Improving Wound Care in a Pediatric Surgical Ward

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Wound care management is becoming more complex for nurses due to new insights into wound healing (Hayward & Morrison, 1996, p.11) and because of the wide variety of wound dressings that are available (Wikblad & Anderson, 1995, p.312 and Miller, 1994, p.62). Erwin-Toth and Hocevar (1995, p.46) stated that there were approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favorability and cost (Findlay, 1994, p.836). Because of these many different wound care techniques and dressings, nurses are becoming confused and nonplussed regarding wound care practice. Unfortunately, Millers (1994, p.62) research showed that in 85% of cases nurses were using inappropriate dressings, and O’Connor (1993, p.64) found in her study on wound care that nurses were having difficulty in applying their theory and knowledge to their practice.

Action Research was the strategy used for this study because it is very appropriate for nursing research. Traditional nursing research is failing nurses because so often they do not see its relevance to their practice (Greenwood, 1984, cited in Hart, 1995, p.9). Action Research is more suited to nursing, not only because of its problem solving and evaluating features, but also for its similarity to the stages of the nursing process of planning, acting, observing, reflecting and often replanting (Bellman 1996, p.130) . Action Research is also appropriate for nurses because, it does not require expert researchers; the participants define the problem themselves; both researchers and practitioners participate together in the process (Kemmis & McTaggart, 1988, pp.22-23, Hart & Bond, 1995, p.55 and Birkett, 1995, p.191); it is less structured and leaves room for possible changes; it is empowering for the participants; and reflective of their practice (Kemmis & McTaffart, pp.11-12, 50 and Titchen & Binnie, 1993, cited in Hart, 1995, p.8). Titchen and Binnie (1993, cited in Hart, 1995, p.8) also highlighted the empowering effect, and reflective practice, action research gave nurses so that they can hopefully free themselves from the medical hierarchy

The Setting and Problem

The setting of this project was a 16 bed surgical ward of a major pediatric teaching hospital. It was classified as a clean surgical ward and the case mix of patients were cardiac, ear, nose and throat (ENT), ophthalmic and the occasional others. Most of these patients were under the age of five years which made their participation in the project impossible. Because of the range of surgery performed there were many different wounds and many surgeons using different techniques in wound management even for the same procedure. This was confusing to the nursing staff and created an attitude that they did not have any say in their patients wound care.

Two issues of concern were raised by different members of the nursing staff. Firstly, the Unit Manager and Clinical Educator were concerned about the nursing staffs lack of observation and reflection on their patients wound care and the second was from the nurses regarding the many types of dressings and treatment used by different surgeons for as many different wounds--was one better than the others and for what wound? This was exacerbated even more by the introduction of yet another new dressing by one of the surgeons. From discussion on these two concerns it was decided to perform a ward audit using action research on how the nurses could improve their wound care practices and devise it so that quantitative outcomes could be compiled in the long term regarding the many types of wound management and dressings that were being used. The long term project would also be used to monitor infection rate which is required by the Health Department.

As the project was implemented as a ward audit, which did not involve patients or parents, neither financial assistance nor approval from the Hospital Ethics Committee was required.

The Planning

During the planning stage when discussions were held with senior nursing staff, the following strategies were proposed and developed:

1. A wound survey chart (See Appendix A) was devised that documented the process of observations to assess the effectiveness of wound care procedures and dressings for all the different wounds. This was formulated by two members of staff and shown to other staff for comments and suggestions for changes. For a long term project this survey chart was also shown to a member of the Hospital Research Department who made suggestions on how to improve it so data could be processed for quantitative research outcomes.
2. A research proposal was written in order to be able to inform, not only the nurses, but also the other disciplines that will be involved in the goals and objectives of the project.
3. The Head of the Surgical Department was also informed of the project and on his own reflection decided to collect data and take photos himself in his office when he saw the patients post-operatively. This information would also be made available for our project. The new dressing he was using, which he felt would promote better scarring outcomes in the future, was not removed until two weeks post-operatively so we needed his cooperation in obtaining the final outcome of the wound healing. The other surgeons and community liaison nurse were informed of the project by letter and discussion at a senior staff meeting. Out of the discussion at this meeting it was suggested that the data collected should be processed with the data they already had on the patients in their department. The same problem was raised when the Infection Control Department was informed of the project. This was our first major problem but was only relevant to the larger project in collecting data for quantitative outcomes. The facilitator would meet again with these departments to resolve this issue.
4. To provide us with a knowledge base for our decision making it was decided that the members of staff who were on relevant hospital committees, such as, infection control, product review, wound care, quality assurance, research and professional practice, would carry out literature reviews pertaining to their specific committee subject and our research project. This information they would present to the rest of the staff at following meetings or in-services. This would equip the nurses with evidence-based knowledge to obtain consensual agreement on decisions made for better practice strategies.
5. The Nurse Educator, who was reasonably familiar with the process of action research, became the facilitator and in this capacity held in-services to educate all the nurses regarding action research. This also helped to solicit more participation and inform the nurses of their role in the process.

