Health Problems Related to Musculoskeletal Function - Essay Example

Running head: Orthopedic Care Orthopedic Care By _____________________ Orthopedic Care Orthopedic nursing is defined as the diagnosis andtreatment of human responses to actual and potential health problems related to musculoskeletal function, More specifically, orthopedic nursing focuses on promoting wellness and self-care and on preventing further injury and illness in patients with degenerative, traumatic, inflammatory, neuromuscular, congenital, metabolic, and oncologic disorders. Traditionally, orthopedic nurses have needed to operate special mechanical and traction equipment. Today, they need to understand principles of internal and external fixation, prosthetics, orthotics, immobilization, and implantation. Despite the evolution of complex surgical procedures and mechanical devices that characterized modern orthopedic care, some things remain the same. A patient hospitalized for any orthopedic procedure whether its cast application, traction or arthroplasty is vulnerable to similar complications such as: Joint stiffness and skin break down from impaired physical mobility Fractures from mishandling of osteoporotic extremities Neurovascular compromise from pressure on measure blood vessel and nerve caused by immobilization devices or compartmental edema Infection of surgical wounds or skeletal pin tracts Prolonged healing from failure to observe sound principles of immoblization In addition, the patient's level of understanding and effectiveness of coping skills must be assessed. Consistent Care Without exception, orthopedic complication can be prevented or minimized by appropriate and consistent assessment, monitoring, and therapy. For example, the orthopedic patient's neurovascular status must be assessed at regular intervals; otherwise, signs and symptoms of neurovascular compromise may go undetected until irreversible damage occurs. Consistent orthopedic care remains the surest way to promote rapid healing and successful rehabilitation. Ready for and emergency Orthopedic nursing care is characterized by the high incidence of emergency procedures a nurse, likely to perform. The first step in administering emergency care at the scene of an accident is immediate assessment for a life-threatening condition. Do not move the patient unless danger is imminent because this might worsen the injury and increase pain. I the patient must be moved, assess him for possible spinal injury so that the appropriate transfer techniques can be used. After determining that no life-threatening injury exists, conduct an initial head-to-toe assessment, comparing bilaterally where applicable. Always evaluate neurovascular status. Check the five P's: pain, pallor, pulse, paresthesia, and paralysis. Assess the injury thoroughly, and use strict sterile technique when caring for oopen wounds to prevent infection. If the nurse suspect a bone injury, apply a splint to reduce injury and immobilize the bone. In non-emergencies, performing orthopedic procedures correctly can ease pain, prevent further injury, and encourage proper healing. Case The player: Fred Johnson during a local football match sustained an open fracture to his tibia and fibula. After rushed down to a local hospital, he underwent an emergency surgery to wash the open fracture. It is very important to wash the open fracture site within 8 hours of the injury to avoid infections. The scar was about four inches above his right ankle is hardly visible and the slight bend in his right leg is barely noticeable. His right leg was mangled. His bone had snapped in two, with one end protruding from his skin and a shattered fibula. After the open fracture was thoroughly washed, the fracture required stabilization. Stabilization of these fractures can be accomplished with internal fixation (rods, plates and screws), external fixation, or as in his case, a cast. With all the professional approach that the surgeons and nurses had taken, with all the new technologies, which were there, but the nature of his injury, is complex enough to heal 100%. And he ultimately ended up with a slighthly-shortened leg on the side of the injury. Nurses' Role During his whole treatment, a team of qualified nurses was there to give the best possible treatment. The nurses during the whole treatment efficiently manage the following aspects: Pain Wound Management Infections Intravascular Therapy Blood Transfusion Management Pain Pain is among the most complex and at the same time the most threatening of all the domains of ordinary human experience. The quotation above highlights the very personal nature of the pain experience and the bleak sense of loneliness when the experience cannot be conveyed to another. However, in the presence of a compassionate and knowing other, this pain and loneliness can be acknowledged and ameliorated. The