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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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101
Action
Rationale
13. Using the forceps in the pack, arrange
the sterile field with the handles
of the instruments in one comer or around
the edge of the sterile field. Where
appropriate, swab along the “tear area”
of lotion sachets with chlorhexidine
gluconate 0,5 % and isopropyl alcohol
70 %. Tear open sachet and pour lotion
into gallipots or an indented plastic tray
All fluids that come into contact with
the wound must be sterile if the risk
of contamination is to be reduced.
Individual sachets of fluids should
be used (if available) in preference
to bottles of solutions which are re-used.
The contents of each sachet will
be sterile, whereas solutions and lotions
stored in bottles are no longer sterile once
they have been opened and the risk
of contamination is increased
14. If appropriate, put on sterile gloves,
touching only the inside wrist end
To reduce the risk of infection. A no
touch technique is essential to ensure that
hands, even though they have been
washed, do not contaminate the sterile
equipment or the patient. This can
be achieved either by the use of forceps
or sterile gloves. It is important
to remember that care is necessary
in both cases: gloves can become
damaged and allow the passage
of bacteria, while forceps may
damage tissue
15. Carry out the procedure using
a no touch technique
Any equipment that becomes
contaminated during a procedure must
be discarded. On no account should
it be returned to the sterile field. While
following aseptic techniques, it is also
important to evaluate the whole
procedure to ensure the principles
of asepsis are being followed throughout.
Errors such as taking adhesive tape from
a contaminated roll or using dressings left
over from a previous dressing must
be avoided
102
Action
Rationale
16. Monitor the patient's reaction
and maintain the patient's comfort
throughout the procedure
Maintaining the patient/client's comfort
and minimizing fear, pain and anxiety
is a primary goal of nursing.
The patient/client is an active participant
in his or her own care and its evaluation.
The patient/client will be able to provide
feedback to the nurse on her dexterity,
gentleness and skill
17. Provide information and patient/client
teaching related to care
of the wound/procedure site
as appropriate
For example, the patient/client’s skin
flora is an important source of infection
following invasive procedures.
Patient/client hygiene will reduce this
risk. Studies comparing washing with
soap or chlorhexidine solution
demonstrated a marked decrease
in bacteria in patients washing with
chlorhexidine. Studies to establish
whether the incidence of infection
or prolonged or delayed healing occurred
when stitches became wet during bathing,
showed that this was not detrimental
to wound healing. Therefore, a patient
with, for example, an indwelling
intravenous Hickman catheter, with
stitches still in situ, may shower but
should keep the dressing on. After
showering, any no waterproof dressing
should be changed immediately
18. Dispose of waste in waste bags
(according to hospital policies
for the disposal of clinical waste)
To prevent environmental contamination
and reduce air-borne transmission
of infection
19. If necessary, draw back curtains or,
if appropriate, help the patient/client back
to the bed and ensure he or she
is comfortable
103
Action
Rationale
20. Check that the trolley remains dry
and physically clean. If necessary, wash
with liquid detergent and water and dry
thoroughly with a paper towel
To reduce the risk of spreading infection
21. Wash hands with soap and water
To reduce the risk of spreading infection
Note: Studies have shown that not wearing a mask does not alter
infection rates. However, there may be some justification in wearing
masks when giving prolonged close care to major burn patients.
5.4. TISSUE DAMAGE AND WOUND HEALING
Introduction. The day-to-day management of wounds is a basic nursing responsibility... Although governed by the requirements of the surgeon, hospital policy, cost and nursing tradition, success ultimately depends on knowledge and experience. When caring for wounds, asepsis is
essential because the air, other people and nurses are all potential sources
of infection from which the patient must be protected. Honesty is always
important. If nurses are aware they are carrying infection (a sore throat,
septic spots, or cuts), they should avoid changing dressings.
We all gain practical experience of wounds from an early age, watching our own and others' traumas, building up a picture of what is normal.
Some wounds seen in hospital follow this natural pattern closely, others
such as ulcers and infected wounds do not. Healing in others, though apparently normal, is delayed because of the patient's illness or treatment. Inexperience of complications may leave the nurse unsure of what to expect.
In recent years there have been a number of new developments in wound
management, and research has provided a better understanding of the healing and inflammatory process. New techniques such as microsurgery, new
methods of wound closure and the development of biological dressings all
mean that the knowledge to be acquired by the nurse increases daily.
Nurse education on the wards involves the observation of dressings. Every
opportunity should be taken by learners to observe different types and
104
conditions of wounds. They should not of course be asked to undertake
dressings until they have gained experience by watching the techniques.
Experienced nurses should always carry out more complicated dressings
and dress potentially dangerous wounds.
Causes of tissue damage. Wounds are the visible result of individual
cell death or damage. They can be classified by site, size, depth and cause.
