This essay is written as a case study referring to a patient from my practice area. As I will be reflecting on my practice in relation to the case study, use will be made of first person writing where appropriate. Hamill (1999) supports the use of first person writing in academic essays such as case studies and suggests it develops self-awareness, reflection, analysis and critique.

As this essay is focused on a specific patient from my practice area it is important to consider issues of confidentiality. Therefore, throughout neither my practice area nor the patient name will be identified. However to be able to discuss key issues in relation to the patient I will refer to their age, gender and lifestyle, and use a false name to aid the flow of writing.

Introduction

Asthma affects 5.2 million people in the UK: 1.1 million children and 4.1 million adults according to Asthma UK in their 2004 report. However, depending which report one reads, this number can almost double to 10.1 million (Masoli et al 2003). This wide variation of prevalence maybe explained by the different studies and reports used to gather the data and differing inclusion criteria used. There is nevertheless agreement on the fact that the numbers of cases of asthma are increasing. Asthma UK (2004) reports a 400,000 increase in the number of adults with asthma in the UK between 2001 and 2004. The rising patterns of asthma prevalence however are not explained by current knowledge of causes of asthma, but are paralleled by increases in other allergic conditions such as eczema and rhinitis (Masoli et al 2003).

There is currently no agreed definition of the disease. Widely documented in the literature however, is the National Heart, Lung and Blood Institute (1992) definition who describe it as, ‘a chronic inflammatory disorder of the airways causing widespread but variable airflow obstruction…Obstruction is often reversible, either spontaneously or with treatment.’ The severity of the condition varies significantly (Rees and Kanabar 2000) from mild intermittent asthma, to a distressing disabling condition which results in time off work or school, disturbed sleep, restriction of social and leisure activities and anxiety (Hyland 1998). The main aim of asthma management is to control symptoms, minimise asthma exacerbations and optimise quality of life (Scullion 2005).

As a student of the Acute Care Pathway Degree, one of the specific learning outcomes for my pathway is to be able to manage programmes of care for patients with chronic diseases (St Martins College 2006). Hyland (1998) states that the Advanced Nurse Practitioner has become a major provider of asthma care in the UK. Watkins, Edwards and Gastrell (2003) agree, and suggest that currently the management of long-term conditions, including asthma, are a core component of a Advanced Nurse Practitioner’s work. Therefore it is crucial that I have an understanding of this condition and be able to review patients effectively (Wiggins 1999) using evidence based guidelines, and to have the confidence to provide advice on the management of their condition.

I aim to improve my understanding and asthma management skills through critically reviewing key issues of patient care as a case study. The key issues I intend to focus on relating to a specific patient are:

• Treatment of Asthma in the Emergency Department
• Patient education
• Patient concordance

Initially this essay will examine my current practice in relation to asthma management through reflecting on my present level of knowledge and understanding, discussing the level of care I can provide for patients with asthma at the moment. I then intend to give a brief outline of the patient chosen for this study, explaining the reasons for that choice and the rationale behind the key issues highlighted for discussion. A critical review of the key issues will follow using up to date evidence based literature and considering relevant policies. The conclusion will summarise the main points, reflect on what I have learned from this module and consider ongoing learning requirements in relation to asthma management.

Reflection on current practice

At the time of writing I have so far completed 16 hours in practise, Therefore my first few days in practice were spent adjusting to this new and very different area of nursing. Nevertheless I have had the opportunity to observe my mentor assessing patients with asthma and recently have become more involved in the review of these patients, with supervision.

Prior to starting the course I did feel I had some understanding of the disease process of asthma from working in the Emergency Department, albeit very fundamental, and some basic knowledge of the management. Some of this understanding comes from personal experience but also through my previous experience working in dermatology. Often patients presenting with atopic eczema would also be asthmatic, there is a well known link between these conditions (Hyland 1998). Some of the advice given in eczema management, for example allergen avoidance, will also be relevant in asthma management (Rees and Kanabar 2000).

Using Benner’s (1984) novice to expert model I would classify myself at present as an advanced beginner. This is someone who has a marginally acceptable performance with some background experience but who still requires supervision. I feel this accurately describes my current ability in practice in relation to asthma management. With supervision I am able to undertake an assessment using a template for guidance, check medication usage, check symptoms and carry out peak flow assessment. However I still find the array of inhalers confusing and don’t feel confident in interpreting the information gleaned during assessment into planned care within the time constraints of the clinic. When I have the time to reflect on the information and review the guidelines away from the patient I feel more confident. I need however to be able to make the transition from an advanced beginner to a competent practitioner, increasing my level of proficiency to no longer requiring supervision but being aware of my own limitations. I feel with more experience in practice and by working through this case study I should be able to achieve this.

Rationale for choice of patient and key issues

Rolfe, Freshwater and Jasper (2001) suggest that choosing an event or incident to reflect upon or analyse is concerned with anything that happens to us that we want to write about for some reason. It is the significance of the experience within our daily lives which helps us choose one experience over another. Having decided to focus on asthma as the topic for my case study, when I looked back at the patients I had seen with asthma, it was the above episode of care which held the most significance for me.