compassionate acknowledgement of pain and a resolve to ameliorate pain are primary responsibilities of nurses towards patients in pain (Judy et al, 2000:3) A report commissioned by the Agency for Health Care and Policy and Research in 1992 found that less than 50% of surgical patients reported having adequate pain management in the post-operative period (AHCPR, 1992). Studies undertaken in general surgical wards (Donovan, Dillon & McGuire, 1987:69-78) and intensive care units (Puntillo & Weiss, 1994:31-36) all showed that up to 75% of post-surgical patients reported moderate to severe pain which was inadequately managed. Despite advances in knowledge and technology these statistics are disappointingly similar to those reported by Marks and Sachar as long ago as 1973. Research indicates that 71 to 83% of frail elderly living in aged care facilities experience severe pain, over one half of them on a daily basis (Ferrell, Ferrell & Osterwell, 1990:409-14) while children often undergo painful procedures without adequate analgesic cover (Southall, Cronin & Hartmann, 1993:560-3). The nature of pain Pain is a multi-dimensional phenomenon and a biopsychosocial construct. It needs acknowledgement as being moulded both by the person experiencing it and by the particular context within which it is experienced. Pain perception is a combination of physical, psychological and environmental factors; it is influenced by past experiences and learning, as well as culture (Judy et al, 2000:4). Barriers related to pain assessment Scarry (1985) noted that while to feel pain is to have certainty, to hear about pain is to have doubt. The multi-dimensional nature of pain makes assessment of pain a complex issue. Patients are disadvantaged if they are managed by clinicians who operate from a biomedical model and whose education has emphasised objective signs as the gold standard for patient assessment. Lack of knowledge and insight will also affect the clinician's intention to assess the patient for pain, particularly if there is a concomitant lack of knowledge of the patient's culture (Walker, Tan & George, 1995:48-57). Within the biomedical framework, assessment of pain relies primarily on biological factors. This is a reductionist approach that assumes the pain problem results solely from neural and biochemical processes associated with pathology. A prime example of this is seen when the timing and amount of post-operative analgesia is based solely on the type of operation performed. Assessing only the uni-dimensional intensity of pain ignores the cognitive, affective and social impact of surgery and hospitalisation. Relying on the patient's self-report of the nature and intensity of their pain should be a fundamental principle of pain assessment. The patient has a key role in successful management since only the patient knows where the pain is and how much it hurts. However, several factors, including the culture of the patient and nurse as well as the quality of the patient-nurse interaction, will influence the ability or willingness of the patient to express pain and the nurse to hear what is being said. Inadequate or erroneous knowledge about pain assessment is a major factor in poor pain control. If clinicians do not accept and act upon a patient's report of pain or fail to ask patients about pain, then the fundamental basis of pain assessment is compromised from the beginning. When patients' reports of pain are elicited but minimised or not even believed, then under treatment is the likely outcome. One of the principles of pain management highlighted in the National Health and Medical Research Council (NH&MRC) guidelines under the heading 'Safe and effective analgesia' is frequent assessment and reassessment of pain intensity and meticulous documentation of pain assessment and efficacy of analgesia. It is necessary to distinguish between assessment and measurement of pain. Measurement requires quantification of one aspect of pain intensity and is unidimensional. Assessment encompasses the entire multi-dimensional pain experience and requires acknowledgement of the psychological and social impact of pain (Judy et al, 2000:5-6). Nursing issues in pain management (Procedural pain) Many patients are subjected to painful procedures in the course of treatment, often performed without appropriate analgesia. These procedures take place in many settings, the intensive care unit being one such environment. It is not hard to imagine the dread the patient feels in anticipation of the next approach by the nurse or doctor if analgesia is not given. After enduring intense procedural pain patients often report feeling victimised, violated or attacked (McCaffery & Pasero, 1999). Before beginning a procedure, clinicians should discuss whether analgesics and sedatives might be needed. The decision to provide analgesia during a procedure