The management of wound dressings whilst on placement

This reflective piece will look at the management of wound dressings whilst on placement in the community. I will use the Gibbs model of reflection this will allow me to describe the event, explore my thoughts and feelings, make an evaluation on the event and then analysis different components which can be explored separately including different dressings and why they are used, finally I will conclude and action plan looking at if this happened again what I would do differently.

Whilst on placement in the community I visited a lady who had chronic leg ulcers on both legs and the district nursing team had been visiting this lady for a number of years. The lady had oedematous legs and poor mobility and sat in a recliner chair although the chair was never reclined. I had visited the lady previously on a number of occasions and had applied her dressings and documented what I had done and the dressings used in her district nursing records. On this occasion the lady requested that I didn’t put the K-lite dressing on and allows the other nurse do this, as previously when I had dressed her legs she stated the dressing had become loose.

I mapped the dressing so that the notes had an up to date record of the size of the wounds and washed and redressed the legs as per the plan of care. The plan of care stated to wash the legs apply aqualcel ag silver this is used for wounds that have a high level of exudates, then atruman was applied covered by mesorb, comfifast yellow then K-soft and then I passed over to the Registered Nurse (RN) to apply the final layer, whilst she applied the final layer I documented the notes that the leg had been mapped, washed and redressed as per the plan and noted that strikethrough was on the dressing prior to removal I also noted the patients level of pain at the time of the cleaning and mapping of the wounds and also after the legs had been redressed. I documented the patient’s records that the patient had been advised to elevate the legs when resting to aid healing.

When the patient advised me that she would prefer the RN to do the top layer I felt like my confidence had been knocked. The patient had never said this before and always stated not to wrap the dressings too tight as she found it very uncomfortable. I told her that I didn’t do them too tight as she always stated not to do so and apologised to her that they had fell down and in future would ensure that they weren’t too tight but would not fall down either. When I left the patients house with the RN she told me that this lady does this to all the new nurses that visit her and not to worry about it.

Pressure sores and leg ulcers are classed as chronic wounds and are defined as slow healing wounds with the likely hood of reoccurrence and the pain that a patient feels may be severe and ongoing (Dealey 1999). The dressing plays a major part in the reduction of pain and by choosing the wrong dressing this can cause discomfort when removing the dressing and the nurse needs to avoid this by using careful assessment prior to administering the dressing (Dealey 1999).

For a wound to heal the key is to have successful wound management, the nurse should use a wound assessment tool this will ensure that there is valid reliable and also consistent information documented. Wounds need to be regularly reassessed to ensure that evaluation is given on the treatment that the patient has received. When making a wound assessment this should include the location of the wound, the cause, etiology, tissue type the size and the exudates and finally the level of pain the patient is experiencing (Prescribing Nurse Bulletin). To achieve optimum healing the role of the nurse is to be able to select the most appropriate dressing for the wound, this is to be based on the most up to date evidence, and recent development of new dressings makes this a challenge for the nurse (Lansdown 2004).

The wound should be assessed for slough and necrosis, signs and symptoms of infection and wound malodour. The patients records need to be documented to state if the wound is healing, e.g. granulisation and epithelisation (White 2005).

The ideal wound dressing that will meet the treatment objective and promote the wound from further injury would be a moist wound healing dressing, that manages excess exudates and prevents the wound from maceration and further wound breakdown, ensure that it prevents the exit and entry of organisms, it will cause minimal trauma at the time of removal and is cost effective (Northern Health and Social Services Board NHSSB 2005). One important factor in wound dressings is to ensure that dressings get the maximum exposure to the wound bed. This can be achieved by a dressing that decreases the voids and spaces where bacteria can thrive (Jones etal 2005).

Aquacel Ag dressings contain Hydro fibre Technology and it gels on contact with the exudates and micro-contours to the wound bed this helps to eliminate voids or spaces where bacteria and fluid can collect it maximising exposure of the wound to antimicrobials. It is presented as a soft sterile, non-woven pad and is impregnated with ionic silver (Aquacel Ag 2006). This dressing can absorb a large amount of fluid and helps to prevent exudates leakage onto the periwound skin. The dressing can be left in place for up to 7 days however should strikethrough be evident on the dressing then the dressing needs to be changed (NHSSB 2005).

It has been recognised that silver is an effective antimicrobial agent (Thomas and McCubbin 2003). It has proved that it is effective against methicillin and vancomysin-resistant strains of bacteria (Lansdown 2002)

Atrauman dressings are made of a fine mesh of hydrophobic, polyester fibres and have mesh pores with a smooth surface this effectively counteracts adhesion to the wound by preventing new tissue from penetrating the dressing and allowing the exudates to pass through, this means that the dressing is easy to remove and causes minimum discomfort to the patient and also to the wound. The dressing is highly permeable to air and water vapour and has been found to be very well suited to the management of infected wounds (Hartmann 2010).

In recent years Honey has been found to benefit wound healing, clinically topical honey treatment has been found to possess antimicrobial properties, promote autolytic debridement, deodorise wounds and stimulate the growth of wound tissues to quicken healing, it also stimulates anti-inflammatory activity helping to reduce pain, oedema and exudates (White 2005). A fast rate of healing has been reported in wounds treated with honey (Ahmed 2003) it helps the developing of a clean granulating wound bed (Stephen-Hayes 2004)

It is clear that wound management is a complex area and the it is the nurses responsibility to ensure that they give the correct care to the patient and they use the dressings that are selected on their knowledge and understanding of what the dressing will achieve they need to be constantly aware of new products available to treat the wounds. By regular assessment of the wound they will be able to see if the dressing selected is helping to promote wound healing.

I am aware that if I wish to work in the community I would need a good knowledge of dressing that is used in wound management. I know that I am likely to meet patients who try to make me doubt my ability however this is something that I know I will over come as my confidence builds and I become more used to working in the community.