Pharmacological management

The aims of the pharmacological management of asthma are to control symptoms, prevent exacerbations and achieve the best possible lung function while minimising side-effects and long-term sequelae (Scullion 2005). National clinical guidelines developed in 2003 by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) were produced in collaboration with, amongst others, Asthma UK and the Royal College of Physicians of London, and have more recently been updated in 2005. They are widely accepted as the ‘Gold Standard’ of evidence-based asthma care for health care professionals working in the UK (Levy and Pearce 2004).

Patient education and concordance

The issues of education and concordance will be discussed together as they are inextricably interlinked. It is difficult for the health professional to achieve concordance with the patient without providing education about their disease and its management (Levy and Pearce 2004). It is estimated that one quarter of asthma patients in the UK have a compliance rate of 30% or less (Das Gupta and Guest 2003). The term compliance in health care has become less fashionable recently due to it implying that a patient is perhaps ineffectual and hasn’t followed the health professionals’ instructions (Hyland 1998). Whereas in reality the reasons for non-compliance are complex (Holgate and Douglass 2006) and not necessarily the fault of the patient, for example, not being shown how to use their inhaler device properly (Carter et al 2005). Nevertheless non-compliance is thought to contribute to between 18% and 48% of asthma deaths (Asthma UK 2003). Concordance is the term used to describe a negotiated agreement between health professional and patient with regard to the management of their condition (BTS/SIGN 2005). However even when concordance seems to have been achieved a patient still may not adhere to the agreed plan of care for many reasons (Weller and Booker 2006).

Ensuring patients are well informed about how their medication works has been shown to improve adherence and control (Boulet 1998). They need to be aware of the risks of taking and of not taking their medication (Levy and Pearce 2004). The latter is of particular concern in asthma in that persistent inflammation of the airways may lead to irreversible obstruction (Rees and Kanabar 2000). Written personalised asthma action plans have been shown to improve outcomes of care (BTS/SIGN 2005). They reinforce verbal education and set out for patients what to do if their symptoms worsen (Roberts 2002).

Conclusion

Asthma is a frequently seen chronic condition in the Emergency Department and one that Advanced Nurse Practitioners are expected to be involved in the management of (Hampson 2002). Therefore as am Acute Care Pathway Degree Student, I need to develop my knowledge and skills in this condition to enable me to provide a high standard of evidence-based care for patients. Throughout this essay I have endeavoured to demonstrate my understanding of asthma especially in relation to the pharmacological management and issues of education and concordance. These issues have been discussed and have shown to be interrelated; without achieving concordance, adherence to prescribed medication cannot be achieved and without patient education concordance cannot be realised.

Although I have been unable to discuss all aspects of asthma management due to word limit constraints, my understanding of asthma medications and the use of the stepwise guidelines has increased significantly to the point where I now feel more confident in practice. More recently when seeing patients with asthma I have been able to visualise which ‘step’ they are on which has helped me to decide whether they are on the correct medication in relation to the severity of their disease. Reviewing the issues of concordance and education has made me realise how important these aspects of management are; however the time needed to address these issues in practice often doesn’t correlate to the time allowed for appointments.

To enable me to become a competent practitioner in asthma management I need to consolidate the increased knowledge I have gained from writing this essay with more experience in practice. I need to increase my knowledge in areas not discussed in this essay, such as non-pharmacological management through self-directed study and perhaps consider further education through an accredited asthma diploma course, on completion of my degree course.

Tissue Viability & Wound Management

Wound types and Management

According to NHS report, 1998, ‘Wound care has, in the past, not been well managed because of the limited understanding of the healing process and the inadequate range of dressing materials available. Wound management has now come full circle, back to Hippocrates’ principle and dressings are being developed to provide the ideal environment for nature to do its work’.

The primary function of normal intact skin is that it can control microbial populations living on skin surface from entering underlying layers or organs and thus protects the body from pathogens. Exposure of subcutaneous tissue with a wound provides a moist and warm environment for microbial organisms. However factors such as wound type, depth, and location, quality, level of tissue perfusion and anti-microbial efficacy or resistance is important for examining microbial effects on wounds. Wounds are broadly categorized as either acute or chronic. Acute wounds are caused by external damage to intact skin and include surgical wounds, bites, burns, minor cuts and abrasions, and more severe traumatic wounds such as lacerations and those caused by crush or gunshot injuries (in Bowler et al, 2001, p.245). Acute wounds are expected to heal within a predictable and specified time frame and with minimal intervention although in severe cases such as gunshot wounds, anti-microbial therapy or surgical intervention may be necessary. In contrast, chronic wounds are most frequently caused by endogenous mechanisms associated with a predisposing condition that ultimately compromises the integrity of dermal and epidermal tissue (Bowler et al, 2001, p.245). Pathophysiological abnormalities that may predispose to the formation of chronic wounds such as leg ulcers, foot ulcers, and pressure sores include compromised tissue perfusion as a consequence of impaired arterial supply (peripheral vascular disease) or impaired venous drainage (venous hypertension) and metabolic diseases such as diabetes mellitus.

