Implications of the Use of the Myiasis for Nurse and Patient - Term Paper Example

Nursing Wound & Pain Management Part A – Wound Management – Maggot Therapy/Bio-surgery (Myiasis) Introduction: Removal of slough or necrotic tissue (debridment) is a key component in wound management towards early healing of the wound. For a patient wounds are painful and can result in long periods of immobility, while from the perspective of the nursing professionals caring of wounds is demanding with the need to maintain the wound site in a condition amenable to the healing process. Any intervention that assists in quicker healing thereby reducing the morbidity of the patient and the demands on the nursing professionals need to be evaluated as it improves the quality of wound management. Maggot therapy or bio-surgery (Myiasis) is one such intervention strategy with known benefits in wound healing and management (Lau & Lee, 2000). Bio-surgery or Myiasis: Treatment of wounds using maggots or fly larvae is not a newly developed procedure, as it has been used since ancient times, but was discouraged in by modern medicine as it was believed to be a filthy process. Several factors have seen the resurgence of myiasis by the end of the twentieth century, including the concern with increasing microbial resistance to powerful antibiotics and the realization that maggots remove necrotic tissue effectively, safely and in a simple manner (Sherman, Hall & Thomas, 2000). Furthermore myiasis has also been found to be effective in cases where the conventional procedures of debridement have not been successful (Bonn, 2000). The larvae preferred in bio-surgery are the larvae of the green bottle fly Lucilia sericata (Benbow, 2007). The exact manner in which maggots debride wounds is yet to be found. However, the mechanisms involved in debridement by maggots is believed to involve ingestion and destruction of bacteria, exertion of a bacteriostatic effect through the increase in pH level of the wound, secretion of proteolytic enzymes that are critical to eschar degradation and increase in tissue oxygenation levels (Enoch, 2003). Air and moisture are essential for the survival of maggots and for wound debridement and the wound site needs to be well lubricated and well supplied with oxygen in the use of myiasis. Myiasis is not used for wounds within the body cavity (Benbow, 2007). Initial studies on the antimicrobial activity have shown myiasis to be effective in the case of wound infections from Staphylococcus aureus and Streptococcus A and B, and partial activity against Pseudomonas and methicillin-resistant Staph. aureus (MRSA), because of their antimicrobial activity against these pathogens. (Benbow, 2007). More recent evidence of the antimicrobial activity of maggots indicate that they are useful in wounds infected with Gram-positive bacteria, like Staphylococcus aureus, but not so much for wounds infected with Gram-negative bacteria, especially Proteus spp. and Pseudomonas spp. strains. In addition, Bacteria from the genus Vagococcus demonstrate resistance to larvae secretions (Jaklic, et al, 2008). This indicates that myiasis may be more beneficial in manageing some wounds and use of myiasis may be selective. Wound dressing with larvae requires special techniques and skills to ensure that the maggots remain in a condition to clean the wound and address the squeamish feelings that may arise in patients. To address the concerns of squeamish patients specially created biobags are becoming popular in the use of larvae for debridement. In these bags the maggots are completely enclosed within a polyvinylalcohol membrane and not visible to the patient and do not have to be handled by the nursing professionals. The larvae are able to feed on the necrotic tissue through the open cell polymer and at the same time are not easily visible to the patient or the nursing professional (Parnes & Lagan, 2007). Larvae are used with discretion in wound management. The number of larvae to be employed in the debridement is governed by several factors, which include wound size, percentage of wound comprising slough/necrotic tissue and the kind and thickness of slough. The thumb rule in the use of maggots is not more than 10 larvae/sq. cm. (Benbow, 2007). According to Parnes and Lagan, 2007, myiasis has been found to be useful in the management of a wide range of wounds that include arterial leg ulcers, osteomyelitis, necrotising fasciitis, traumatic necrotic leg wounds, primary burns, pressure sores, diabetic foot ulcers and amputation sites including digital amputations in diabetic feet, due to the effective debridement of devitalised tissue that led to rapid development of granulation tissue. Some drawbacks have been associated with associated with myiasis. Pain has been reported by patients with ischaemic wounds that my have