Each wound is unique and requires individual care. No method has so far
been developed to speed up the healing process of damaged tissues. Healing can proceed unhindered only in optimal conditions — normal temperature, adequate nutrition, oxygen and freedom from further damage - both
locally and within the body. At a cellular level, tissue damage or death can
be caused by hypoxia, physical and chemical agents, micro-organisms, radiation and inflammatory and immune responses.
Table 4 describes the mechanisms of tissue damage.
Table 4
The mechanisms of tissue damage
Mechanism
Cellular Effect
Hypoxia
Cell death through lack of oxygen
Mechanical (surgical and traumatic
injury, orpressure distortion
and shearing force)
Disruption of the cellular membranes
Extremes of temperature
Heat coagulates the cells' cytoplasm. Cold
forms crystals in the cytoplasm
Chemicals
Act as toxins on cells, either causing contact
damage (as caused by strong acids and alkalis)
or by interfering with the cells' metabolic
processes
Micro-organisms
Use the cell contents and products as food
Radiation
Ionizing radiation affects cells' replication
capacity, particularly cells in the process
of dividing (such as those in the bone marrow
and epithelial system)
105
Mechanism
Cellular Effect
Inflammation and immunity
Can act inappropriately against normal cells,
so that the cells' protective mechanisms
are falsely directed against the host
The body's response to injury. The body's response to injury is:
• Survival.
• Preservation.
• Repair.
This response operates at several levels (systemically, locally and affectively). Local tissue damage is only one aspect of the response to injury
(see tab. 5). It is important that the whole person and not just the visible injury is assessed and treated, and that evaluation is also concerned with the
holistic nature of the body's response to injury.
Table 5
The body's response to injury
Survival
A stress reaction is stimulated by an adrenaline
release, preparing the body for “flight”
or “fight”. This manifests itself at the time
of injury as:
- Heightened awareness.
- An increase in blood pressure.
- A dulling of pain.
At the site of injury there is:
- A brief period of vasoconstriction which
reduces hemorrhage and allows clot formation
in small, damaged vessels.
- Capillary dilatation follows, with increased
permeability resulting in edema and loss
of function
106
Preservation
After the initial “survival” reaction, the body acts
to preserve life. There is:
• Peripheral vasoconstriction.
• Lowered blood pressure.
• A reduction in the blood supply to non-vital
organs.
• Pallor.
• The peripheries become cold.
• The person may feel faint.
• The person may experience a primitive desire
to creep away and lie still. If injury or blood loss
is severe, the person may go into shock
and hemostasis can no longer be maintained.
Outside intervention is then necessary
for survival
Repair
Healing is usually described in three
or four phases
Phase 1:
Inflammation (0–3 days)
Cell damage caused by injury stimulates
an initial vasoconstriction, then vasodilatation,
followed by changes in the permeability
of vessel walls, which allows leakage of blood
plasma into the damaged area, and increased
blood flow. These effects — visible in external
wounds — also take place in deeper tissues
and are often referred to as the “triple response”.
Blood cell responses include:
• Clot formation — this takes place immediately
following injury. During vasoconstriction,
platelets respond to exposed collagen
in the damaged vessels. They adhere to the vessel
walls and are stabilized into a clot by a network
of fibrin.
• Margination of leucocytes — during
the vasoconstriction stage, leucocytes arrive
in the blood and stick to the walls of the blood
vessels. The endothelial cells lining the vessels
begin to swell and then separate, making
the vessel walls more permeable and allowing
leucocytes to move into the damaged tissue.
107
These white cells are attracted to the damaged
cells and engulf foreign material and debris
in the damaged tissue
Destruction (2–5 days)
This is a very active phase in which leucocytes
and macrophages (transformed mononuclear
leucocytes) destroy and ingest bacteria, debris
and devitalized tissue. There is some overlap
between the inflammation and destruction phase
and the reconstruction phase
Phase 2:
Reconstruction days (3–24 days)
Reconstruction is characterized
by the proliferation off cells and the production
of collagen fibers. The collagen fibers form
a network which increases the strength
of the wound. This phase is dependent
on the presence of iron, vitamin C and oxygen.
At the same time there is a gradual
revascularization of the area of damaged tissue.
Fragile capillary loops protrude into and link
across the wound, held within the framework
of collagen. This complex is known
as granulation tissue. The surface is easily
damaged by friction and drying, and is irritated
by chemicals. Granulation tissue can grow into
wound dressings such as gauze. On removal
of the dressing any adhered delicate granulation
tissue is also destroyed
Phase 3:
Remodeling (24 days onwards)
At the end of the reconstruction phase, a wound
is considered to have healed. The process
of remodeling, which continues within
the wound for months or years, is one
of strengthening, which eventually results
in better function and improved aesthetic results.