Tissue viability is considered as a growing specialty that primarily addresses all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers, and leg wounds and ulceration. Tissue viability includes but not just restricted to wound management and covers professional aspects of wound care, nursing and also a wide range of organizational, political and socioeconomic issues.

Wound management and tissue viability are intricately related and Schultz et al (2003) indicate that the healing process in acute wounds has been extensively studied and the knowledge obtained from these studies have been used for the care of chronic wounds with the assumption that non healing chronic wounds suggest an aberration of the normal tissue repair process. However the healing process associated with chronic wounds is quite different from that of acute wounds. As Schultz et al discuss, usually in chronic wounds, the sequence of events which lead to repair in acute cases becomes stuck or disrupted at different stages of the healing process and before the normal healing process could be resumed, the barrier to the healing process has to be recognized and correct techniques have to be applied. Thus for appropriate understanding of the healing process and the interventions necessary to speed up healing and to repair chronic wounds, it is necessary to understand the underlying molecular events. Wound bed preparation is the management of wound that accelerates endogenous healing and facilitates the effectiveness of therapeutic measures and is an important concept in wound management. Wound bed preparation is an educational tool in wound management and several key issues form part of wound management and tissue viability. These include status of wound bed preparation, analysis of acute and chronic wound environment, wound bed preparation in the clinic, cellular components of the wound bed preparation concept, and analysis of the components of wound bed preparation.

An important part of wound management is realizing the potential dangers of wound infection. Surgery itself carries a 1 to 5% risk of wound infection and if proper care is not taken, there is a 27% chance of endogenous contamination. Bowler et al (2001) write, ‘Infection occurs when virulence factors expressed by one or more microorganisms in a wound out compete the host natural immune system and subsequent invasion and dissemination of microorganisms in viable tissue provokes a series of local and systemic host responses’ (p.247). Wound infection and presence of pathogens in the skin and body are primarily responsible for delayed wound healing although host immune response and local environmental factors such as tissue necrosis, hypoxia and ischemia impair immune cell activity. Antiseptics, antibiotics, antimicrobial therapy, vacuum assisted wound closure, enzymatic and surgical debridement, pressure reduction in wounds and complementary and alternative therapies are the common techniques of wound management.

Tissue Viability and Wound Management – Nursing Perspectives

In a study by Maylor (2005), tissue viability nurses, nurse practitioners and post registration nurses responded on a wound management survey and ranked signs and symptoms of wound healing, stasis and deterioration according to their supposed importance. According to the survey the top ranking sign for a healing wound was size or reduction of the wound, a static wound was recognized by no marked changes in the wound, and a deteriorating wound is marked by increased pain. However results have been generalized with caution although the study supports the fact that some words are used in common by different respondents in specific wound phases.

Kingsley (2001) suggests that the management and treatment of infection is a complex and important area in tissue viability nursing and in this regard microbiology is important in clinical practice along with the fact that a proactive approach to management of infected wounds using an infection continuum can help promote effective care.

Pain is one of the most common accompaniments of wounds and it is important to understand whether pain relief has any relation whatsoever with wound healing. Pediani (2001) cite a study of 5150 hospital patients and found that 61% suffered pain due to wounds of which 87% had severe or moderate pain. Pain is considered to be of protective function as it warns of damage and initiates treatment. However postoperative pain can heighten cellular stress response; autonomic, somatic and endocrine reflexes are diminished resulting in a suppressed immune system which can impair wound healing.

In chronic wound management and tissue viability, wound bed preparation is a popular term describing the method of treatment. Vowden and Vowden (2002) describe that the concept of wound bed preparation represents a new direction in wound care thinking as wound management tend to focus both on the wound and on the patient necessitating a multidisciplinary and structured approach to care. Wound management focuses on the study of the interrelationship of functionally abnormal cells, bacterial balance, inappropriate biochemical messengers and dysfunctional wound matrix components. These elements are influenced by the patient’s physical and psychological status and the aim of the wound bed preparation is to create optimal wound healing environment as well as vascularised and stable wound bed with no exudates. The five primary aspects of wound bed preparation include Restoration of bacterial balance, Management of necrosis, Management of exudates, Correction of cellular dysfunction and Restoration of biochemical balance (Vowden and Vowden, 2002).Vowden (2005) bring out the complicating factors in wound management and suggest that exudate, infection, co morbidity and polypharmacy constitute to a complex wound and a holistic assessment is necessary in wound care.

Pieper (2005) brings out the challenges faced by nurses in wound management and highlight the problems of wound management in rehabilitation patients as well as in vulnerable populations that are at risk. Rehabilitation nurses are challenged to understand issues that are related to working with vulnerable patients affected with wounds and these factors include poverty and payment for care, culture and literacy. Hampton (2004) emphasizes that preserving the skin’s integrity in a patient is one of the primary jobs of a nurse and this can often be a complex and difficult task especially in cases of chronic wounds. Factors affecting the repair and management of chronic wounds also shed light on maintenance of skin integrity and general nursing needs in wound management.