should be based on the likelihood that it is going to produce pain. These discussions will be facilitated if standardised pain management protocols for particular procedures have been established in the unit. These protocols should include guidelines about the use of anxiolytics and sedatives as well as analgesics. In addition, the patient needs to understand what is about to happen and be aware of how the pain is to be managed. The patient's report of pain during the procedure is a reliable indicator of the intensity of the pain. If a conscious patient is unable to talk, an alternative signal should be established that can be used to alert the clinician if the pain is unacceptable. In an unconscious patient observations reveal pathophysiological changes taking place in the nervous system in the absence of inadequate pain control. Although the patient cannot report the pain, changes in vital signs, muscular rigidity, groaning and grimacing are all reliable signs. Even in the absence of overt signs, the patient should be given the benefit of the doubt and receive analgesia before procedures that are known to be painful. Evidence-based practice and practice guidelines for pain management Since nurses are involved in patient care around the clock, spending more time in contact with patients than other team members, it is a serious situation indeed if the nurse lacks the appropriate knowledge, skills and attitudes to assess pain. If a comprehensive picture of the patient's response to pain and interventions is to be transmitted to doctors and nursing colleagues, regular assessment of pain and treatment outcomes need to be documented as meticulously as other clinical data such as blood pressure, pulse and temperature. In the light of what is known about neural plasticity in response to noxious stimulation, it makes good sense to take steps to prevent or reduce pain occurring. Nurses are well placed to influence patients' perceptions of pain. They can reduce anxiety by listening to patients' stories about previous encounters with pain and how they coped or how they did not cope. Explaining to surgical patients what to expect and how they will be helped is a prerequisite for reducing anxiety. Treating the operation as 'just routine' is likely to have the opposite effect to what is intended by such utterances. An operation or even a test, no matter how minor, is not routine to the person about to experience it. Pain assessment should begin at admission, establishing a pain history; questions related to previous painful episodes, their management and outcomes are as necessary as those questions used to elicit past medical history and fitness for anaesthesia (Judy et al, 2000:14-15). Encouragement of Patients and Their Family Members Nurses should encourage patients, their families and care givers to learn the facts about pain and its treatment. There are three statements that, if adopted universally, would reform the practice of pain management. These are: I have a right to have my reports of pain accepted and acted upon by health care professionals I have the right to have my pain controlled, no matter what its cause or how severe it may be I have the right to be treated with respect at all times. When I need medication for pain, I should not be treated like a drug abuser (Judy et al, 2000:16-17). Patients are often told they must expect to have pain and so are encouraged (or coerced) not to request analgesia until the pain is moderately severe for fear of being labelled as 'wimps'. This especially applies to young males (Cohen, 1980:265-74). Wound Management If ever there was a facet of nursing practice that must reflect the wisdom expressed here by Miss Nightingale, it is wound management. As nurses we practice in an exciting age. New information about wound healing is being generated at an extraordinary rate and advances in technology have resulted in a plethora of wound management products and devices from which today's practitioners may choose. Scientific advances have provided wound clinicians with so many choices that wound management decisions are becoming more complex and, for some, confusing. In an effort to eliminate confusion and simplify decision making some nurses limit their wound dressing choices to a few known favourites and appear reluctant to embrace the latest technology while others return to traditional practices or alternatively seek solutions in therapies other than those generally recognised and accepted in mainstream nursing practice (Judy et al, 2000:24). John Hunter (1728-93) described healing by primary and secondary intention and expanded on the physiology of wound healing (Brown, 1992). Since then, teachers of medicine have educated succeeding generations of doctors in this ever-expanding body of knowledge. Nurses were not so fortunate in receiving such education. To many nurses