Nursing Case Studies

ASSESSMENT TASK 1 – Case Study Scenario

You are a nurse working in a surgical ward and are assigned to the care of Mrs. Smith, a 79-year-old female who has recently undergone surgery. Mrs. Smith has been on strict bed rest for five days, and on the assessment, you notice a grade one pressure injury on her right heel. As Mrs. Smith will be confined to her bed for at least another week, you want to take precautions to make sure the pressure injury does not progress further. You are aware that a specific type of mattress is best for preventing pressure injuries but can’t remember which. You do some research to determine which bed you should prepare for Mrs. Smith – a standard mattress, an air mattress, or a foam mattress?

Pressure injury results from a breach of the integrity of the skin due to unrelieved pressure from soft tissues compressed between an external surface and the skeletal framework for an extended period. Besides poor blood circulation, friction, and ischemia of the muscles may also contribute to pressure injury. When it is allowed to remain in force for relatively more extended periods, then PI can damage the subcutaneous fat, bone, muscle, and skin. In the case of Mrs. Smith, too much rest may make the tissues to develop pressure. Again, given her age, complications may also emanate from the reduced flow of blood. In such circumstances, there is a need to put in place proper pressure injury management strategies. Given that Mrs. Smith is a patient who has been recommended for total bed rest, the PIM must factor in the type of mattress that she is going to use.

In the hospital setup, the clinical guidelines outline that to deal with PIs; the care providers need to deal with extrinsic factors responsible for pressure in patients and individuals. One of the most common strategies in managing pressure injuries in hospitals is through the provision of the right support surfaces, for example, pressure mattresses, pressure cushions, standard mattresses or foam mattresses (NPUAP, EPUAP, & PPPIA, 2014). It is imperative to underscore that there are several types of support surfaces available to aid in the management of pressure injuries in patients. Therefore, while prescribing the most appropriate mattress, clinicians have to factor in several factors like the risk level of the individual patient to be treated, the ability of the patient to move and reposition of the area that is affected adversely, the common risk factors and the environment under which the selected support surface will work (NPUAP, EPUAP, & PPPIA, 2014).

In most cases, clinicians depend on the prescriptions of the suppliers when it comes to mattress choice for use in PIM. However, development in technology has made it clear that reactive mattresses are more effective in managing pressure as compared to other forms of beds. Additionally, the responsive mattresses have added advantage in that they are easily adjustable, thereby making it easier to reposition the patient from time to time.

There is no clear cut distinction on the level of effectiveness of the different types of mattresses as far as the management of pressure injuries is concerned since the focus of most of the researches that have been conducted on this field have relied heavily on mattress brands instead of type and quality (Department of Health and Ageing 2013).

Though both standard and pressure mattresses can help in the redistribution of pressure, pressure mattresses have been qualified to be more productive and highly reliable as compared to standard mattresses. The findings from randomized controlled trials are indicative that pressure mattresses are more effective in managing pressure injuries. They are better than the conventional beds. Therefore, in the case of Mrs. Smith, given her pressure injury is still in grade one, changing her mattress type to pressure mattress would help in healing her conditions much better.

Issues to Address

Previous literature reviews indicate that most of the RTCs conducted to involve the use of mattresses and cushions that have been discontinued thereby making the findings from such studies inappropriate for use to make a logical conclusion regarding the level of effectiveness of the various types of support surfaces that can be used in managing pressure. Again most of the previous studies have concentrated on brands of mattresses as opposed to looking into the mattress types. Therefore, relying on one brand of mattress may provide misleading information that may lack clinical applicability. In this regard, it is recommended that subsequent researches in this area should lay emphasis on the components of the mattress as well as mattress type as opposed to brands of the bedding. Additionally, for better results on this field, the focus should also be made on the manner in which the chosen mattress type provides relief to the PI to enhance their applicability in clinical decision making Van et al. 2013).

Significance of this Research

Asses a trained nurse, the insights from this case study, have supported my work practice in several ways. First, through this research, I have gained insight into the various types of mattresses recommended for managing pressure injuries among patients suffering from the same. Additionally, I have also refreshed my knowledge and understanding of the different grades of pressure injuries in patients and the appropriate methods of managing them. Besides, working with Mrs. Smith as a surgeon, I have also improved my clinical competences on matters relating to the effective clinical management of patients. Generally, the experience has been a fulfilling one by presenting new challenges and invoking my memory into reasoning (Palese et al. 2015).

It is imperative to note that when recommending a method of managing pressure, the clinician must take into consideration the personal condition of the patient, the cost of the equipment: especially in circumstances where the value is likely to be passed on to the patient. Moreover, the research must be done with due respect to morality and ethics. For instance, when dealing with an elderly client like in the present case, the support surfaces used should be those that are accommodative of her condition to avoid subsequent injuries.

Assessment Task 2: Hand Washing Exercise

Case

The family of a patient has expressed concern that they might pass on the infection to their relatives and are thus conscientious about washing their hands before entering the patient’s room. They have relied on using hand soap while washing their hands, but they are also aware of alcohol and sanitizer. They seek to know which would be better to use.

Hand washing is recommended for controlling the spread of diseases. This is because the hands washing soap, alcohol, or sanitizer all has detergents that sterilize the hands thereby killing the germs and can consequently check the spread of diseases from their patient to the neighborhood and relatives. In terms of improvement in work ethics and practice, the research is very insightful to me in a number of ways. First, it would enable me to learn about evidence-informed decision making on how health hygiene can help in controlling the spread of diseases.  Again, the research has widened my insight regarding the different alternatives that could be used in hand washing exercise. Research evidence has indicated that through engaging in handwashing and hygiene practices, the nurse gets to increase their levels of knowledge, build on their attitudes and improve their behaviors, thereby enhancing compliance with healthcare nursing codes of conduct.