Nursing issues in tissue viability and wound management include acquisition of coherent knowledge and a systematic understanding of the process of healing and this naturally leads to the development of problem solving strategies. However the limitations of knowledge as well as cutting edge technological innovations in wound management that cannot be overlooked.

One challenging aspect in wound care is nursing of fungating wounds as these wounds pose a challenge as it is difficult to manage the physical aspects of such a wound which is accompanied by pain, bleeding, exudates and odour. The psychological impact of fungating wounds on patients, their families and carers can be quite strong and irreversible. Fungating wounds require sensitivity in nursing management and consideration of social and psychological issues. Dowsett (2005) emphasize on the need for nurses to work in partnership with patients to meet their clinical, quality of life and psychosocial needs. Franks and Bosanquet (2004) bring out another challenging aspect of wound management, namely cost effectiveness and discusses different methods of evaluating cost in relation to the outcomes of treatment and reviews the evidence of cost-effectiveness (CE) in the management of chronic leg ulceration. Higher cost effectiveness seems to allow either for the same number of patients to be treated more efficiently at a lower cost or more patients to be treated for the same financial input. Studies on the relative cost effectiveness for different systems of care lead to overall suggestions that modern wound dressings provide a more cost effective alternative to saline gauze. The use of compression bandaging has also been found to be more cost effective when compared with a system of care where there is no compression. The evaluation of cost effectiveness is an important aspect in wound care and management as striving for greater healthcare efficiency using scarce resources is a challenge that highlights the need for cost effective treatment methods. To make treatment more effective, many innovative techniques are used and Dunford (2005) emphasize the innovative techniques of honey-derived dressings in promoting effective wound management and healing. Clinical studies have shown that honey has significant promise as an effective treatment for many medical conditions and can be especially effective for chronic non-healing wounds. Honey has been suggested as being effective in management of chronic leg ulcers and has a number of healing and antiseptic properties.

Wilson (1999) explores the role of clinical governance on tissue viability specialists and nurse practitioners. Principles of clinical governance have considerable significance for healthcare organizations and highlight on the different processes of application, including responsibilities that have to be adopted. Wilson emphasizes that the dimensions of clinical governance are applied to the quality of care expected and given by staff and ways of assessing performance, ensuring that quality is a general feature of healthcare. Wilson concludes by saying that, ‘ It is up to us all as healthcare practitioners to ensure that we keep professionally up-to-date, enhance our education, research and development, and have a mechanism for monitoring and safeguarding our performance’ (p.95).

Dealey (1998) gives the blueprint for clinically effective wound care and suggests that in tissue viability as in other aspects of healthcare, there is an increasing recognition for the need of healthcare interventions and the randomized controlled trial (RCT) is the most accurate evidence of effectiveness. Evidence of effectiveness of healthcare interventions in wound care and other aspects of care, several factors such as funding, sample selection, sample size, recruitment of patients, mortality and attrition rates. As with other aspects of effective wound care, pain reduction during dressing is a challenging management issue and has been examined by Meaume et al (2004). Meaume and colleagues attempted to examine pain in patients with acute or chronic wounds of various causes during dressing removal and the effects of switching to non-adherent dressing and in their study 656 primary care physicians reported details of acute and chronic wounds during routine visits. The pain experienced during dressing changes was evaluated after patients completed a self-evaluation questionnaire. 5850 patients with chronic and acute wounds reported moderate to severe to very severe pain. Dressing removal was considered painful when there was an adherence to the wound bed and switching to non-adherent dressing reduced pain during dressing changes in most cases. Thus authors conclusively argue that pain is a major problem and challenge to nursing management in wound care and is almost always related to dressing selection. They point out that selecting a suitable non-adherent dressing improves patient acceptability.

The major challenges in tissue viability and wound management seem to be the following:

• pain management
• wound infection and pathogens
• providing cost effective treatment
• maintaining quality of care according to principles of clinical governance
• improving healing and reducing mortality rates

Stalick (2004) discusses the case of a 91 year old woman who has been admitted to the hospital from her own home and was found to be with reduced mobility, constipation, increased confusion, and reduced oral intake. She has been reported to have small vessel disease and a stroke and also two pressure ulcers on her buttocks. The surrounding skin of the ulcer was macerated although after the skin was cleaned and treated, it was expected to heal fast. The healing however took longer than expected and exposed many risk factors for macerated skin conditions. Among the vital factors in the management of wounds, nutrition has been considered important and the role of nutrition has been studied by Lansdowne (2002). Lansdowne’s review suggests that the essential biological features of human skin, their origins and cellular relationships serve as the basis for understanding nutritional requirements in health and disease. The importance of a well balanced diet, sufficient in proteins, fats, carbohydrates, vitamins, and minerals is emphasized in the management of skin wounds. The evidence for the study is based on clinical trials and case studies of patients who have genetic deficiencies affecting dietary metabolism. Experimental studies on laboratory animals also provide information on the role of nutrient deficiencies in wound repair. Lansdowne emphasize on the need for a detailed study of key nutrients at principle phases of wound healing cascade and on how metabolism is regulated by growth factors such as cytokines and hormones and metals and how all these factors affect wound healing as a whole.

