Wound management Surname Essay Example

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Sepsis, which includes septic shock and severe sepsis, posses a major healthcare issue internationally, and remains at greater than 20%, even though it has slightly reduced in the last ten years (ARISE, ANZICS, 2007, 8-18 ) To further provide optimum care to patients in this group, Surviving Sepsis Campaign (SSC) has provided evidence-based clinical practice guidelines in order to reach better outcomes (Dellinger RP et al, 2008, p 296–327). Even though the SSC guidelines are comprehensive, yet they provide only a little guideline on the nursing care of such patients which is essential for better outcome in them. Both in case of known severe sepsis patients and freshly developed ones on account of post operative scenarios, it is widely accepted that expert nursing skill and knowledge are essential for optimum outcomes.

Consequently the World Federation of Critical Care Nurses, which is a premier worldwide network of critical care nurse, embarked on the task of providing expert advice on nursing care of severe sepsis patients, which is provided by registered or advanced practice nurse, including clinical nurse specialist, nurse practitioner, and consultant; all part of acute hospital settings. Although, the roles of these three may vary from region to region on account of their authorization, scope, legislation and education, the recommendations were such that they would not be limited by any regional factors and thus apply to all nurses involved in sepsis care.

It is important for nurses to be familiar with best evidence-based post operative care practice, the goal of which is to prevent infections, post operative complications and promote healing. Assessment, diagnosis, planning, intervention, and outcome evaluation are the major milestones of post operative care the duration of which would depend on the extent of sepsis developed.

Importance of obtaining information during a nursing admission in relation to post operative assessment

Post operative care is care of patient immediately after post operative period, which could mean both in postanesthesia care unit (PACU), operating room and during the days following surgery. Sophie Smith is two days post operative following an appendectomy and is to be assessed for further treatment and follow up on account of the sepsis that has developed in her wound. Post operatively nurses would ideally require accepting responsibility that they have been ideally trained for and optimal post operative care in case of Sophie would require clinical assessment and monitoring, cardiovascular management, respiratory management; fluid, electrolyte and renal management, control of sepsis and nutrition.

On nursing admission it is important to assess the patient’s perceptions, carefully noting physiologic and behavioral responses. Sophie is communicative and thus can self -report it. Pain has to be evaluated and if it is present it would have to be observed whether or not the interventions are changing.

It is important for nursing practice to be based on the best available evidence available since results of studies conducted in the last two decades have demonstrated the inconsistency on part of nurse practices particularly regarding pain assessment (Cathy, 2009, p 174-187).

Nurse’s role in consent procedures for patients undergoing a procedure involving general anesthesia

Nurses do not have an authoritative role in consent procedures for patients undergoing general anesthesia; instead the only role she has in the same is that of a witness. The nurse observes the patient sign the consent procedures in order to witness; later on, if the need be, that the consent was given by the patient voluntarily. When the consent is given by the bedside the patient can ask nurse any questions regarding the procedures and the outcomes and even nursing care involved in the procedures, which she would need to answer correctly and factually. It is important to differentiate between a nurse standing witness to consent and a nurse anesthetist, who is trained to administer general anesthesia to the patient, normally under the supervision of a physician.

It is a nurse’s duty to check if the consent already exists in the current medical records of the patient, and if it does, can it still be held as valid for the forthcoming procedures involved in sepsis evaluation and treatment. The nurse is responsible for informing the physician/ surgeon the absence of an informed consent and has to compulsorily follow the hospital’s policy in this regard. Advance-practice nurses are supposed to informed, as part of consent taking procedures, the risks and outcomes of invasive procedures that are part of the sepsis treatment. The nurse is responsible to define clearly what is risky and invasive keeping in view the regional and hospital policy on informed consent and minutely detail the patient on the proposed procedure, treatment, benefits, side effects and the likely goals expected to be achieved (Westrick and Dempski, 2008, p 79-80).

Purpose of vital sign data in the pre and post operative period

Identification and assessment of vital sign data are important factors that determine the patient outcomes in any pre or post operative intervention. The vital signs include respiratory rate, temperature, blood pressure and heart rate/ pulse beat. All of these signs can be either measured, monitored or observed. If not zero, which means the person has ceased to live, changes in vital sign data would depend on, among many factors, the underlying medical condition. Sepsis/ infection would normally be associated with fever. Nurses collecting vital sign data must possess the ability to i) select valid assessment tools for measurement, ii) collect data systematically through observation, interaction, and measurement, iii) accurately analyse and interpret the data collected.

Since Sophie is a post operative patient, her vital signs could have been affected by anesthesia and surgery. There is a lack of evidence base from which best practice can be determined post operatively for recording vital signs post-operatively (Aylott, 2006, p 38-42), but it is generally it is prudent to consider that a post operative vital sign data should include the level of patient consciousness. Sophie’s oxygen saturation, heart rate, ECG, skin temperature, respiratory rate, and blood pressure needs to be recorded (Trigg and Mohammed, 2006)

Purpose of wound assessment

Clinically correct wound assessment, using tools as wound tracings, digital photography and width and length measurements form the cornerstone for the effective management of a wound (Hammond et al, 2007). However, as such tools have certain limitations since they establish contact with the wound, and still lack accuracy; recent advances have been made in wound assessment with a measurement and documentation device called the ARANZ Medical Silhouette Mobil, which uses two laser beams and a digital camera for accurate assessment. Correct wound assessment provides the extent of deterioration around the site of wound and provides a clue on the treatment modality that must be used to heal the wound (Nixon et al, 2006).