been caused by sharp mouth hooks that the larvae used to fix themselves to the wound site. Another possible cause is that the changes in pH level at the wound site may have an impact on the pain receptors of the healthy tissues in proximity to the wound site. There is evidence to suggest that myiasis is contraindicated in managing wounds associated with fistulae, exposed blood vessels and wounds connected to vital organs (Parnes & Lagan, 2007). In Australia the use of myiasis is yet to become a popular wound management measure. However, there are signs that that maggot therapy is on the ascendancy in Australia, given that increased demand for sterile maggots has caused the Department of Medical Entomology, Institute of Clinical Pathology and Medical Research (Westmead Hospital) to set up facilities for the production and supply of sterile Lucilia sericata larvae for use in Australia and abroad. The factors that are influencing the increased use of myiasis in wound management include increasing incidence of soft-tissue wounds, increased prevalence of diabetes mellitus, increasing bacterial resistance to antibiotics and low costs involved in the use of myiasis (Geary & Russell, 2004). Implications of the Use of the Myiasis for both Nurse and Patient: Maggots bring to mind thoughts of decay and rotting and this has an impact on the patients, as well as the nursing professionals. This revulsion on seeing and handling maggots that deters the use of myiasis is termed the “yuk” factor, which is applicable to the patients as well as the nursing professional involved in the use of myiasis in wound management. The nursing professional has to handle the maggots in the placement at the wound site, while the patients get a creepy feeling when the larvae are placed in the wound and has to live with it during the intervention procedure in wound management (Steenvoorde, Buddingh, Engeland & Oskam, 2005). The use of biobags can go a long way in mitigating the negative emotions that arise in the patient and the nursing professional. Biobags come with larvae in them and can be applied to wound sites for a period of up to five days that allow changes in the outer dressing. (Benbow, 2007). The use of biobags prevents the nursing from having to handle the larvae directly and prevents the patient from viewing the larvae. Part B – Pain Management Introduction: Assessing pain in a patient is crucial to the management of pain in the patient. Appreciating pain experienced by an individual and taking the necessary steps for its alleviation is a challenge to both the medical as well as the nursing professionals. This is particularly so in the case of the elderly, because of the confusion in them due to their condition and also because of the likelihood of the cognition difficulties in them because of age. With the population segment of the elderly in all societies on the increase due to increasing life spans, the challenge of pain assessment and management in the elderly becomes an issue of that calls for serious attention (Ware et al, 2006). Assessing Pain in the Elderly: A very large percentage of the elderly suffer with some form of pain arising from any of the several conditions or diseases that have come with age, which has an impact on their quality of life. Control of pain in the elderly population is quite often insufficient because of they underreport the pain because of the decline in communication and comprehensive abilities of the elderly because of their confused state or due to dementia. There have been several developments in pain assessment tools to remove the deficiencies in the management of pain in the elderly. Evidence from studies suggest that in spite of these developments in pain assessment tools, satisfactory pain management in the elderly particularly when they are confused or suffer from dementia is still to be achieved. The possible reason attributed for this is the unfamiliarity of the medical and nursing professionals with the pain assessment tools (Pautex & Gold, 2006). Pain Assessment Tools: There are several ways in which people communicate when they experience pain. Self-reporting and non-verbal expressions are among the means used to communicate the experiencing of pain. This has led to the development of pain assessment tools based on self reporting and non-verbal expressions as separate entities (Hadjistavropoulos et al, 2002). According to Zwakhalen et al, 2006, self-reporting is frequently taken as the ‘gold standard’ in pain assessment. In self-reporting the component of pain that is normally assessed is the intensity of pain. The Visual Analogue Scale (VAS) is one such common tool used for the assessment of pain (Zwakhalen et al, 2006). Self-reporting has however a draw back in that it is useful only when the patient can communicate clearly and is often impacted