This essay will discuss a clinical skill in which I have become competent in practising, as ‘developing the ability to perform practical skills safely is necessary for all nursing students’ (NMC, 2002). I will reflect on this skill and discuss how I achieved this level of competence and how it influenced the individualised care the patient was given. The clinical skill I have chosen to focus on is the dressing as part of treatment for healing of pressure ulcers. I have chosen to do this, as in my first clinical placement this was a skill I found interesting and I was involved in.
I therefore researched the topic of pressure ulcer management and treatment. A pressure ulcer is defined by the European Pressure Ulcer Advisory Panel (EPUAP) as ‘an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or combination of these’ (EPUAP,2003). The patient was an elderly woman who had been on the ward for a few weeks. Over this period of time she had developed a pressure ulcer on her left heal, approximately 2cm round. I was asked to assess the patient’s pressure ulcer and determine which stage it was in.
I found that deciding this was difficult as I had limited knowledge of pressure ulcers and the information surrounding the treatments involved. However, my mentor was very reassuring and referred me to a poster that showed the different stages of pressure ulcer development. The patient had partial thickness skin damage involving the epidermis and the dermis. This is classed as a stage two pressure ulcer, based on a grading system devised by Reid and Morison (1994), which was devised specifically for the use on pressure ulcers.
The pressure ulcer was inflamed at the edges and appeared to be red and slightly swollen. The surrounding tissue felt warm to touch and the patient mentioned that it was causing her discomfort from the pain. Dowsett (2002) suggests that these symptoms are generally associated with the blood vessels in the injured area becoming more permeable and vasodialting. The ulcer also had a slight exudate coming from it which may have been due to slight infection. The cause of the pressure ulcer may have been due to her reduced mobility, having had rheumatoid arthritis for many years.
It is suggested by Fletcher (1996) that reduced mobility is considered to be the most important factor in the development of pressure ulcers as they occur due to prolonged pressure on the skin. So for example, patients who have reduced mobility due to a previous operation are at risk for developing these pressure ulcers. Throughout the procedure I was observed by a qualified nurse, who was my mentor. In preparation for this task, I explained to the patient the procedure and my mentor asked the patient for consent and co-operation to have a student perform it, the patient agreed.
I went and prepared myself for the procedure, I placed on an apron and I washed my hands. I understood that the trolley used must be cleaned thoroughly before use and that local policies may vary, but hot soapy water is usually sufficient. (Nicol, M et al, 2004). It must then be dried thoroughly to discourage the growth of micro-organisms. The policy in my establishment suggested I cleaned the trolley thoroughly with an alcohol wipe ensuring not to touch the areas which I had previously cleaned.
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.