CHAPTER V CONCLUSION AND RECOMMENDATIONS. findings are presented, implications for nursing practice and education are discussed,

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1 CHAPTER V CONCLUSION AND RECOMMENDATIONS In this chapter, a summary of the findings and conclusion drawn from the findings are presented, implications for nursing practice and education are discussed, and limitations and recommendations for future research are addressed. Findings and Conclusion This study is a one group, single center pre-post test design aimed to evaluate the feasibility and acceptability of a wound care program for open wound healing for Thai patients by using a portable vacuum bottle dressing combined with patient education on avoidance of wound trauma and nutrition. The study was conducted over an eight-month period from March to October 2004 at Ramathibodi Hospital, Bangkok. A purposive sampling was used to recruit 30 patients with 34 wounds; three patients had more than one wound; two had two wounds that joined the program at different times and one had three wounds. The wounds were from various etiologies, sizes, and locations including wounds with infection and without infection. All 30 patients with 34 open wounds received topical wound care of a All portable vacuum rights dressing solely by the researcher, reserved received education for self-care for keeping the dressing intact, avoiding wound trauma and consuming adequate dietary intake from the researcher. Feasibility of the program was evaluated based on ability to maintain a dressing vacuum for 2 days, retention of the study s subjects, and patients view on the dressing and the program. Acceptability of the program was

2 175 evaluated based on ability to optimize wound healing, complications (infection, pain, and discomfort), and cost-effectiveness. Data regarding ability to maintain dressing vacuum, retention of the study s subject, serum albumin levels, infection rate, and cost of dressing were gathered by the researcher. Others were obtained by two research assistants. One asked patients perception of pain after each dressing and measured wound area as well as assessed wound status at the beginning, every week, and at the ending of the study. Another one interviewed the patients views of the wound care program and the dressing and asked the patients perception of discomfort caused by the dressing at the ending of the study. The results of the study revealed that the wound care program using a portable vacuum bottle dressing along with education on maintaining dressing vacuum, avoiding wound trauma and nutrition was feasible and acceptable. The evidence included: 1. Of all the enrolled 34 wounds, 28 wounds (82.4 %) could be vacuum sealed every dressing; 18 wounds (52.9%) and 10 wounds (29.4%) could maintain a vacuum and change the dressing every 2 days and every 3-4 days, respectively. Two wounds could not be sealed as airtight closure and four wounds could maintain vacuum less than 48 hours in the first several dressing changes. 2. The retention of study s subjects was 71.4 % (20 out of 28 subjects). The reasons for dropout were not due to subjects refusal but were because of uncontrollable conditions. 3. Patients had two major concerns regarding the use of a portable vacuum bottle dressing, namely pain and infection. Patients had high positive views on the wound care program and the dressing but low negative views on the dressing portion.

3 Among 30 wounds that could be applied with a portable vacuum bottle dressing, 24 of them (80%) could be cared for through the end of the study. Of these 24 wounds, 23 wounds (95.8%) could heal to the expected outcomes; 13 (54.1%) wounds were completely closed and 10 wounds (41.7%) were closed surgically. 5. The average times for cleansing phase and for healing to the expected outcomes was 9.5 days (SD = 7.0) and 17.7 days (SD = 10.1), respectively. The overall healing rate was 4.7 ± 3.2%/day. 6. Infection presented only on one wound. Short duration and low intensity pain with an average level of 20% was reported during the first several dressing changes by all 25 patients who had intact sensory perception. Only 10 patients (38.5%) reported discomfort. Most of whom had discomfort at low level of 20%. 7. The average cost to heal one wound to the expected outcomes was low as 1, baht. Wounds located on abdominal area had the best response, yielding 90% healing to the expected outcomes with shorter time to heal and less cost, whereas the two with least response and highest cost were wounds located on trochanter and on the foot. Implications of the Findings This study has contributed to the growing body of nursing knowledge by examining the proposed wound care program utilizing Orem s theory of nursing system (Orem, 2001) and physical mechanics. The results suggested that Orem s selfcare concept and theory of nursing system as well as a portable vacuum bottle dressing could be used in caring for patients with open wounds. The knowledge

4 177 generated from this study empirically supported the potential of patients self-care ability and nursing agency related to wound management. The findings add up and strengthen nursing practice regarding wound care for both hospitalized and ambulatory patients with open wounds. It could support hospital administration in designing and organizing hospital services that can reduce the problem of hospital bed shortage due to an ability to provide service as ambulatory care for wounded patients. 1. Implications for nursing practice The values of the wound care program using a portable vacuum bottle dressing combined with patient education on avoidance of wound trauma and nutrition is not questionable because the evidence from the current study has shown its effectiveness in optimizing the healing of open wounds. Besides reducing the frequency of dressing changes from usual practice from two or three times a day to every two days or twice a week, more patient s quality of life seem to be much improved and precious time for the nursing staff may be saved. Thus, nurses can use a wound care program that combines a portable vacuum bottle dressing and patient education on avoidance of wound trauma and nutrition for patients with open wounds. In doing so, nurses should work with patients towards the shared goal of a healed wound since wound healing using a portable vacuum bottle dressing is more likely to success when the patients adopt an active role. Notwithstanding the guidelines for the application a vacuum dressing that have been reported elsewhere, the findings from this study suggest the following additional practical and procedural guidelines to implement a portable vacuum dressing for patients with open wounds.