Considering a completely different aspect of tissue viability and wound management, Flanagan (1997) tried to establish a profile of practicing tissue viability clinical nurse specialists in the UK. The aim of his study was to establish baseline data on the role and conditions of employment and identify any discrepancies and he used a sample of 110 practitioners and 87 participated. The majority of practitioners were in general wound management, with 36% having responsibility for tissue viability services and responsible for pressure sore preventive equipment. The study highlighted the lack of available role models and isolation of a practitioner’s position. Most (90%) of practitioners seemed to be working full time and 62% are on Grade H; 28% are graduates with a further 19% studying for a first degree; 6% already hold a master’s degree while 20% are undertaking courses at this level. However, according to Flanagan, 39% have no academic qualifications and only 34% had completed ENB courses in tissue viability (Flanagan, 1997). These results suggest that increasing workforce and specialist nurse practitioners for tissue viability seems to be an important challenge for nursing and clinical management.

Conclusion

:

In this essay we provided a detailed evaluation of wound management and tissue viability using various studies to show the nursing perspectives of wound care and the various aspects of wound management including nutrition, dressing and pain conditions. The challenges of wound management have been highlighted suggesting that clinical governance, pain management from wounds and improving quality of life through effective wound care are intricately related.

Bibliography

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Douglass J. Wound bed preparation: a systematic approach to chronic wounds. Br J Community Nurs. 2003 Jun;8(6 Suppl):S26-34.

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Dimond B. Legal concerns in tissue viability and wound healing. Nurs Stand. 2003 Feb 19-25;17(23):70-2, 74, 76.

Dowsett C. Malignant fungating wounds: assessment and management. Br J Community Nurs. 2002 Aug;7(8):394-400.

Dowsett C. Assessment and management of patients with leg ulcers. Nurs Stand. 2005 Apr 20-26;19(32):65-6, 68, 70 passim.

Kingsley A. A proactive approach to wound infection. Nurs Stand. 2001 Apr 11-17;15(30):50-4, 56, 58.

Culley F. Managing risk in tissue viability. Nurs Times. 2000 Nov 9;96(45 Suppl):5-6.

Bowler PG.

Wound pathophysiology, infection and therapeutic options. Ann Med. 2002;34(6):419-27.

Bowler PG, Duerden BI, Armstrong DG. Wound microbiology and associated approaches to wound management. Clin Microbiol Rev. 2001 Apr;14(2):244-69.

Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. Journal of Wound Care. 1999 Nov;8(10):499-502.

Bowler PG, Davies BJ. The microbiology of infected and noninfected leg ulcers. Int J Dermatol. 1999 Aug;38(8):573-8.

Dunford C. The use of honey-derived dressings to promote effective wound management. Prof Nurse. 2005 Apr;20(8):35-8.

Franks PJ, Bosanquet N.

Cost-effectiveness: seeking value for money in lower extremity wound management. Int J Low Extrem Wounds. 2004 Jun;3(2):87-95.

Flanagan M. A profile of the nurse specialist in tissue viability in the UK. Journal of Wound Care. 1997 Feb;6(2):85-7.

Flanagan M. The role of the clinical nurse specialist in tissue viability. Br J Nurs. 1996 Jun 13-26;5(11):676-81.

Hampton S. A guide to managing the surrounding skin of chronic, exuding wounds. Prof Nurse. 2004 Aug;19(12):30-2.

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Silver: its antimicrobial properties and mechanism of action

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What has pain relief to do with acute surgical wound healing? Ramon Pediani, 2001

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NHS report on wound care www.nhsdirect.nhs.uk

This essay will discuss nutrition and the effects it has on wound management, and what impact communication skills have on patient’s health. I will include some information about my experience of wound management, while working along side my mentor in a rehabilitation unit, for a patient who was admitted with multiple scleroses (M.S), the patient is wheel chair bound and had a pressure sore which developed into a sacral sinus wound (grade 4).

In accordance with the Nursing and Midwifery Council (2008), Guidelines on Confidentiality, I will refer to the patient as Ben, who is 72 years old. Ben’s wound had caused extensive destruction of his tissues and damaged to his muscle and supporting structures. A swab was taken and reports confirmed that his wound had been infected with (Methicillin-resistant Staphylococcus aureus) MRSA. Flanagan(2000) states that age reduced mobility, malnutrition, incontinence, skin integrity, friction, moisture, and pain. It can lead to skin breakdown and wound developing.

Ben’s observation were taken regularly, he had a supra pubic catheter, which was monitored on regular basis to minimize the risk of infection, Ben’s bowel motion was also assessed; it was made sure that the wound would not be contaminated with overflow of bowel. His over all conditions were monitored every day but his dressing were not changed every day. The nurse, my mentor, was using a local wound assessment chart for managing his wound. The chart was used for the assessment of his wound and every time it was updated after changing the dressing. All changes and appearance of the wound were noted down in the chart. Progress in daily assessment and plan of care were noted down in the chart to carry out regular reassessment of his wound.

