A Reflective Essay on Wound Care. Examining Nursing Practice

Acknowledgements

Sincere gratitude’s to all those individuals who saw me survive the turbulent time of juggling writing of this essay coinciding with completion of my competencies in the clinical environment, cold weather, new neighbours and homesickness miles away from home not forgetting daily journeys in the Metro to and fro the University.

Particularly Kathryn, Sue and Jennifer- you are a treasure to students.

REFLECTIVE ESSAY ON WOUND CARE

Several scholars have deduced that as the human body ages due to intrinsic and extrinsic aging factors it stops functioning optimally (Smeltzer & Bare, 2004). They realise that one aspect greatly affected by the normal aging process is wound healing.

Due to the fact that I am taking my overseas nurses program (ONP) in an elderly care set up, I have chosen to explore wound care to augment my existing knowledge and learn new skills to achieve a robust and empirically sound approach in wound management in an elderly care setting.

Due to its effectiveness and popularity among authors, I have integrated a critical incident in this essay to form a platform from which to examine reflective nursing practice; a style appreciated by among others Hong & Davies (2002) albeit Timmons (2006) reputes this viewing it as lacking rigour.

Reflection and reflective practice have been reiterated in literature to be key approaches to learning (Timmons, 2006) hence enabling a judicious mixture of theory and practice among nurses. In the ever changing climate of nursing arena (Parsloe, 1999), the Nursing and midwifery council (NMC), (2004) emphasizes on the need for nurses to embrace the philosophy of continuous learning and one way of achieving this is by utilising reflective practice in their daily professional endeavours to enhance competency. Reflection in nursing is geared towards scrutinising nurses’ actions to improve practice or even build on existing good practice (Schon, 1983). Various reflection models have been developed based on educational theory related to experimental learning to aid nurses in examining their practice (Rolfe, 1986; Cotton, 2001; Markham, 2002).

Atkins & Murphy (1993) developed a concise reflective framework which I shall employ in exploring wound management. This choice is influenced by my feeling that their framework is easy to follow, articulate, user friendly and forms a simple methodical approach to explore practice. In his analysis, Schon (1983) identified reflection in action as scrutiny of actions while performing a task while reflection on action as being examination of actions after the task. These will both be highlighted in this essay.

Eighty year old Ken (pseudonym used for confidentiality and consent obtained to write on his case) (NMC, 2004), has a wound on his left lower limb dorsal region and various health professionals are involved in his management. His past medical history includes Laminectomy in 1977, hypertension on treatment and urinary incontinence. He manages most of his activities of daily living (ADL) (Roper, Logan & Tierney, 2000) independently. The National Institute for Clinical Excellence (NICE) (2001) in its ulcer management guidelines advices on the need to put in consideration factors which influence wound healing hence the importance of a comprehensive medical history.

Kens’ wound developed from an abrasion he sustained post a fall while trying to reach the toilet. Immediate management included assessment for obvious injuries other than the abrasion but none were elicited. Bleeding was arrested by slight pressure application with a dry gauze (ConvaTec, 2005). The edges were then approximated and secured as close together as possible using steristrips an intervention which was aimed at helping the torn edges granulate back together (Smeltzer & Bare, 2004). They argue that wherever possible practitioners performing wound care need to approximate the edges of the wound to aid in quick healing for wounds with minimum tissue destruction which fundamentally heals through first intention.

He then had a waterproof gauze dressing (ConvaTec, 2005) applied to protect the wound and ultimately evade infection as advised in evidence based practice (Smeltzer & Bare, 2004). NICE (2005) directs that there is need to create an optimum wound healing environment using dressing as well as considering other dimensions of wound healing. A nursing care plan (Holland,et al, 2003) was formulated eliciting the nursing diagnosis and the care to be accorded to Ken. Carpenito (1993) and Hollandet al(2003) argue that care plans are integral in ensuring continuity of care, reference point, for progress evaluation and as a legal requirement.

Ken’s wound was noted to be oozing sanguineous fluid (Smeltzer & Bare, 2004) on the sixth day. The possibility for this was an eminent infection (Timmons, 2006). The dressing was removed and the wound examined. The edges looked necrosed with sloughy tissue and foul smelling. Moody (2006) highlights the importance of a systematic thorough wound review as a vital aspect in wound management. She realises that a comprehensive wound review enables the practitioner to decide on the management and encompass other variables which determine wound healing (NICE, 2005). These may be intrinsic factors e.g. mental status of the patient, age, pain, mobility, nutritional status or co-morbidities and extrinsic factors e.g. peri-wound skin status and infection. This holistic assessment also entails the clients’ ability to meet the twelve ADL (Roper, Logan & Tierney, 2000).

Though ken was feeding adequately on high protein diet aimed at aiding in tissue repair hence enhance wound healing (NICE, 2005), his mobility was poor. He had an unstable gait worsened by the wound pain and had history of frequent falls. Urine incontinence married with above problems meant ken did not have a settled mind hence occasionally got agitated. The General practitioner (GP) was involved who prescribedpro re nata(PRN) Valium for agitation (British National Formulary (BNF), 2004) which when administered made him too drowsy to feed or mobilise and got doubly incontinent!

This critical analysis ties with Atkins & Murphy’s (1993) second stage of reflection were examination of how the situation affected the client or how the client affected the situation forms a base for pragmatic and rational decision making. Upon reading and understanding this reflective framework and reflecting on Kens’ wound, I realised that it is of paramount importance to relate theoretical and practical knowledge in analysing a situation to be able to make pragmatic evidence based decisions which Nurses are encouraged to embrace by among others, the Department of Health (DoH), (2001).

After assessment the wound was aseptically cleaned with Chlorohexidine 0.5% and a Mesorb dressing (ConvaTec, 2005) applied. They advise that Mesorb is a cellulose dressing, highly absorbent, has fluid repellent backing indicated primarily in exudating wounds and has no contra-indications. They further highlight that where appropriate, evidence based practice recommends that among the armamentarium of available wound healing dressings a universal dressing which has no contra-indications should be used especially for individuals with several allergens as it was the case with Ken.

The dressing was then secured with a bandage and the need for not soiling it explained to him. The Nursing care plan was updated and a new nursing diagnosis thus: ‘potential for presence of infection’ formulated.

Evidence based practice (Dicenso,et al,2005) indicates that wound healing is a dynamic pathway that progress through four processes Viz. vascular response, inflammation, proliferation, epithelialization and remodelling happening at varied time lengths depending on the wound type and the factors influencing wound healing (North tyne PCT, 2005-6). In this respect I appreciate that this conforms to Atkins & Murphy’s (1993) reflective framework stage of identifying underpinning knowledge to be able to explore alternatives in practice.

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