Implementation

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Irritable Bowel Syndrome

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Irritable bowel syndrome (IBS) is a very common gastrointestinal condition that is diagnosed when a person has any of a variety of abdominal symptoms and/or a change in bowel habits in the absence of detectable organic pathology. It has been called a number of different names including “Spastic Colon.” Some individuals with IBS have abnormal sensations in their abdominal organs. It usually occurs in people who are between the ages of 20 and 50. It is seen in both sexes but is more common in women. It can be a chronic condition which tends to come and go over one's lifetime. Although it causes varying degrees of discomfort and inconvenient symptoms, it does not progress to any other diseases or cancer.

What Causes IBS?

IBS may be due to a variety of factors such as stress, diet, or hormones. Studies have shown that people with IBS may have changes in the way their intestinal muscles move food and liquid through the digestive tract.

What are Symptoms?

Individuals with IBS may have some of the following symptoms:

1. Change in the frequency of bowel movements from what is normal for the person ("normal" bowel movements are highly individual and range from 3 times a day to 3 times a week.)
2. Diarrhea, constipation, or alternating diarrhea and constipation.
3. Abdominal pain or discomfort which is often relieved by having a bowel movement.
4. Rectal pain or sensation of incomplete evacuation after having a bowel movement.
5. Increased abdominal bloating and/or gas.
6. Occasionally, painless diarrhea.

These symptoms may be associated with nausea, heartburn, headache, fatigue, anxiety, or depression. Factors such as stress may play an important role; some people can learn to recognize when their IBS is likely to "act up."

The following are not symptoms of IBS and should be reported immediately to your health care practitioner:

• Being awakened from your sleep by abdominal pain or diarrhea
• Fever, chills
• Blood in stool

How do I get tested for IBS?

The diagnosis of IBS is made after your health care practitioner reviews your medical history and does a physical examination. As indicated, additional blood and/or stool tests may be done.

Your medical history and description of symptoms is the most important part of the evaluation of IBS, since the physical exam and laboratory tests are usually entirely normal.

Your diet, especially regarding fiber, fat, lactose, gas-forming foods, caffeine, and alcohol intake, is important to consider. Also, drug use--including prescription and over-the-counter medications as well as recreational drugs--must be considered.

Symptoms similar to irritable bowel syndrome may be caused by lactose intolerance. This is the body's inability to digest lactose, a disaccharide found in milk products, which is frequently acquired as people get older. To test for this, you may be advised to eliminate milk products from your diet for 2 weeks to determine if your symptoms improve without lactose.

What is the Treatment for IBS?

Treatment may include counseling, dietary changes, and medications. There is no cure for IBS, but many things can be suggested to lessen the severity and frequency of symptoms.

Stress reduction

• Stress reduction techniques are often very useful for those individuals who note an association between their irritable bowel symptoms and stress.
• Exercise may reduce symptoms of IBS.

Diet

• Increase fiber content in your diet.
• Decrease fat intake.
• Avoid caffeine, alcohol, and sorbitol (a sweetener found in chewing gum).
• Avoiding gas-forming foods from the cruciferous vegetable family (cabbage, broccoli, brussel sprouts, cauliflower, radishes, turnips), beans, and legumes may help.
• Avoid large meals - smaller, more frequent meals may reduce symptoms.

Medications

• If diarrhea is a prominent symptoms of IBS, an antidiarrheal medication may be recommended by your health care practitioner.
• If pain, gas, or bloating are prominent symptoms, an antispasmodic medication may be prescribed.
• Antidepressants are sometimes used for chronic pain problems.

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Cerebral Palsy

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Cerebral palsy, a disorder that affects motor skills, muscle tone, and muscle movement, is a disorder which is most commonly due to damage during prenatal, perinatal, and postnatal periods during the pregnancy process.