According to Eunis and Menesis (2000), the excess of exudates within the wound can also inhibit healing, control of exudates is therefore essential. This is usually achieved by selecting a dressing of the appropriate absorbency. The nurse selected an Aqua Cell Silver dressing to use for Ben’s wound, as his wound was infected with MRSA. (Methicillin Resistant Staphylococcus Aureus). British National Formulary (2006) says that “aqua cell silver is an appropriate dressing for infected wounds”.

Gunnewicht and Bun (2004) described that if the wound is clean, healthy, granulating and happy; it does not require cleaning because the wound exudate itself has beneficial bactericidal properties, which may be inappropriateely removed. The general strategy of my mentor, in the cleansing of Ben’s wound was based on providing minimal necessary intervention. She was using normal saline to clean the wound. Griffiths et al (2001) stated that the solution should be of a non- irritant and free of bacteria. Normal saline is the most commonly used wound cleaner, it is best to use the solution at body temperature.

We identified and addressed the nutritional needs of Ben. This was of a puree diet and the supervision of his meal times, to aid optimum recovery. A dietition was envolved in Ben’s nutritional needs. It is obvious that nutrition plays a crucial role in wound healing. All patients with wounds should have appropriate nutritional assessment. If a patient’s nutritional status is compromised, and they are unlikely to meet their requirements, recovery will be delayed. Boon (1998) said that “a good nutritional assessment involves the multidisciplinary approach including medical, nursing and dietretic staff”.

Ben was kept on a food chart which was updated everyday after each meal. The correct quantities of Ben’s intake were entered on the chart. If we examine the importance of nutrients, we would know that they have key roles in the healing process, such as, protein depletion can affect the rate of wound healing because it is required for the granulation of tissues, carbohydrates are also a part of healing process, cellular activity is fuelled by adenosine triphosphate (ATP), which is derived from glucose, providing the energy for the inflammatory response to occur. If carbohydrates are not sufficient, the body breaks down proteins to provide glucose for cellular activity. Therefore, carbohydrates are required as well as proteins. Ben was given fruit yougurt or pudding after every meal, mash potato and meat were the regular part of his diet along with some mashed vegitables. Fats and vitamins have a key role in cell membrane structure and function, certain fatty acids are essential as they cannot be synthesised in sufficient amounts, so must be provided by diet.

Williams and leaper (2000) states that B complex vitamins are co-factors or co-enzymes in a number of matabolic functions involved in wound healing, particularly in the energy release from carbohydrates. The doctor had prescribed 30mg of zinc per day for six weeks, along with multivitaminal tablets. According to Grey and Cooper (2001) vitamin C has an important role in collagen synthesis in the formation of bonds between strands of collagen fibre, while vitamin K is involved in the formation of thrombin. Deficiency of vitamin K (in the presence of wound) can lead to haematoma. Vitamin A supports the proliferation of epithelial cells. Minerals like zinc, iron and copper play a vital role in wound healing. Zinc is required for protein synthesis and also has an inhibitory effect on bacterial growth; it is envolved in the immune response. Long term of zinc supplimentation must be accompained by

copper supplimantation to prevent zinc induced copper deficiency. The deficiency of copper and iron delay wound healing.Perkins (2000), defined that the ideal way to meet requirements of nutritional needs, is by consuming adequate intake of normal food.

My mentor and I were spending time with Ben, explaining and educating him about the process of his wound healing and the importance of medication, nursing interventions and nutrition. I felt that Ben needed support and care for his treatment. According to Quality and Safety in Health Care (2008) Communication looks easy when it is done well, it requires engagement, empathy, and ability to listen and respond, and it requires time.

To conclude: I feel that wound care requires multi skills and broad spectrum of knowledge because nurses are the first one to take responsibilities of wound care. Bens wound care management and assessment provided me with opportunities, which enabled me to improve my knowledge and understanding of wound care. I feel I have improved my confidence about the wound management.

Psoriasis

This research paper is going to introduce the topic of psoriasis. Psoriasis is a disease that affects the skin. This condition causes rashes and scaly patches to form on the skin (© 1996-2019 National Psoriasis Foundation/USA). Knowing that Psoriasis affects the skin, it is labeled as a skin condition or disease. Psoriasis can also be associated with other serious health conditions such as diabetes, heart disease, and depression (© 1996-2019 National Psoriasis Foundation/USA). Psoriasis typically affects the outside of the elbows, knees, or scalp, though it can appear on any location (© 1996-2019 National Psoriasis Foundation/USA). According to the National Psoriasis Foundation, men and women develop this at equal rates. In general, there are more than three million cases per year involving psoriasis. This condition usually requires a medical diagnosis from a dermatologist or another health care provider. Unfortunately, this skin condition is incurable. Though this disease is incurable, there are many ways to treat this condition and its symptoms. Doctors and scientists recommend treatment options like oral pills and ointments to help fight this disease. This disease is so prevalent, and because of that, scientists are constantly working on new innovative ways to cure and treat psoriasis. There are five different forms of psoriasis. This research paper will cover the following: Plaque, guttate, inverse, pustular, and erythrodermic psoriasis. This paper will also discuss therapeutic options for those who prefer a more “medicine-free” method, as well as medicinal options.