the science of wound healing remained a mystery for it was rarely taught until the introduction of tertiary institution-based education for nurses. Prior to that, nursing training focused on the rituals of dressing wounds, rather than the science of healing them. Considering nursing is, and has always been, predominantly involved in the care of the patient's integument-either preservation of its integrity or endeavours to promote its repair-this short-coming in earlier nursing education was remiss and supported traditional practices rather than scientific endeavour. However, there is not much evidence to suggest that more informed medical practitioners were also more enlightened when it came to clinical practice. Enlightenment gradually dawned following George Winter's discovery in 1962 that epithelialisation occurred more speedily in the presence of moisture. Winter's research was published in a one-page report in the journal Nature. Although it went largely unnoticed at first, it was without doubt the stimulus for wound research and the development of technology. As a result, today we have an enormous variety of 'new generation' wound care products that promote moist wound healing principles. It could be said that it was during the late 1960s and early 1970s when the art and science of wound management finally merged. Since then there has been more research into wound healing than ever before. Much of this research has challenged the wound care practices of the past and, for some, also the present (Judy et al, 2000, 26). Practitioners across all disciplines were gradually exposed to new research and technology that was being rapidly generated. Nurses in particular were at the forefront of change and information was disseminated widely through nursing literature and professional meetings. Often there was confrontation among the traditionalists and revolutionists from both nursing and medical disciplines about the use of moist wound healing, topical antimicrobials (especially the sodium hypochlorites), the use of occlusive dressings, clean instead of sterile equipment and other contentious issues (Judy et al, 2000:27). The concept of maintaining a stable wound temperature of around 37C (Hermans & Bolton, 1993:362-5) was a challenge to the wound care ritual of leaving wounds exposed in preparation for medical rounds or dressing teams. The small delays caused to these 'inspection teams' when this practice was discarded in favour of maintaining temperature and promoting mitotic activity in the wound was often interpreted as tardiness on the part of the nurse. Responsibilities and routines were challenged when the scientifically supported move away from antiseptics and frequent wet compress dressings (especially those wet with sodium hypochlorites) favoured the new moisture retention dressings. One nurse manager insisted that the move away from compress dressings would lead to unemployed nurses because they would have nothing to do with their time if they didn't dress wounds! The conflict over the use of antiseptics on wounds was particularly heated and was stimulated by research during the 1980s that demonstrated the cytotoxic effect of antiseptics on the healing wound (Brennan & Leaper, 1985:780-2). Hospital wards, community settings and the literature became battlefields on which were bandied terms such as negligence and malpractice and lists of detriments to healing from both sides of the antiseptic conflict. Frustrated nurses searched and cited the research literature as well as nursing and common law acts to support the removal of sodium hypochlorite disinfectants from treatment rooms to pan rooms. It took almost a decade before collaboration and consensus on this issue reconciled all practitioners to the fact that, although routine use of antiseptics in healthy wounds is detrimental, there is a therapeutic advantage in the appropriate and prudent use of antiseptics in some infected wounds, particularly those with insufficient vascular status to support systemic infection control. Aligned with the antiseptic debate was the issue of asepsis in general. Wound cleaning and dressing rituals which were taught and performed with precision though little consensus, were re-examined. Nurses, it appears, could never agree whether wounds should be cleaned from the inside out, or the outside in, from top to bottom or circumferentially. The most creative approach was a zig-zag method of cleaning that adopted most of the previous approaches! It is hard to imagine that, regardless of direction, we really believed that by wiping a few moistened cotton balls over the wound and periwound skin that we could sterilise the wound and protect it from potential contagins, let alone normal skin flora. Gradually we came to realise that the healthy individual lives in harmony with large numbers of resident bacteria. Dry skin