I gathered together the equipment I would need, which included: - dressing pack, cleansing fluid, gauze and a new dressing according to the assessment made. The choice of dressing would relate to the wound assessment whilst taking into account the quality of an effective wound care product. Particularly important issues that to consider are the stage of wound healing, site of wound, pain relief and amount of exudates (Baillie, L, 2005). I felt that it was appropriate for my mentor to decide which dressing to use as it is obvious that she was trained in this particular field of skill. At this point I felt that as part of future development I would need to gain more experience and conduct further research into this required topic. I understand that it is important to keep up to date with continually changing research regarding dressing choices and new products coming into the market.
The wound dressing my mentor suggested to use to cover the pressure ulcer was a granuflex. This type of dressing is made from polyurethane foam sheer fixed onto a semi permeable film. Its benefits include that it provides a protective barrier against micro-organisms, it can be left in place for several days and bathing and showering can continue to take place (Baillie, L, 2005).
Whilst collecting this equipment I made sure I checked the expiry date of all the equipment and solutions and I placed them on the bottom of the trolley. When the trolley was ready, I took the trolley to the bed area, where I closed the curtains around us, to maintain privacy and dignity and adjusted the height of the bed to prevent me bending too much and injuring my back.
Before progressing any further, I checked with the patient that she was still happy for me to continue with the procedure. I communicated with the patient in an appropriate manner which was adapted to her individual need. As she was slightly hard of hearing I ensured that I explained things clearly, slowly and slightly louder than usual. I ensured that she was in a comfortable position, but one that was convenient for me to access and treat that area that needed dressing.
I removed the dressing pack from its outer packaging and placed it on the trolley, taking care to maintain sterility (Nicol, M et al, 2004), and opened the pack to reveal its contents. Inside was a yellow waste bag which I placed to one side. I was advised to use alcohol-hand rub to cleanse my hands before starting the hands on procedure.
My mentor was talking me through the procedure step by step, this gave me the confidence that I would be able to do the job to the best of my ability, but also if something were to go wrong she was there to reassure me.
My mentor asked me to open the yellow waste bag and put my hand inside so that the bag acted like a glove and remove the previous soiled dressing. This was to reduce the risk of cross infection and to prevent cross contamination of the environment (Dougherty and Lister, 2004).I then opened the glove pack, taking care not to touch the outside of the gloves as they were sterile and I put them on. Hollinworth and Kingston (1998), state that a sterile technique helps prevention of transmission of micro-organisms. However, Williams and Young, 1998 suggest that some dressings are difficult to apply using gloves and may not need to be used but hand hygiene is essential to prevent contamination of the dressing.
I was asked to use a gauze swab dipped in the cleaning solution to clean around the wound to remove the exudates coming from the ulcer. In some hospitals the solution is warmed to prevent cooling and vasoconstriction at the wound site (Dyson, 1978) both of which would inhibit healing as it would decrease blood flow to the area. I was told to use fresh gauze swabs to dry around the wound (not the wound itself), to use each swab only once and to swab the area from the cleanest side through to the more infected side, to prevent spread of any infection. Swabbing of wounds using gloves or forceps and gauze swabs is a traditional method of wound cleansing (Baillie, L,,2005) but Tomlinson’s (1987) study argued that this merely led to redistribution of micro-organisms rather than the removal of them entirely. Another identified method of wound cleansing is irrigation and it can be considered preferable to swabbing (Fletcher, J, 1997). Also, it can be argued that gloves provide a greater sensitivity than forceps and are less likely to traumatize the wound or the patient’s skin (Dougherty and Lister, 2004). These approaches I may use in the future, however at the time I was to treat the patient according to the local policies.
My mentor told me not to use the gauze swab to clean inside the wound, and Davies(1999) suggests for this reason that it has been shown to damage the delicate granulating tissue of a healing wound (Davies, 1999). Writing from a similar perspective, Dyson (1978) suggests that the effected area should not be rubbed as this would cause maceration and degeneration of the subcutaneous tissues, leading to a delay in healing, especially in elderly patients.
My mentor then explained how to apply the new dressing. When the procedure was finished, I ensured the patient was repositioned so that she was comfortable and that the bed was readjusted to a suitable height.
Throughout the procedure I felt very nervous, although I had watched the process many times and it seemed simple, it was much harder in practise. I was very conscious that I didn’t want the patient to think I was unsure at any point about the treatment I was giving her. I referred to my mentor regularly throughout the process to ensure I was conducting the procedure correctly and appropriately. I understand that it is important as a nurse to be assured that I am delivering the best possible care to a patient. In this situation, it was providing the patient with appropriate dressing along with evaluations and treatment of her pressure ulcer enabling healing to occur.