The most common type of psoriasis is plaque psoriasis. This type of psoriasis appears on about 85-90% of people with this condition. Psoriasis usually develops as raised, red patches covered with a silvery-white accumulation of dead skin cells or even scales on people with lighter skin. On the other hand, according to

psoriasis.org

, those with darker skin tones tend to have a more greyish/silver or dark brown discoloration. These patches are commonly found on the elbows, knees, scalp, neck, hands, feet and arms part of the body. These patches can be itchy and/or painful. They can form anywhere on your body, which includes your genitals and the soft tissue inside your mouth (© 1998-2019 Mayo Foundation for Medical Education and Research). This type of psoriasis can cause dermatitis, also known as skin inflammation. “Dale, a man in his fifties in North Carolina, copes daily with his severe plaque psoriasis. As a skilled construction worker, he has had to give up working due to the severe pain affecting his swollen hands”, (© World Health Organization 2016).

The second most common type of psoriasis is guttate psoriasis. This type of psoriasis is a condition that often starts at an early age from childhood to a young adult (© 1996-2019 National Psoriasis Foundation/USA).  According to

psoriasis.org

, only about 8 percent of people with psoriasis develop guttate psoriasis. This type of psoriasis appears as small, round spots called papules that are raised and sometimes scaly. The lesions, or wounds, usually appear on the arms, legs, and torso. In some rare cases, it can be seen forming in the scalp, face, and ears. This condition usually develops suddenly and the exact cause is still unknown. Doctors think genes and the immune system are involved. Though the causes aren’t known, common triggers include the following: upper respiratory infections, streptococcal infections, tonsillitis, stress, injury to the skin, and certain drugs including antimalarials and beta-blockers (© 1996-2019 National Psoriasis Foundation/USA). This type of psoriasis can also be triggered by a bacterial infection such as strep throat (© 1998-2019 Mayo Foundation for Medical Education and Research). According to

medlineplus.gov,

guttate psoriasis is diagnosed based on what the spots look like. Doctors use skin biopsies, throat cultures, and blood tests for recent exposure to strep bacteria to confirm the diagnosis.

The third type of psoriasis is inverse psoriasis. Inverse psoriasis is also known as intertriginous psoriasis. This type of psoriasis shows up as red smooth lesions in body folds. According to

psoriasis.org,

many people have another type of psoriasis elsewhere on the body at the same time. This type of condition is found in the armpits, groin, under the breasts, and in other skin folds on the body. Unlike plaque psoriasis, this type of condition doesn’t scale as much. The reason is that the irritation from rubbing and sweating causes the environment where these lesions are to be moist. The friction and sweating may worsen this type of psoriasis. Since these places are tender, it makes the condition of the lesion even worse. Dr. King-man HO described this type of psoriasis as “More wet looking and with erosion in extramammary Paget’s disease” (Medical Bulletin Vol.15 No.5 May 2010). A dermatologists usually diagnosis this by the way it looks. Sometimes, this type of psoriasis is mistaken for fungal infection. Doctors may take small skin samples to examine if they are unsure.

The fourth type of psoriasis is pustular psoriasis. This type of psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin (© 1996-2019 National Psoriasis Foundation/USA). The wounds pustular psoriasis causes are blisters with pus that consists of white blood cells. According to Dr. King-man HO’s book, the roof of the pustules is easily broken. This condition usually affects adults and the lesions are commonly seen on certain body locations like the hands, arms, and feet. Factors that may trigger pustular psoriasis include the following: Internal medications, irritating topical agents, overexposure to UV light, pregnancy, systemic steroids, infections, emotional stress, and sudden withdrawal of systemic medications or potent topical steroids. There are various types of pustular psoriasis. One of them is Von Zumbusch and this type of pustular psoriasis can be severe and life-threatening.

The final type of psoriasis we’ll cover is erythrodermic psoriasis. This type of psoriasis is a particularly inflammatory form of psoriasis that often affects most of the body surface (© 1996-2019 National Psoriasis Foundation/USA). Although the lesions of this condition are not clearly defined, erythrodermic psoriasis shows up as fiery redness and exfoliation of the skin. It’s symptoms can include the following: Severe redness, shedding of skin over a large area of the body, exfoliation in large “sheets” instead of smaller scales, skin looks as if it has been burned, heart rate increase, severe itching and pain, and body temperature may go up and down (© 1996-2019 National Psoriasis Foundation/USA). This type of psoriasis can cause protein and fluid loss. With this condition, edema may also develop. Edema is the swelling from fluid retention.