flora averages 10 to 1000 bacteria per gram of tissue, with dramatic increases in the bacterial load of moist tissue, saliva or faeces (Lawrence, 1992:541-61). Resident skin flora will colonise a wound as it does intact skin surfaces, without necessarily being detrimental to healing. A surgical wound is said to be infected if there is a level of bacterial growth of 100000 (10 5) organisms per gram of tissue with the exception of beta haemolytic Streptococcus, which appears to cause infection at levels lower than 10 5 (Robson, 1979:493-503). There is evidence, however, that chronic wounds can contain higher levels of bacteria (Gilchrist & Reed, 1989:337-44) or greater numbers of different species of bacteria (Trengove et al, 1996:277-80) before infection is clinically evident and healing is retarded. It is perhaps a revelation to some to discover that bacteria actually have a positive role to play in healing, for granulation only occurs in the presence of bacteria (Heggers, 1998:389:92). Entrenched beliefs and rituals are being challenged. The clean versus sterile wound care debate remains one of the current controversial issues in wound management and yet it is one of the most under researched. The fact that there is a dearth of research into the use of clean instead of sterile equipment remains a mystery, for the implications to clinical practice and cost-savings are extensive. The meagre amount of research that exists demonstrates no significant difference between a clean or sterile wound dressing technique (Stotts et al, 1997:10-18). However, most practitioners could supply a large amount of anecdotal evidence to support the washing of many wounds and the use of clean instead of sterile dressings. But until there is more credible research to substantiate this practice in all situations, the onus remains on the clinician's ability to assess the person, their wound and their healing environment for compromising factors that warrant the use of sterile equipment (Judy et al, 2000:27-29). Today, there are many more that provide an array of options from an ever-expanding variety of generic categories of dressings. Not only are there more brands available within each generic category of dressings but many manufacturers produce more than one dressing within each generic group or use marketing relationships between international companies to expand their product varieties. We now have wound dressings that, in many instances, resemble multi-layered 'club' sandwiches, for they offer many properties or generic characteristics in one product. Some manufacturers even describe their dressings as 'intelligent' and the novice clinician could be forgiven for thinking that one only has to choose that product and the need for ongoing decision making will be eliminated. In an effort to simplify decision-making, some nurses are restricting their choice of dressing products, not taking advantage of the latest technology. Often this restriction is directed by managers who limit available dressing selections in the belief that it will promote cost containment. Either way it is short-sighted: technology advances, even if practitioners do not. The degree of advancement is evident with the range of topical autologous and exogenous recombinant growth factors, biological dressings and tissue engineering products that are infiltrating the wound care market. The manipulation of human tissue cells to produce cytokines and skin substitutes herald hope for people with chronic wounds or large areas of tissue destruction. As these third generation products become more commercialised and less cost prohibitive they will make obsolete those dressings we use today. In the meantime, the informed clinician must be aware that wound management is more than putting on a dressing and that there is no dressing suitable for every wound or every person: the choice of dressing can only be determined after assessing the needs of the person, their wound and their healing environment. All wounds need to be seen as fragile healing environments and healing must not be retarded by wound practices, pharmaceuticals or dressings that traumatise or litter the wound. The onus is on the nurse, therefore, to be skilled in assessment and to understand the 'too Is-of-the-trade': the mode of action, contents and contraindications of dressings and devices. Infections The task of preventing and controlling infectious disease became fare easier in the 19th century, when Louis Pasteur and other microbiologists discovered the link between bacteria and infection. For a nurse, the goal of infection control is to prevent the transmission of disease among patients, health care workers, and visitors (Marcy et al, 2003:88). For a patient, which has undergone an orthopedic surgery, requires that the nurse takes following precautions while changing the dressing of his wound. Contact