Although the process of remodeling is basic
to healing throughout the body, it is important
to be aware that there are variations
in the specialized body tissues and organs, such
as bone, cartilage, muscle, nerve tissue
and external sensory organs
108
Promoting wound healing. The rate of healing of a wound varies according to the general health of the person, the location of the wound and
the degree of tissue damage. There are a number of factors in relation to
each of these determinants which can delay wound healing. An awareness
of the factors which can delay wound healing is important to the assessment, planning, implementation and evaluation of care for an individual
patient or client. It enables us to plan care to minimize or prevent these
factors, in order to provide the optimum conditions for each patient or client’s wound healing.
Exercise. Factors which delay or prevent wound healing
Drawing on your own experience (and the information presented so
far), draw up a table with two columns. In the left hand column, list the
factors which in your experience delay or have a detrimental effect on
wound healing. In the right hand column of the table, try to explain why
each factor negatively affects wound healing.
As you work through the remainder of this section you may wish to
add to your list.
General care of the patient. Where possible, health care should be
aimed at preventing wounds occurring, for example, preventing the development of pressure ulcers by regular changes of position and adequate nutrition. Promoting wound healing is concerned with optimizing the local,
internal and external environments. This includes controlling disease or
underlying pathology, reducing external risk factors such as infection, and
maintaining an ideal microclimate for healing in the wound. Table 6 summarizes some of the key factors involved in promoting wound healing.
Wound care theories. David suggests that “the nurse must realize
that many theories and traditions exist. Only by gaining experience of different methods and by reading about different theories will he or she be
able to make an independent judgement as to the choices available”. David
compares and contrasts traditional wound care theory and research-based
wound care theory as follows:
109
Table 6
General care of the patient/client to promote
wound healing
Factor
Interventions
Psychological support
This is important in order to help the person to cope with
his or her injury or disease and the resulting tissue damage and healing processes, both at an emotional
and a practical level. A patient/client's emotional state
immediately after wounding is difficult to predict.
Wounds can be distressing, disfiguring and disruptive
to the person's self-esteem, body image and lifestyle.
Where a wound is associated with underlying disease
(for example, a carcinoma or a diabetic ulcer) there may
be complex and multiple aspects to the psychological
assessment and support of the person. Explaining,
supporting and encouraging the patient/client
is necessary to help him or her to understand
the conditions necessary for healing of the wound,
to reduce stress (which delays wound healing)
and to gain the person's co-operation, with procedures
and precautions aimed at preventing further tissue
damage and promoting wound healing. As in all other
areas of care, the person needs to be an active partner,
wherever possible. Wound management plans need
to be acceptable to the person and realistic in terms
of then practical circumstances. The assessment
and relief of pain associated with the wound
(and its treatment) is essential
Nutritional support
Good nutrition is necessary for wound healing.
A nutritional assessment of the patient/client should
be made, if possible, by a dietician.
- Patients/clients are considered “at risk” for wound
healing if they have lost 20 % or more of their body
weight within the previous six months or 10 %
in the previous two months.
110
Factor
Interventions
Particular attention to nutrition is essential where the
person's nutritional status is adversely affected
by co-existing socioeconomic factors (poverty), disease
(acute and chronic malabsorption conditions),
insufficient intake (due to loss of appetite, depression,
or iatrogenic starvation), or high energy demands.
Examples include: Metabolic conditions, such
as diabetes or liver disease, Gastro-intestinal conditions,
e.g. gastrointestinal surgery, Crohn's Disease, Long-term
steroid therapy, Malignancy, Major trauma, particularly
bums injuries, Substance misuse, for example, alcohol,
tobacco, illegal drug use, Fever and inflammatory
disease. Dietary supplements (particularly Vitamins A
and C and zinc) may be indicated in certain conditions.
In the absence of any underlying cause of malabsorption,
the provision of adequate nutrition by diet or supplement
is the easiest and often the cheapest method of ensuring
the patient/client is adequately nourished
Tissue hypoxia
The majority of chronic, non-healing wounds
are hypoxic wounds. The major conditions that
predispose to this are diabetes, venous stasis, vascular
insufficiency, cardiopulmonary disease, irradiation,
edema, hypovolemia and tobacco smoking. The use
of measures to prevent tissue hypoxia due to pressure
distortion and shearing force (for example using
specialist mattresses) may be important in both
preventing wounding and promoting healing
Associated pharmacology
Drugs that may delay wound healing should be reduced
or withdrawn where therapeutically possible
Fluid management
Adequate fluid replacement post-operatively or after
trauma is important in minimizing hypovolaemia
and tissue death and in promoting wound healing
Infection
Preventing, containing and removing infection (both
local and systemic) is important in reducing tissue
damage and promoting healing
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