After completing the procedure I felt relieved that it was over but at the same time satisfied that what I had done would make a difference to this patient healing time.
After the procedure, my mentor asked me to observe and monitor the patient for the rest of my shift, ensuring that the patient was repositioning herself throughout the day and was not in a position where her heals were taking her leg weight all day. Positioning and repositioning of the patient is a prime nursing consideration (Barbenal, 1990). Repositioning at least every two hours is recommended by the NICE (2001) although this should be determined by the skin and the individuals needs. An awareness of interface pressures e.g. creased bed lines and night clothing, is also important to avoid increased friction and further skin breakdown (Dougherty, L and Lister, S, 2004).
As part of post procedure, my mentor asked me to continue to fill in a waterlow pressure ulcer risk assessment form on this patient and others (see appendices). A patient’s risk of developing a pressure ulcer should be assessed on admission to the hospital. The NMC professional code of conduct (2002), states that nurses must act to identify and minimize the risks to patients.
The patient’s pressure ulcer began to heel over the next few weeks, assessments continued on a regular basis and the treatment was adapted to suit the patients changing needs. Throughout this period the patient was educated and encouraged to change her position throughout the day to allow recovery and prevention of future reoccurrence.
The purpose of this clinical skill for my patient was to create an optimal healing environment for this pressure ulcer, by producing a well vascularised, stable wound bed with minimal exudates (Dowsett, C, 2002). This is because the maintenance of skin integrity and management of acute and chronic wounds is a major component of nursing care (Bryant, 2000) and the care should be aimed to relieve the pressure as well as minimizing the symptoms (Dougherty and Lister, 2004).
My level of awareness concerning evidence based practice, and its importance, has been enhanced with the use of critical reflection. My competence, within this clinical skill, has been further developed through the research I undertook to increase my knowledge and awareness surrounding this subject and I therefore realise that any procedure that I participate in, I must evaluate my performance and the effectiveness of the treatment ensuring I implement any necessary improvements to ensure patients receive the best possible care. This has also highlight to me the importance of adapting the care to the individual patient according to their needs. I now feel that my personal and professional development is progressing and I would feel confident to inform and deliver evidence-based care on pressure ulcer management and treatment.
References.Baillie, L (2005). Developing practical nursing skills (2nd edition). London. Hodder-Arnold.
Barbenal, J.C. (1990) Movement studies during sleep in Pressure sores-clinical practise and scientific approach (ed D.L.Bades) cited in Dougherty, L and Lister, S. (2004) The royal marsden hospital manual of clinical nursing procedures, 6th edition. Oxford. Blackwell publishing.
Bryant, R.A. (2000) Acute and chronic wounds: Nursing management, 2nd edition. St Louis. CV Mosby. Ix-x. cited in Baillie, L (2005). Developing practical nursing skills (2nd edition). London. Hodder-Arnold.
Casey, G (1998). Wound healing. Primary health care, article 641. 8,10,31-38.
Davies ,C (1999). Cleansing rights and wrongs. Nursing times 95 (43): 71-75.
Dougherty, L and Lister, S. (2004). The royal marsden hospital manual of clinical nursing procedures, 6th edition. Oxford. Blackwell publishing.
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Dyson, R (1978) bed sores- the injuries hospital staff inflict on patients cited in Dougherty, L and Lister, S. (2004). The royal marsden hospital manual of clinical nursing procedures, 6th edition. Oxford. Blackwell publishing.
EPUAP(European pressure ulcer advisory panel), 2003. Pressure ulcer classification.
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Fletcher, J (1996). The principles of pressure sore prevention, Nursing Standard 10 (39) 47-55.
Hollingworth, H and Kingston, J.E (1998). Using a non-sterile technique in wound care. Professional nurse 13, 226-29 cited in Baillie, L (2005). Developing practical nursing skills (2nd edition). London. Hodder-Arnold.
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Nice (2001) Pressure ulcer risk: Assessment and prevention. National institute for clinical excellence. London.
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Nicol, M et al (2004. Essential nursing skills. China, Mosby. Elsevier LTD.
Nursing and Midwifery council (2002).Requirements for pre-registration nursing education. London: NMC
Tomlison, D (1987). To clean or not to clean. Nursing Times 83 (9): 71,73,75.
Williams, C and Young, T (1998). Myth and reality in wound care cited in Baillie, L (2005). Developing practical nursing skills (2nd edition). London. Hodder-Arnold.
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