Precautions Contact precautions prevent the spread of infectious diseases transmitted by direct contact with the patient (skin-to-skin), patient-care items (bedpans, urinals), or indirect contact with surfaces in the patient's room that are contaminated with the infectious microorganism (Marcy et al, 2003:91). While giving treatment to the patient, keep all contact precaution supplies outside the patient's room in a cart or anteroom. After that the nurse should follow following steps: Situate the patient in a single room with private toilet facilities and an anteroom, if possible. If necessary, two patients with the same kind of surgery may share the room. Explain isolation procedures to the patient and his family. Wash hands before entering and after leaving the patient's room and after removing gloves. Place any laboratory specimens in impervious, labeled containers, and send them to the laboratory at once. Attach requisition slips to the outside of the container. Limit the patient's movement from the room. If the patient must be moved, cover any draining wounds with clean dressings. Notify the receiving department or area of the patient's isolation precautions so that the precautions will be maintained and the patient can be returned to the room promptly (Marcy et al, 2003:93). Droplet precautions Droplet precautions prevent the transmission and spread of infectious diseases caused by large-particle droplets (larger than 5 mm in size) from the infected patient to the susceptible host. Effective droplet precautions require a private room. If the room is not available then the patient which is undergone an orthopedic surgery, if not having any infection must not be shared with a patient having an infection (Marcy et al, 2003:93). Hand washing The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to the patient, or from a staff member to the patient. To protect patients from nosocomial infections, hand washing must be performed routinely and thoroughly. Mechanical removal of microorganisms occurs when the hands are washed with plain soap or detergent; in this process, microorganisms are removed from the hands, which are then rinsed. Chemical removal of microorganisms occurs when the hands are washed with an antimicrobial agent; this process kills or inhibits the growth of microogranisms. The decision as to when hand washing should occur depends on four factors: Intensity of contact with patients or fomites Degree of contamination that's likely to occur with contact Susceptibility of patients to infection (Marcy et al, 2003:95). Intravascular therapy More than 80% of patients require some form of I.V. therapy. Although nurses may not be required to insert all types of I.V. lines, they are responsible for maintaining the lines and preventing complications throughout the therapy. Nurses also assist in minor surgical procedures, such as insertion of central venous and arterial lines. The factors involved in choosing a specific type of I.V. therapy include the therapy's purpose and duration, the condition of the patient's veins, and his diagnosis, age, and health history. Peripheral I.V. therapy, for example, typically involves intermittent or short-term administration of solutions given through the hands, arms, legs, or feet. The most common uses for I.V. therapy are maintaining and restoring fluid and electrolyte balance, administering drugs, transfusing blood, and providing nutrition. The I.V. route allows for rapid, effective drug administration. Commonly infused drugs include antibiotics, thrombolytics, antineoplastic drugs, cardiovascular drugs, antivonvulsants, and patient-controlled analgesics (Marcy et al, 2003:104). Depending on the degree of the complexity, which the patient posses, the following different kind of I.V. methodologies are used: Central Venous Catheter Intraperitoneal chemotherapy Endotracheal administration Peripheral Intravenous therapy In most cases peripheral I.V. therapy is used, which definitely requires administration and maintenance in order to avoid any catheter based external or internal infection. Routine maintenance of I.V. sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, tubing, and solution. These measures help prevent complications, such as thrombophlebitis and infection. Transparent semipermeable dressings are changed whenever I.V. tubing is changed (every 48 - 72 hours), and I.V. solution is changed every 24 hours or as needed. The site should be assessed every 2 hours if a transparent semipermeable dressing i8s used or with every dressing change other wise and should be rotated every 48 to 72 hours. Equipment needed for I.V. maintenance are: For dressing changes: Sterile gloves, povidone-iodine or alcohol pads, adhesive bandage, sterile 2 inches X 2 inches gauze pad, or transparent semipermeable dressing, 1 inch adhesive tape. For tubing changes: I.V. administration