The Castledine column
Wound care: how well do you dress? George Castledine, University of Central England in Birmingham
my 12-year-old child falls W hen over and grazes herself, like many other children of a similar age she demands a plaster. Usually, the more severe the wound looks, the higher the expectation of a fancy dressing. This curious observation leads me to wonder how relevant such an early experience is to expec tations in later life. Daily dressings
Nurses often say to patients that they will feel better once their wound has been dressed and patients often want to have their wounds dressed daily, especially if they are in hospital. But does it make any difference how often and what type of dressing is placed on a wound? The clinical nurse specialist in wound care will certainly claim that it does, as will the whole army of medical supply manufacturers whose business de pends upon us selecting their dress ing as the one to use in certain con ditions. At the turn of the century the types of dressings were not as adProfessor Castledine is Head of the Depart ment of Nursing and Community Health, at the University of Central England in Birm ingham, Perry Barr, Birmingham B42 2SU British Journal of Nursing, 1992, Vol 1, No 7
vanced as they are today. There was simply not the range of bandages and wound materials about. Look ing back over the pages of the typical nursing text of 1903, instruction re lates very much to procedure and the individual responsibility of the nurse: ‘There is great scope for the care ful observation in the prepara tion of dressings. Some nurses need to be shown this same thing over and over again, while others more intelligent and more careful to notice a great deal for themselves need only to be told once what things will be required for doing different dressings’ (Liickes, 1903). Nurses in those days could easily be divided into certain characteristic groups by their attitude and ap proach to dressings. The same ritual istic habits have been passed on so that even today we often find nurses whose approach to dressing wounds falls into the following categories: 1. First, there is the ‘do it up nicely nurse’ who has cultivated the habit of supreme neatness and finish. Such a nurse will make even the simplest of plasters look fashionable and stylish. Bandaged limbs will represent textbook photographs; sticking plaster and tape will be cut to precision and economical lengths. 2. Second, there is the ‘let me have a pick at it nurse’ who just loves daily dressing rounds and the op portunity to have a go at any type of wound that needs attention. Such a nurse usually thrives on removing dead skin and scales from necrotic wounds. Forceps and scissors are the natural tools of this nurse’s trade. Such an ap proach is seen in the typical sur gical nurse who loves a wound challenge.
3. Third, a complete contrast to the former surgical approach, is the ‘leave it well alone nurse’. Dress ings are quickly and efficiently carried out, but only if they re quire attention. This nurse be lieves in natural healing and let ting nature take its course. 4. Fourth, there is the trendy ‘try anything nurse’ who loves to be using the latest product or new idea. She/he will often be seen visiting all the manufacturers’ stands at a medical exhibition, whereas most nurses go away from such events with a poly thene bag full of pens and cheap promotionals. This wound care nurse takes a sample of each product and usually tries them out, one after the other, on the same patient in the same week. 5 Fifth is ‘the traditional dressing nurse’ who approaches the task of wound care in a fixed habitual way. Her/his technique is firmly rooted in the past and any new product or idea is seen as threatening and unnecessary. 6. Sixth is the ‘academic wound care nurse’ who spends so much time pontificating and theorizing over what could be done that the pa tient’s wound has usually turned septic. Dangerous practice
It is dangerous for a nurse to per form a dressing change without proper education, preparation and experience and it is also upsetting for the patient. The nurse’s judgment is important during assessment and evaluation of wound care, particu larly if the character of a wound changes. Although I have rather lightheartedly referred to some nursing approaches to wound care, there is no doubt that wound care today has
347
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 14, 2019.
