during injury and used as an alterantive energy source to aid the healing process. Poor nutirtional status diminshes the effectiveenss of the systemic response and subsequent the delays wound healing (Morrison et al. 1999) Therefore, nutritional intervention should be provided early enough to prevent this catabolic decline in lean muscle mass, thus further impairing wound healing . Subsequently, GPN’s need to understand the roles of specific nutrients in wound healing. Such an understanding would enhance their role in the assessment of nutritional risk and enable them to obtain more easily the necessary support for patients to promote optimal wound healing.
According to Casey (2003) wound healing can be divided into three distinct phases, which often overlap; inflammation, proliferation and maturation. At each of these stages the activity in the wound bed is increased. The phases of wound healing require additional demands of energy. Depleted energy sources impair wound healing (Clark, 2002). Specific vitamins, protein, and specific amino acids have been targeted as crucial in wound healing. Studies have shown that people with high intakes of fresh fruit and vegetables have a lower risk of chronic diseases . This principle may therefore be applied to wound healing in acute and chronic situations. A literature review by Russell (2000) found that studies on nutritional intervention have established a significant correlation between nutritional status, body weight and wound healing.
The literature shows that nutrition plays a key role in the pathology of wound healing. Continued and improved community based care of those with wounds also maintain independence and quality of life. Therefore it is possible that careful assessment by GPN’s of patients' nutritional histories and habits prelude reasonable nutritional intervention to improve wound healing.
Reflections
The reflection model to be used for this section of the portfolio is based on Boud, Keough and Walker, 1985.
PREPARATION
With increasing awareness from practice, theory and media, I had become interested in the role of nutrition and the health benefits it can provide (DoH, 2005). For my portfolio subject I decided to link the notion of nutrition with another area that was new to me, wound care. I decided to see if there was any literature on this subject within my practice setting, there was much on each subject separately but I was unable to find information on the subjects combined. I audited (appendix 1) a small hand full of patients that attended the leg ulcer clinic at my GP practice, to ascertain their levels of understanding on the role of nutrition in healing, and if they would like to see further information. 60% of patients I audited were unaware that nutrition could influence their healing, and further 80% wanted more information in the form of a patient leaflet. I therefore decided that for the practice element of my work based learning, I would devise a patient leaflet on nutrition in wound healing. The aim of this subject choice for me was to improve my levels of understanding and also to educate patients and help improve their levels of self care. I realised that I would need to research this area of practice and collaborate with other healthcare professionals. I also knew that I would need to see what practice was currently in place in all aspects of primary care and to develop my own ideas and knowledge from this.
I felt that anxious initially about investigating an area of practice that was new to me, however I also felt challenged and keen to tackle the subject. I was astonished that 60% of the patients I had audited were unaware of nutrition and the effects on their wounds. I myself as healthcare professional knew very little and I wanted to be able to provide education and signpost to patients to improve their knowledge. I was unsure where to start researching information and was concerned that I may waste my time looking in the wrong areas for information. Fortunately, at the beginning of the module I was able to attend a wound care conference. This conference allowed me to network with other healthcare professionals with an interest in wound care and also allowed me to learn about the nurse specialists that may be useful to spend time with. I felt more confident after attending the conference.
During my time researching nutrition in wound care, I was able to perform a number of literature searches and gather materials from practice relevant to nutrition and wound care. I was able to collaborate with other healthcare professionals. Initially I spent time with the community nurses; I was able to work with them in our own practice based leg clinic as well. I attended the local Leg Club, where patients can visit to receive care education and socialise with others in the local community with similar conditions. I spent time to with specialist nurses such as the vascular nurse specialist and the dermatology nurse specialist. I spoke to those in the commercial sector from medical companies about nutritional supplements and looked at the evidence behind these. I was also able to visit the community and hospital based dietician clinics appreciate how referrals are received and the help available to patients.
ENGAGEMENT
I discovered form the literature I obtained that there were strong correlations between nutrition and wound healing. From my visits I made I was astounded that although each discipline had an appreciation for nutrition and its effects on healing, very little emphasis was paid to the correlation I discovered from the research. Many of the specialist nurses gave mention to nutrition but unless there was particular patient with obvious malnourishment, then there was no emphasis. Within my own GP practice there was also very little mentioned about nutrition to patients, even when community nurses were present in the leg ulcer clinic the focus was more often on the use of appropriate dressings. However I discovered form the protocols available to me a screening tool that could be used to detect malnutrition, but felt that this tool was inappropriate as it did not help to provide knowledge and education to patients. I also felt that the screening tool was merely a checklist, I wanted to present advice to patients in neutral terms. I felt that a patient information leaflet as a visible tool that could prompt discussion and learning with patients. According to Rollnick et al (2000) assessing the readiness of patients to reciev information leaflets and a brief explanantion can assist to motivate change in behaviour. I also decided to incorporate a nutritional self assessment tool within the leaflet to further prompt thought and learning in patients. I also wanted to provide signposts for patients should they wish to seek further information or help in the subject, and offer them invitation to return should they need it.
PROCESSING
In developing this portfolio and information leaflet I have informed and improved my knowledge in both nutrition wound care, and also that of my patients and colleagues. When carrying out assessments of patients, staff within the practice have become more aware of the impact of poor nutrition and the effects on healing. I have yet to distribute my leaflet but have discussed prototypes with patients and had positive feed back. Currently the leaflet (See Section 6) has been presented to the Primary Care Trust with a view for publication. I have drafted an evaluation sheet (See Section 6) and hope to disseminate this in the near future to ascertain the effectiveness of the information.
I feel that I have gained confidence in this area of clinical practice, and look forward to the publication of my leaflet in the near future. However, I still think that the importance of nutrition is still a vastly underestimated and ignored issue in primary care, not just my general practice. I at the beginning of this module knew little about nutrition and healing and feel that perhaps other health professionals could become better informed. On reflection incorporating teaching sessions for other healthcare staff may have addressed this concern. I intend to now keep myself informed of advances in nutrition and healing and continue to assist patients and colleagues understanding.
Inclusion of material from practice activity
Including Patient Information Leaflet and Evaluation Sheet.
APPENDIX 1
Audit
Q1)
Are you aware that certain types of food can influence your rate of healing?
YES
NO
If yes which ones?
Q2)
Did you know that eating a poor diet, for example to little calories can slow down your healing?
YES
NO
Q3)
Do you currently buy any special food with wound healing in mind?
YES
NO
If so, what?
Q4)
Do you think there is anything that prevents you from eating a healthy diet?
YES
NO
If so, please state.
Q5)
Would you consider liquid supplements to add to your diet to improve your rate of healing?
YES
NO
Q5)
Would you like to receive more information about how certain foods can influence your wound healing?
YES
NO
If so how would you like to receive this information?
For example, a leaflet, discussion with practice nurse/GP, poster in GP surgery etc.
References
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(30th April, 2005).
Casey, G. (1998) “The Importance of optimum wound healing”. Nursing Standard, 13, (3), 7-13.
Casey, G. (2003) “Nutritional support in wound healing”. Nursing Standard. 17, (23), 55-58.
Collier.J.,( 2006) Nutrition and wound healing. .
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.
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(5th May, 2006)
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