The assessment of the area involved in the wound must be the first step in determining its severity and must always be a repeated act since wounds change dynamically. Wound dimension and tissue involvement are two important parameters that give an idea on the nature of wound in the first place. Both invasive and noninvasive techniques can be used to determine the extent of wound through evaluating surface area, dimensions of the wound, volume, and tissue involvement. The ARANZ Medical SilhouetteMobile is considered to be giving accurate assessment on depth and surface area of the wound (Koel, 2008).

Four nursing priorities to be undertaken in assessing Sophie’s wound

Appearance of a wound gives a firsthand indication of the extent of a wound, but cleaning a wound before assessing it makes a logical clinical sense. Correct wound assessment aids the nurse in problem identification and priority selection for wound treatment. A nurse should note the following while assessing the wound: i) wound position, ii) wound shape, iii) wound dimensions, iv) wound margins and colour, v) presence of exudates, vi) presence of eschar or slough. vii) wound odour, viii), any associated pain.

Since a thick yellow discharge has been seen oozing from the Sophie wound, it signals exudates which are normally associated with necrotic wounds. This would require the nurse to remove the slough or necrotic tissue as a priority. If the wound site is painful, red in colour, and swelled, it could indicate infection which would need appropriate drainage and antibiotic treatment (Torrance, 1997, p 181-82).

Purpose of aseptic technique in wound management

An aseptic technique is a preventive measure that helps restrict spread of infection during clinical procedures from a wound to other susceptible areas – either an object or a person – through organisms present at the site of infection. Aseptic techniques are recommended to be used in procedures that fall outside of body’s natural defence mechanism. The technique aims at i) preventing micro-organisms pathogenic in nature into susceptible areas within the body, ii) preventing micro-organisms from a patient to another person, and iii) preventing medical staff from picking the infection. Sophie can be considered a case for aseptic technique since she is presenting a wound that is exudating indicating infection.

The degree of risk in an infected wound determines the principle of an aseptic technique. The standard aseptic technique is Aseptic Non-Touch Technique (ANTT), where ANTT is an acronym standing for ‘A’- always wash hands effectively, ‘B’ — never contaminate key parts, ‘T’ — touch non key — parts with confidence, and ‘T’ — take appropriate infective precautions. On ANTT, Hart (2007) has suggested that “when handling sterile equipment, only the part of the equipment not in contact with the susceptible site is handled.”

Two causative factors of wound breakdown in relation to the case study

Sophie presents with a surgical site (SSI) infection and SSIs are not uncommon post operatively. However, the incidence of SSIs vary from one setting to another and even from one surgeon to another. As a result of this Sophie’s wound cannot be attributed to or even generalised to one particular cause. Given previous literature on pathogens isolated from wound sites in post operative cases, the causes have been seen either to be based on the pathogens present in either exogenous or endogenous environment of the patient. Normally Staphylococcus aureus-related infection happens on account of patient exogenous environment related to bacteria present in patient’s skin flora. Another causative factor could be related to endogenous if Sophie;s wound anaerobic or polymicrobial aerobic flora.


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ARISE, ANZICS APD Management Committee (2007). The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Crit Care Resusc, 9:8–18

Dellinger RP, Carlet JM, Masur H, et al (2004). Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med, 32:858–873

Dellinger RP, Levy MM, Carlet JM, et al (2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock, Crit Care Med, 36:296–327

Cathy CL (2009). Use of Three Evidence-based Postoperative Pain Assessment Practices by Registered Nurses, Pain Manag Nurs, 10(4):174-187.

Westrick SJ (2009) Essentials of nursing law and ethics, Susan J. Westrick, Katherine Dempski, Jones Bartlett Publishers, Sudbhury, MA

AylottM (2006). The neonatal energy triangle. Part 2: Thermoregulatory and respiratory adaptation, Paediatric Nursing, 18 (6), p.38-42.

Trigg E andMohammed TA (2006). Practices in children’s nursing guidelines for hospital and community (2nd edition), London: Churchill Livingstone Elsevier.

Hammond C, Randles J, Lewis D, Roake J, Nixon M, McCallum B, Davey B. (April 2007). Evaluation of a hand held, electronic wound measurement and documentation device in clinical practice. Presented at: 20th Annual Symposium on Advanced Wound Care (SAWC); Tampa, FL.

Nixon M, Davey B, Fright WR, Preddey J, Kieser D (2006). Comparison between two methods of wound measurement on wound models: manual methods and Silhouette, a hand-held electronic wound measurement and documentation device. Presented at: 13th National District Nursing Conference; Christchurch, New Zealand.

Koel G and Oosterveld F (2008). Reproducibility of current wound size surface measurement. Conference Proceedings, European Wound Management Association (EWMA); Lisbon, Portugal; May 14-16.

Torrance C. and Serginson E. (1997). Surgical nursing, p 181-82, Bailliere Tindall, Oxford, UK

Hart S. (2007). Using an aseptic technique to reduce the risk of infection. Nursing Standard, 21 (47), p 43 – 48