Wound care: the art of dressing it up become increasingly scientific and advanced. Utilizing research and carefully integrating theory with practice has resulted in rapid im provements in the nursing manage ment of patients with wound prob lems. Past advice
In the past, nurses were advised to ‘fill their nails with soap’ (Liickes, 1903) when touching wounds or soiled dressings. Today, sterile gloves allow the nurse to handle ma terials more easily without the risk of contamination. Good aseptic technique and thor ough hand washing remain one of the keys to a high standard of wound care. Ironically, so too is the economical use of materials: ‘Nurses cannot begin too early in their career to cultivate econ omical habits in reference to sur gical dressings. Most of them would be astonished to find what a serious item these are in the ex
penditure of every hospital. Nurse would do well to acquaint themselves with the cost of the various dressings in common use as occasionally it will be in their power to use the cheaper dress ing, without detriment to the patient’ (Liickes, 1903). This advice is certainly something that we should all subscribe to even though it is 90 years old. Modern textbooks of nursing ad vise us that the purpose of a dressing is to: protect a wound from micro organisms; aid haemostasis; pro mote healing by absorbing and drainage, and debriding a wound; support or splint the wound site; and ‘hide the wound from the pa tient’ (Potter and Perry, 1985). It is claimed that patients become highly anxiou« over the appearance of a wound and a dressing can hide what is often an unpleasant sight. While I would support this view, particularly with children, I wonder how much such an attitude affects
the crucial question of whether to involve the patient or family in the care carried out. Family involvement
I have found that there is consider able benefit to be gained if the pa tient or significant family member can be involved in participating and observing the progress of the wound. By dressing wounds up too much we may be affecting the long term overall psychological and emo tional response of the patient. The key is, of course, good nurs ing assessment and psychological preparation of the patient before a dressing change. This responsibility is as important as the type of dress ing itself.
Liickes ECE (1903) General Nursing. Kegan Paul, Trench and Trubner, London: 137-9 Potter PA, Perry AG (1985) Fundamentals of Nursing. GV Mosby, St Louis: 1384
British Journal of Nursing 1992 Conferences Nursing the cancer patient
23 June
Royal Marsden Hospital, London
Wound care
22-23 July
University of Birmingham
Quality in cancer care
28 July
Royal Marsden Hospital, London
Dermatology
2 September
Birmingham Polytechnic
Paediatrics
29-30 September
Kensington Town Hall, London
New developments in breast cancer 27 October
Royal Marsden Hospital, London
Haematology
3-4 November
John Radcliffe Hospital, Oxford
Partnership in audit
4-5 November
York Race Course
Head and neck cancer
1 December
Royal Marsden Hospital, London
For further information contact: The Conference Manager, Mark Allen International Conferences, Croxted Mews, 288 Croxted Road, London SE24 9DA. Telephone: 081-671 7521. Fax:081-671 7327
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Downloaded from magonlinelibrary.com by of 129.215.017.190 on January British Journal Nursing, 1992,Voi l,No714, 2019.
Wound care: how well do you dress? George Castledine, University of Central England in Birmingham
my 12-year-old child falls W hen over and grazes herself, like many other children of a similar age she demands a plaster. Usually, the more severe the wound looks, the higher the expectation of a fancy dressing. This curious observation leads me to wonder how relevant such an early experience is to expec tations in later life. Daily dressings
Nurses often say to patients that they will feel better once their wound has been dressed and patients often want to have their wounds dressed daily, especially if they are in hospital. But does it make any difference how often and what type of dressing is placed on a wound? The clinical nurse specialist in wound care will certainly claim that it does, as will the whole army of medical supply manufacturers whose business de pends upon us selecting their dress ing as the one to use in certain con ditions. At the turn of the century the types of dressings were not as adProfessor Castledine is Head of the Depart ment of Nursing and Community Health, at the University of Central England in Birm ingham, Perry Barr, Birmingham B42 2SU British Journal of Nursing, 1992, Vol 1, No 7
vanced as they are today. There was simply not the range of bandages and wound materials about. Look ing back over the pages of the typical nursing text of 1903, instruction re lates very much to procedure and the individual responsibility of the nurse: ‘There is great scope for the care ful observation in the prepara tion of dressings. Some nurses need to be shown this same thing over and over again, while others more intelligent and more careful to notice a great deal for themselves need only to be told once what things will be required for doing different dressings’ (Liickes, 1903). Nurses in those days could easily be divided into certain characteristic groups by their attitude and ap proach to dressings. The same ritual istic habits have been passed on so that even today we often find nurses whose approach to dressing wounds falls into the following categories: 1. First, there is the ‘do it up nicely nurse’ who has cultivated the habit of supreme neatness and finish. Such a nurse will make even the simplest of plasters look fashionable and stylish. Bandaged limbs will represent textbook photographs; sticking plaster and tape will be cut to precision and economical lengths. 2. Second, there is the ‘let me have a pick at it nurse’ who just loves daily dressing rounds and the op portunity to have a go at any type of wound that needs attention. Such a nurse usually thrives on removing dead skin and scales from necrotic wounds. Forceps and scissors are the natural tools of this nurse’s trade. Such an ap proach is seen in the typical sur gical nurse who loves a wound challenge.