by the moods and culture of the patient (Leong, Cheong & Gibson, 2006). Patients that are unable to self-report pain, like the confused elderly or patients with dementia, require other means for pain assessment, which may include observation of patient behaviour, pathology or estimates of pain by others (Herr, et al, 2006). The Pain Assessment Tool in Confused Older Adults (PATCOA) uses non-verbal cues in the assessment of the elderly experiencing acute confusion (Decker & Perry, 2003). Comparison of the VAS and the PATCOA: The VAS has been used and validated through studies for the assessment of acute and chronic pain and is used in the elderly. It assesses the intensity of pain through a ten centimetre horizontal line on paper with the two extremes of no pain and worst pain at either ends. The patient indicates the intensity of pain felt by marking it as a position on this ten centimetre horizontal line. It requires understanding of the line concept and judgment in the patient, which may be difficult in elderly patients in the confused state. This is the clinical limitation in the use of VAS (Cork, et al, 2004). PATCOA employs nonverbal cues like quivering, guarding, frowning, grimacing, clenching jaws, points to where hurts, reluctance to move, and vocalizations of moaning and sighing in assessing the pain being experienced by the patient. It does not require the patient to use pen and paper or express the experience of pain, which is useful in patients that are not capable of proper expression of their condition, which may be the case in the elderly in an acute confused state (Decker & Perry, 2003). Herr, et al 2006, suggests a hierarchy in the use of pain assessment tools for assessing pain in patients. This hierarchy requires the use of a self-reporting tool in pain assessment, as it is the most useful tool for pain assessment when patients are capable of self-reporting. It is only when patients are not capable of self-reporting, as may be the case of confused elderly patients or elderly patients with dementia that non-verbal pain assessment tools come into picture (Herr, et al, 2006). From Pautex, et al, 2005, comes the finding that even in cases of mild to moderate dementia, self-reporting pain assessment tools like the VAS remain relevant, as these patients show the capability of reliable use of these pain assessment tools. The Decker and Perry, 2003, study that compared VAS and PATCOA in pain assessment of the confused elderly also report no significant differences in the pain assessment capabilities between these two pain assessment tools. Implications of Patient Assessment Tools for both Nurse and Patient: The continued development of pain assessment tools using self-reporting and nonverbal cues is progress in the direction of more satisfactory assessment of pain that leads to more effective pain management. These tools enable assessing pain through the experiencing of pain as reported by the patient and even when such reporting is not possible like in acute confusion in the elderly or in severe dementia. So the elderly patients can be assured that there are tools to assess their pain irrespective of the state that they are in. For the nursing professional the implications are in the selection and use of the available tools. In the first place there is the requirement to fully understand the pain assessment tool and how to use it (Pautex & Gold, 2006). The next issue is in the use of the right assessment tool at the right time. This means taking time to select the appropriate pain assessment tool for each patient, keeping in mind the individuality and state of the patient and the pain assessment hierarchy. Finally, when making use of a self-reporting pain assessment tool time has to be taken in making the patient understand the tool. In the elderly, particularly those in the confused state or those with mild dementia this may prove to be more demanding, but given the usefulness of self-reporting this becomes a part of meeting the care demands of the patient and maintaining the standards of the nursing profession (Pautex & Gold, 2006). . Literary References Benbow, M. (2007). An update on larval therapy. Practice Nurse, 34(9), 16-20. Bonn, D. (2000). Maggot therapy: an alternative for wound infection. THE LANCET, 356, 1174. Cork, C. R., Isaac, I., Elsharydah, A., Slaeemi, S., Zavisca, F. & Alexander, L. (2004). A Comparison Of The Verbal Rating Scale And The Visual Analog Scale For Pain Assessment. The Internet Journal of Anesthesiology, 8(1), Retrieved May 8, 2008, from Web Site: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ija/vol8n1/vrs.xml Decker, A. S. & Perry, G. A. (2003). The Development and Testing of the PATCOA to Assess Pain in Confused Older Adults. Pain Management Nursing, 4(2), 77-86. 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