Like all diseases and conditions, the first choice of treatment usually depends on disease severity (Copyright © 1996-2019 National Psoriasis Foundation/USA). Doctors also have to look at your reactions to previous treatment options. There are about 5 basic different types of ways to treat psoriasis. Using biologic drugs, systemic treatments, phototherapy, new oral treatments, and topical treatments can all help treat psoriasis. Though psoriasis isn’t curable, doctors find ways to make victims of it comfortable. The American Academy of Dermatology recommends practicing a biologic agent if you have moderate to severe psoriasis that hasn’t improved using more traditional systemic agents or you can’t tolerate those treatments because of side effects (© 2005 – 2019 Healthline Media). Biological agents are just another way to refer to medicinal pills. As we know, traditional methods of treating psoriasis have to be taking daily for effectiveness. On the other hand, using a biological agent takes less time and are taken less frequently. According to

psoriasis.org,

tumor necrosis factor-alpha, interleukin 12 and  23, interleukin 17, and T-cell inhibitors are all helpful in treating psoriasis. The second way to treat psoriasis is by using synthetic treatments. Systemic treatments are taken by mouth in a liquid or pill form or given by injection. Acitretin, cyclosporine, methotrexate, and off-label systemic can all be part of the treatment. The third way to treat psoriasis is by practicing phototherapy. This type of treatment is also known as light therapy. Patients with refractory lesions may benefit from this form of treatment (© 2019 American Academy of Family Physicians). First-time treatment options include UVB phototherapy and/or Excimer laser. These treatments target areas of the skin affected by mild-to-moderate psoriasis. The fourth way to treat psoriasis is by taking new oral medicinal pills. The following are a few types that help treat psoriasis: Otezla (apremilast), Xeljanz, and Xeljanz XR. These medicinal pills target specific parts of immune cells. Doing this helps reduce the inflammation in psoriasis. The final way we’ll cover is topical treatments. This type of treatment is medications applied to your skin. While most medications can be bought over the counter, some have to be medically prescribed. These kinds of medications should be used selectively because many can be irritating to inflame or broken skin (© 2019 American Academy of Family Physicians). If your psoriasis continues, your doctor might suggest a combination of treatments. Second-line treatment options include the following: Cosentyx, Siliq, Enbrel, Stelara, Humira, Taltz, Remicade, and Tremfya (© National Psoriasis Foundation – October 2017). Mild cases of psoriasis such as mild guttate, are usually treated at home. Your provider may recommend any of the following: Cortisone or other anti-itch and anti-inflammatory creams, dandruff shampoos, lotions that contain coal tar, and moisturizers (© 1997-2019, A.D.A.M., Inc.). For inverse psoriasis specifically, steroid creams and ointments are considered very effective. Every medication works differently on each patient. One type of treatment might not work for the other and must seek whats best for their type of skin.

The National Psoriasis Foundation Research is a foundation that was formed in efforts to find a cure for this type of skin condition. They have committed more than $11 million to psoriatic disease research since their inception (© 1996-2019 National Psoriasis Foundation /USA). This foundation has a collection of biological samples and clinical information named the National Psoriasis BioBank. This foundation was established in 2006 and is used by qualified scientists to furthermore their knowledge about psoriasis. This foundation helps us move closer to finding other treatments, the causes, and hopefully someday a cure. According to

psoriasis.org

, researchers used National Psoriasis Victor Henschel BioBank samples to uncover a rare mutation in the CARD14 gene that, when activated by an environmental trigger, can result in psoriasis. This discovery helped researchers get closer to finding the unknown cause of psoriasis. “A comparative proteomic analysis was performed with non-lesional and lesional skin from psoriasis patients and skin from healthy individuals. Strikingly, 79.9% of the proteins that were differentially expressed in lesional and healthy skin exhibited expression levels in non-lesional skin” (© 2019 Springer Nature Limited). This research helps doctors see how people suffering from this skin disorder have different proteins. This information can also help doctors and scientists find ways for new treatments and medications specifically for this skin condition. “Comparison of non-lesional and lesional skin proteomes led to the identification of 56 proteins exhibiting at least 2-fold differences in relative abundances. Of these proteins, 32 exhibited higher protein abundance in non-lesional skin compared to lesions, whereas 24 exhibited lower abundance. Functional enrichment analysis of these 56 proteins revealed several biological processes identified in psoriasis pathomechanism, including development, and response to stimulus” (© 2019 Springer Nature Limited). Researchers also use these kinds of information to figure out how different types of treatments work for different types of psoriasis.

Psoriasis, a skin condition that can be divided into five different types. Though there isn’t a cure yet, doctors and researchers are working hard to find a way to cure it. Like all diseases and conditions, it sometimes takes time to figure out a solution. Some types of psoriasis are more severe than others and may take more than one type of treatment. All they can do for now is to keep researching new ways to treat it and make victims of it feel comfortable.

Works Cited

• “© 1996-2019 National Psoriasis Foundation/USA” “Psoriasis.org”
• 
  
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• 
  
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• 
  
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• “© 2019 American Academy of Family Physicians”
• Pardasani, Asha G., et al. “Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians.”
  
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• © 2019 Springer Nature Limited
• “Comprehensive Proteomic Analysis Reveals Intermediate Stage of Non-Lesional Psoriatic Skin and Points out the Importance of Proteins Outside This Trend.”
  
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• 
  
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• . “Comprehensive Proteomic Analysis Reveals Intermediate Stage of Non-Lesional Psoriatic Skin and Points out the Importance of Proteins Outside This Trend.” Nature News, Nature Publishing Group, 6 Aug. 2019, https://www.nature.com/articles/s41598-019-47774-5.