3. Third, a complete contrast to the former surgical approach, is the ‘leave it well alone nurse’. Dress ings are quickly and efficiently carried out, but only if they re quire attention. This nurse be lieves in natural healing and let ting nature take its course. 4. Fourth, there is the trendy ‘try anything nurse’ who loves to be using the latest product or new idea. She/he will often be seen visiting all the manufacturers’ stands at a medical exhibition, whereas most nurses go away from such events with a poly thene bag full of pens and cheap promotionals. This wound care nurse takes a sample of each product and usually tries them out, one after the other, on the same patient in the same week. 5 Fifth is ‘the traditional dressing nurse’ who approaches the task of wound care in a fixed habitual way. Her/his technique is firmly rooted in the past and any new product or idea is seen as threatening and unnecessary. 6. Sixth is the ‘academic wound care nurse’ who spends so much time pontificating and theorizing over what could be done that the pa tient’s wound has usually turned septic. Dangerous practice
It is dangerous for a nurse to per form a dressing change without proper education, preparation and experience and it is also upsetting for the patient. The nurse’s judgment is important during assessment and evaluation of wound care, particu larly if the character of a wound changes. Although I have rather lightheartedly referred to some nursing approaches to wound care, there is no doubt that wound care today has
347
Downloaded from magonlinelibrary.com by 129.215.017.190 on January 14, 2019.
Wound care: the art of dressing it up become increasingly scientific and advanced. Utilizing research and carefully integrating theory with practice has resulted in rapid im provements in the nursing manage ment of patients with wound prob lems. Past advice
In the past, nurses were advised to ‘fill their nails with soap’ (Liickes, 1903) when touching wounds or soiled dressings. Today, sterile gloves allow the nurse to handle ma terials more easily without the risk of contamination. Good aseptic technique and thor ough hand washing remain one of the keys to a high standard of wound care. Ironically, so too is the economical use of materials: ‘Nurses cannot begin too early in their career to cultivate econ omical habits in reference to sur gical dressings. Most of them would be astonished to find what a serious item these are in the ex
penditure of every hospital. Nurse would do well to acquaint themselves with the cost of the various dressings in common use as occasionally it will be in their power to use the cheaper dress ing, without detriment to the patient’ (Liickes, 1903). This advice is certainly something that we should all subscribe to even though it is 90 years old. Modern textbooks of nursing ad vise us that the purpose of a dressing is to: protect a wound from micro organisms; aid haemostasis; pro mote healing by absorbing and drainage, and debriding a wound; support or splint the wound site; and ‘hide the wound from the pa tient’ (Potter and Perry, 1985). It is claimed that patients become highly anxiou« over the appearance of a wound and a dressing can hide what is often an unpleasant sight. While I would support this view, particularly with children, I wonder how much such an attitude affects
the crucial question of whether to involve the patient or family in the care carried out. Family involvement
I have found that there is consider able benefit to be gained if the pa tient or significant family member can be involved in participating and observing the progress of the wound. By dressing wounds up too much we may be affecting the long term overall psychological and emo tional response of the patient. The key is, of course, good nurs ing assessment and psychological preparation of the patient before a dressing change. This responsibility is as important as the type of dress ing itself.
Liickes ECE (1903) General Nursing. Kegan Paul, Trench and Trubner, London: 137-9 Potter PA, Perry AG (1985) Fundamentals of Nursing. GV Mosby, St Louis: 1384
British Journal of Nursing 1992 Conferences Nursing the cancer patient
23 June
Royal Marsden Hospital, London
Wound care
22-23 July
University of Birmingham
Quality in cancer care
28 July
Royal Marsden Hospital, London
Dermatology
2 September
Birmingham Polytechnic
Paediatrics
29-30 September
Kensington Town Hall, London
New developments in breast cancer 27 October
Royal Marsden Hospital, London
Haematology
3-4 November
John Radcliffe Hospital, Oxford
Partnership in audit
4-5 November
York Race Course
Head and neck cancer
1 December
Royal Marsden Hospital, London
For further information contact: The Conference Manager, Mark Allen International Conferences, Croxted Mews, 288 Croxted Road, London SE24 9DA. Telephone: 081-671 7521. Fax:081-671 7327
348
Downloaded from magonlinelibrary.com by of 129.215.017.190 on January British Journal Nursing, 1992,Voi l,No714, 2019.