5 178 Firstly, as the application of the dressing requires patients cooperation for the dressing to be intact, thus, selected patients with open wounds should be in good consciousness in order to not destroy the dressing by themselves, and should not have limited bodily position to avoid direct compressing the dressing. Moreover, the wounds should be located on dry and smooth surfaces. Thus, control of fecal and urinary discharge should be in critical consideration. Additionally, the selected wound should have smooth and dry surrounding skin extend to at least one inch from the wound edge for the adhesive film to adhere to. Secondary, as sealing the wound as an airtight closure is more crucial over other types of vacuum dressing, either a commercial or a wall suction, special techniques should be added. For wounds that are located on high movement areas such as foot and lower abdomen, after sealing the wound and foam dressing with transparent film as usual, another piece of transparent film with larger size should be used to cover the entire dressing and extend to skin surrounding the wound edge about 1-2 inches. In cases where the patient has high perspiration, a skin barrier wafer should be used to frame the wound edge with the transparent film cover on it and subsequently seal the outer part with adhesive tape. Thirdly, to promote patient self-care or dependent care s abilities to help optimize open wound healing, it is imperative to teach the patient or family about the reasons and ways to maintain the vacuum property for the dressing to be intact until the next dressing schedule, to select and consume adequate dietary intake, and to avoid wound trauma. Teaching information to maintain vacuum property should include protecting the tube of the dressing from disruption, disconnection, and kinking. Informing ways to prevent adhesive peeling and teaching ways to evacuate

6 179 air out of the bottle are necessary as well. Evacuating air out of the bottle should be performed periodically only when the dressing losses its vacuum property in order to prevent over-forces of negative pressure on the wound bed. In addition, the amount of evacuated fluid should be used to encourage the patient to take more protein diet and fluids to supplement the loss. Lastly, procedural pain resulting from either application or removal was observed in the current study. There are some effective strategies to manage pain. Initially, pain assessment should be performed regularly. Patients who already have severe pain which may or may not be associated to the wound should be given pain medication following the World Health Organization (WHO, 1996) analgesic ladder 30 to 60 minutes before dressing to achieve an adequate and acceptable levels of pain relief to the patient. A peak immediate pain caused by the initial vacuum pressure applying on the wound can be reduced by, instead of directly connecting the suction tube within the dressing to the tube apparatus of the vacuum bottle, using a 50-ml disposable syringe to gradually evacuate air out of the sponge within dressing until the sponge is collapsed then directly connect it with the tube apparatus of the vacuum bottle. A cyclic acute pain secondary to the disruption of granulation tissue from sponge removal in case of granulation tissue growing into the sponge must be reduced by disconnecting the suction tube from the vacuum bottle to let the sponge expand, then instilling normal saline solution into the sponge to soak underneath the sponge and let it sit for 15 minutes or longer before gently removing the dressing. This technique is essential in acute wounds and patients with low pain threshold.

7 180 Furthermore, in wounds that granulation tissue is growing into the sponge, the dressing should be changed more frequently, around every two days. Additionally, in case that patient has pain caused by denuded wound margin, a hydrocolloid wafer should be used to cover the area in order to heal such area and protect further destruction. Moreover, sponge should not be applied over the intact wound skin margin but should be cut to fit exactly the wound size. In addition, it is beneficial to disseminate the knowledge of negative pressure dressings and the outcomes of the current study, especially outcomes of the wounds on abdomen which had higest positive response, to all health care providers including medical staff in order to gain more cooperation since all involved parties in caring for patients with open wounds, including medical staff, can reduce their workload when the wounds heal quicker. 2. Implications for nursing education. As nurses who deal with complicated wounds should be leaders and be able to contact other health care professions to implement new and effective modalities to care for patients with open wounds, therefore, aside from practical and procedural guidelines for use in nursing practice, it is imperative to have high competency nurses in wound care so that difficulty implementing the dressing in clinical practice could be eliminated. Such nurses should be well prepared as nurse specialists and they should have both theoretical and practical knowledge regarding negative pressure dressing. Thus, nursing curriculums for subspecialty courses of wound care nursing and master courses should incorporate such knowledge into their curriculum. In addition, the knowledge of negative pressure dressing, patient education on nutrition and avoidance of wound trauma, and the knowledge from the

8 181 current findings should be also incorporated into each level of nursing curriculums to enabling nurses at all level know about the new topical wound dressing method. Limitation of This Study The results of the current study should be interpreted with caution due to the lack of control group that makes the effects of the program on wound healing and cost-effectiveness speculative. Recommendations for Further Study 1. The study should be extended by testing in a large scale population and should include control groups in the study design. 2. Since there are few patients with wounds on some areas including sternum, axillar, and trochanter; studies that recruit more patients with wounds on such areas are recommended. 3. Because wounds on abdomen showed having the highest positive response, a randomized control study on patients with abdominal wounds is recommended to confirm the study result. 4. Study that involves nutrition care in patients with open wounds whose wounds are applied with negative pressure dressing should use evacuated fluid containing in a portable vacuum bottle as means to encourage the patients to consume adequate dietary intake. 5. Evaluation of nutritional status in short period should use more sensitive measures such as transferin or pre-ablbumin instead of serum albumin levels.

9 The finding from the study revealed two major concerns that may result in stress and anxiety; future study should assess the magnitude of stress and anxiety by using quantitative measures such as rating scale or anxiety scale and should be assessed before and after enrollment to determine the intervention effects. 7. As a surgical portable vacuum bottle obtains high levels of negative pressure over those of a commercial pump or wall suction apparatus and requires longer times to heal the wounds that are close to bony areas was observed in the current study, a study to examine the effects of the negative pressure within the portable vacuum bottle on microvascular blood flow close to bony area is recommended. 8. Since cost of nursing for other activities within the wound care program such as teaching, informing, and guiding were not included in the current study, additional studies should examine time spent for all activities in the wound care program in order to reflect the whole nursing cost. 9. The findings from the current study suggested that intervention based on self-care ideology is powerful; the recommendation is to conduct more studies that incorporate self-care ideology into nursing intervention programs.