Classifications

• Spastic Cerebral Palsy, Cerebral Palsy includes four classifications. Spastic cerebral palsy, the first subcategory of cerebral palsy, affects about seventy to eighty percent of individuals with the disorder. Spastic cerebral palsy is the most common classification of this particular disorder. This condition involves the stiffness of muscles in the body. Spastic cerebral palsy includes differentiating factors which set apart the levels of severity. The differentiating factors include the number of body extensions affected. The scissors affect refers to both legs muscles becoming tight and hard to control. Scissoring refers to the legs turning in and crossing at the knees.
• Athetoid Cerebral Palsy, Athetoid cerebral palsy affects about ten percent of children. "Athetoid cerebral palsy is caused by damage to the cerebellum or basal ganglia. These areas of the brain are responsible for processing the signals that enable smooth, coordinated movements as well as maintaining body posture (About Cerebral Palsy)." Children with athetoid cerebral palsy also have a difficult time maintaining posture.
• Mixed Cerebral Palsy, Mixed cerebral palsy affects about ten percent of children. This classification of cerebral palsy combines the affects of spastic cerebral palsy and athetoid cerebral palsy. This condition is due to the injuries to both the pyramidal and extra pyramidal areas of the brain (About Cerebral Palsy)."
• Ataxic Cerebral Palsy, "Ataxic cerebral palsy is classified by low muscle tone and poor coordination of movements (About Cerebral Palsy)." Ataxic cerebral palsy is the rarest form of this disorder, affecting about five to ten percent of children with cerebral palsy. It alters the child’s depth perception and balance.

Etiology

In about forty percent of all cases, the cause for cerebral palsy is unknown. The most prevalent cause of cerebral palsy is prenatal factors. Included in this category are radiation exposure, fetal anoxia, and brain growth deficiency. Perinatal factor include birth complications, cerebral hemorrhage, and trauma to brain during birth. Postnatal factors include prematurity, asphyxia, and head trauma.

Symptoms

Individuals with cerebral palsy will have neuromotor symptoms, such as persistence of primitive reflexes in infancy. A symptom that is connected with each disorder is spasticity and rigidity of muscles. Ataxia, which affects balance and coordination, also affects many individuals with cerebral palsy.

Those with cerebral palsy also have problems with motor development. A delay in motor development is expected in most cases. Also, in severe cases, some may develop permanent deficiency in motor control.

Individuals with cerebral palsy may also develop poor perceptual and attention problems, emotional disturbances, educational problems, and communication and speech disorders. Those with cerebral palsy can expect to have normal mental development in about fifty percent of all cases.

Treatment

Therapy is considered crucial in order for those with cerebral palsy to receive a good prognosis for their future. A large part of treatment involves physical therapy, which usually begins a few weeks after birth. In physical therapy programs, two sets of exercises work towards specific goals for the cerebral palsy patients. The first goal prevents the weakening or deterioration of muscles. The second prevents muscles from becoming fixed in an uncomfortable position.

Drug therapy is also used to control spasticity. The drugs help the child’s muscles to become less tense and more easily controlled. "The three medications that are used most often are diazepam, which acts as a general relaxant of the brain and body; baclofen, which blocks signals sent from the spinal cord to contract the muscles; and dantrolene, which interferes with the process of muscle contraction (Treatment of Cerebral Palsy)."

Surgery is another option for those suffering from cerebral palsy. This option is recommended when the tensing of muscles is severe enough to cause problems with movement. The main reason for surgery is to elongate muscles. Even so, surgery is usually accompanied by a long period of rest and recovery, which usually lasts about six months.

Prognosis

The prognosis of cerebral palsy depends upon each individual with the disorder. Depending on the severity of each case, prognosis for higher levels of functioning with rehabilitation is considered good for most children.

Overcoming Cerebral Palsy

Many young individuals with cerebral palsy try to overcome their disability. One young boy who was diagnosed at birth with spastic cerebral palsy was limited in the amount he could do, but not in the amount he wanted to achieve. He is now in his twenties, but throughout his life he has been able to accomplish many of his goals. Aside from attending school until his graduation in 2000, he has been able to work a part-time job. He was also able to attend all of his high school dances. He has maintained a stand that he wants to be independent, and for most of his daily activities he is able to be. Like many with cerebral palsy, he has a normal functioning brain, but is handicapped by his limited motor ability.

The motivation of those with cerebral palsy is also shown by a young girl, who made a huge impact on my life. Although this child is young, she has made a huge impact on my life. She is one of the happiest kids I have had the chance to meet. She always manages to have a smile on her face. She, like the young man above, has spastic cerebral palsy, but to a more severe condition. She is wheelchair bound, but there is hope that her physical therapy will help her to overcome the use of the wheelchair. She also has very strong feelings about being independent. It would be very easy for her to let others do things for her, because many try to. This little girl will not let that happen. For example, she wants to crawl from room to room, without being carried, and she wants to feed herself, and take her drinks without the help of others.

Looking at these two amazing people, makes me realize how much drive they must have to want to be independent. They strive to do anything that can be done without the help of others by themselves. Children with cerebral palsy have a hard time doing things normal kids can , but the rewards to see them accomplish what may seem impossible is unlimited.

Mechanical aids are also very useful for individuals with cerebral palsy. These devices range from computers to walkers or wheelchairs. These devices help individuals with cerebral palsy overcome the limitations their disorder has given them.

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