set, sterile gloves, sterile 2 inches X 2 inches gauze pad, adhesive tape for labeling, optional: hemostats. For I.V. site change: Commercial kits containing the equipment for dressing changes are available. The nurse, before performing any maintenance activity must wash hands thoroughly to prevent the spread of microorganisms and must wear gloves. Also the nurse must explain the procedure to the patient to allay his fears and ensure cooperation (Marcy et al, 2003:142-3). Blood transfusion reaction Management Usually before or after an orthopedic surgery, blood transfusion is required depending the degree of complexity. During blood transfusion, one of the main constraint is the transfusion reaction. A transfusion reaction typically stems from a major antigen-antibody reaction and can result from a single or massive transfusion of blood or blood products. Although many reactions occur during transfusion or within 96 hours afterward, infectious diseases transmitted during a transfusion may go undetected until days, weeks or months later, when signs and symptoms appear. A transfusion reaction requires immediate recognition and prompt nursing action to prevent further complications and, possibly, death - particularly if the patient is unconscious or so heavily sedated that he cannot report the common symptoms. As soon as the nurse suspect an adverse reaction, she must stop the transfusion and sart the saline infusion (using a new I.V. administration set) at a keep-vein-open rate to maintain venous access. She must not discard the blood bag or administration set and: Notify the physician Monitor vital signs every 15 minutes or as indicated by the severity and type of reaction. Compare the labels on all blood containers with corresponding patient identification forms to verify that the transfusion was the correct blood or blood product (Marcy et al, 2003:174). References AHCPR (1992) Clinical Practice Guidelines: Acute Pain Management: Operative or Medical Procedures of Trauma, Rockville, MD: AHCPR pub. no. 92-0032. Brennan, S. and Leaper, D. (1985) 'The effect of antiseptics on healing: A study using the rabbit ear chamber', British Journal of Surgery, vol. 72, no. 10. Brown, H. (1992) 'Wound healing research through the ages', in Cohen, K., Diegelmann, R. Cohen, F. (1980) 'Post surgical pain relief: Patient status and nurses' medication choices', Pain, vol. 9. Donovan, M., Dillon, P. and McGuire, L. (1987) 'Incidence and characteristics of pain in a sample of medical-surgical inpatients', Pain, vol. 30. Ferrell, B.A., Ferrell, B.R. and Osterwell, D. (1990) 'Pain in the nursing home', Journal of American Geriatric Society, vol. 39. Gilchrist, B. and Reed, C. (1989) 'The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressings', British Journal of Dermatology, vol. 121. Heggers, J. (1998) 'Defining infection in chronic wounds: Does it matter', Journal of Wound Care, vol. 7, no. 8. Hermans, M. and Bolton, L. (1993) 'Air exposure versus occlusion: Merits and disadvantages of different dressings', Journal of Wound Care, vol. 2, no. 6. Judy Lumby, Debbie Picone, (2000), Clinical Challenges: Focus on Nursing. Publisher: Allen & Unwin. Place of Publication: St. Leonards, N.S.W. Lawrence, W. (1992) 'Clinical management of nonhealing wounds', in Cohen, K., Diegelmann, R. and Lindblad, W. (eds) Wound Healing Biochemical & Clinical Aspects, Philadelphia: W.B. Saunders Company. Marcy S. Caplin, Emilie M. Fedorov, (2003), Best Practices, A guide to Excellence in Nursing Care, Lippincott Williams & Wilkins. McCaffery, M. and Pasero, C. (1999) Pain: Clinical Manual, 2nd edn, London, Sydney: Mosby. Puntillo, K.A. and Weiss, S.J. (1994) 'Pain: Its mediator and associated morbidity in critically ill cardiovascular surgical patients', Nursing Research, vol. 43, no. 1. Robson, M. (1979) 'Infection in the surgical patient: An imbalance in the normal equilibrium', Clinics in Plastic Surgery, vol. 6, no. 4. Scarry. E. (1985) The Body in Pain: The Making and Unmaking of the World, New York: Oxford University Press. Southall, D.P., Cronin, B.C. and Hartmann, H. (1993) 'Invasive procedures in children receiving intensive care', British Medical Journal, vol. 306. Stotts, N., Barbour, S., Griggs, K., Bouvier, B., Buhlman, L.,Wipke-Tevis, D. andWilliams, D. (1997) 'Sterile verses clean technique in postoperative wound care of patients with open surgical wounds: A pilot study', Journal of Wound, Ostomy and Continence Nursing, vol. 24, no. 1. Trengove, N., Stacey, M., McGechie, D., Stingemore, N. and Mata, S. (1996) 'Qualitative bacteriology and leg ulcer healing', Journal of Wound Care, vol. 5, no. 6. Walker, A.C., Tan, L. and George, S. (1995) 'Impact of culture on pain management: An Australian nursing perspective', Holistic Nursing Practice, vol. 9, no. 2. Read More

 

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