The findings from this assessment indicated that effective handwashing practices (had hygiene) are critical in maintaining healthy households (Margaret, &  Hans 2017). Furthermore, the results showed that improvement in hand hygiene should focus more on the utilization of disinfectants to make them useful in killing the germs and consequently controlling the spread of diseases. Additionally, it was also established that handwashing could effectively prevent the spread of diseases when it is done when entering the room and leaving as well. Further, nurse managers should be at the core of the whole exercise and lead by example to enhance the implementation process of the training.

Hand hygiene is one of the most effective ways of controlling nosocomial infections. There are three different approaches to hand washing hygiene, namely: human hand washing that focuses on cleaning of the hands with a plain non-medicated bar or liquid soap and water. It majorly aims at removing dirt, soil, and other organic substances. Besides, there is also antiseptic handwashing that involves the use of antimicrobial soaps that majorly contain single active agents. Such solvents can help in eliminating some types of germs. Lastly, there is the hygienic hand washing that involves using alcohol-base that is rubbed on dry hands without using water. All three approaches to hand hygiene help in reducing the spread of infection from patients to other people by keeping hygiene (UNICEF, GIZ 2016). Besides, they both involve the use of disinfection to control the spread of infections. However, whereas handwashing using soap uses water for cleaning the hands, the use of an alcohol base does not involve the use of water for cleaning. Again research findings indicate that the use of alcohol-based hand rubs has proved to be very effective in controlling the spread of nosocomial infection rates. It is relatively stronger to the use of soaps and also lasts for long. Additionally, the handwashing with dry hand cleaning is more relevant since it is the latest technique involved in hand cleaning.  Based on the findings from the study, the use of alcohol-based rub and sanitizer has been found to perform much better than handwashing with soap. It is clear that sanitization and alcohol rub is very effective in treating “Escherichia coli” and fecal streptococci on. Hand washing using soap is less effective in reducing infection. Thus the family should switch from using the traditional hand washing using the handwashing soap to either sanitization or alcohol rub (UNICEF, GIZ 2016). Through this switch, the family will be able to effectively reduce and check the spread of the disease to the relatives and friends. Furthermore, this finding also suggests that more research work should be conducted on handwashing to assess the limits within which it can operate and ways through which it can be improved to be more effective in controlling the spread of diseases. It is imperative to underscore that the lower efficacy in this study the actual scenario under which the evaluation was done.

It is important to note that for hand hygiene to be effective, and then it should be performed at the appropriate time using the most appropriate technique.  In light of the approach that is currently used by the family on handwashing, there are several changes that are supposed to be incorporated to enhance effectiveness (Margaret & Hans 2017). First of all, the family should envisage washing their hands before touching the patient as they have been doing to ensure that their hands are sterilized. Besides, they should also visualize washing their hands immediately after touching the patients to ensure that any pathogens that would survive in their hands are cleaned. Moreover, the family should envisage washing their hands every time they reach the surroundings of their patients to ensure that they keep their hands safer all the time.

When implementing handwashing hygiene for preventing the spread of diseases, one critical issue that should be looked into is a defense against skin infection mechanism. There should be an emphasis on ensuring that the skin is not damaged at all during the hand washing process. Therefore, research should be conducted to establish whether the sanitizers and other detergents that are used for hand washing may have adverse effects on the skin of the individuals using them.  Moreover, another critical issue that should be evaluated for future development is the level of effectiveness of handwashing using water and ordinary soap. In the present research, traditional hand washing has been considered to have a low level of efficacy since its effectiveness in killing the disease-causing pathogens is very low (Margaret &  Hans 2017).

For hand washing exercises to be practical, the approach should be made to be cost-effective to accommodate everyone in the society. Additionally, the exercise should be incorporated into the socio-cultural practices such as the rituals of cleansing so that those who have indulged in an activity that is perceived to be unclean are encouraged to wash their hands.  As witnessed in most religions encourage symbolic washing, and the department of health should work hand in hand with such institutions to promote the act of cleaning.

References

Department of Health and Ageing. (2013). National primary health care strategic framework. Canberra, Australia: Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/6084A04118674329CA257BF0001 A349E/$File/NPHCframe.pdf

Margaret, M. &  Hans, J (19 May 2017). “Approaches to promote handwashing and sanitation behavior change in low‐ and middle‐income countries: a mixed-method systematic review.” Campbell Systematic Reviews. 13 (1): 1–447.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (2 ed.). Osborne Park, Australia: Cambridge Media.

Palese, A., Saiani, L., Pota, I., Laquintana, D., Stinco, G., Di Giulio, P., & and on behalf of the PARI-ETLD Group. (2015). What is the healing time of stage II pressure ulcers? Findings from a secondary analysis. Advances in Skin & Wound Care, 28(2), 69-75. doi: 10.1097/01.ASW.0000459964.49436.ce

UNICEF, GIZ (2016). Scaling up group handwashing in schools – Compendium of group washing facilities across the globe. New York, USA; Eschborn, Germany

Van Leen, M., Hovius, S., Halfens, R., Neyens, J., & Schols, J. (2013). Pressure relief with visco-elastic foam or with combined static air overlay? A prospective, crossover, randomized clinical trial in a Dutch nursing home. Wounds: A Compendium of Clinical Research & Practice, 25(10), 287-292.