CHAPTER 2: LITERATURE REVIEW

2.1.1 INTRODUCTION

Skin is the outer covering of the body. In humans, the integumentary system is the
largest organ. The normal skin flora includes Staphylococcus, Streptococcus, Acinetobacter,
Peptococcus and yeast. Intact skin may be contaminated with up to 103 microorganisms per
gram of tissue without any effect on tissue healing. Once the skin is destroyed in any accident
or operation, wounds or trauma will occur. The introduction of foreign objects into the wound
surface may also cause contamination. Therefore, Dr. Malarvizhi, 2018 mentioned that
wound contamination occurs endogenously or exogenously through the patient’s own flora,
and microorganisms are introduced through external sources (such as the hands of healthcare
professionals).Malarvizhi (2018)
Wound infection is the most common serious infection after surgery, which can lead
to longer hospital stays and increased treatment costs. Xiao-ling Huang, 2015 said that the
critical period for establishing an infection is within the first few hours after the wound is first
infected by bacteria. In general, attention needs to be paid to the recovery of wounds,
especially severe wounds, and bacterial infections. If the wound is bleeding, large, deep or
infectious, it must be treated and monitomanagJun Lei, 2019 cited that the recovery and
management of severe wounds is a complex and collaborative process, including the
treatment and treatment strategies of infectious disease prevention bacteria, with the
participation of doctors, nurses, patients, pathologists and wound specialists .Xiao Liang
Huang (2015)
No citation in this paragraph In particular, the application of wound dressings plays a
vital role in wound healing and infection prevention. There are many different types of
wound dressings, such as silver-containing hydrophilic fiber dressings, antibacterial dressings
and wet dressings. According to different materials, they can be divided into foam gauze,
transparent film, alginate, composite material, hydrocolloid and hydrogel. These dressings
show their own advantages and disadvantages in wound management. They are often used in
our conventional wound treatment. At the same time, high-quality dressings with ideal
functions will speed up wound healing, relieve patient’s pain and prevent wounds from being
infected by bacteria.
No citation The most important part of wound management is the use of aseptic
techniques to change the dressing of patients with open surgical wounds. Sterile dressing
technique has been used to help heal and avoid infection, and is considered the ‘gold
standard’ for the surgical wound management. Aseptic technique refers to specific procedures
performed before and during invasive surgery to prevent surgical site infections (SSIs) and
other infections acquired in hospitals, ambulatory surgery centers, physician offices and all
other areas where invasive surgery is performed. If practiced correctly, aseptic technique can
help reduce microbial contamination of the surgical site and reduce the number of microbes
in the operating room and other clinical environments. Creating, maintaining and monitoring
sterile areas can improve patient outcomes. When preparing, performing or assisting in
operations and other invasive procedures, the use of aseptic techniques is essential to ensure
environmental safety and prevent patients and medical staff from infections related to
medical treatment. Perioperative nurses and all other medical and surgical personnel involved
in surgery and other invasive procedures should improve the safety of patients and workers
by practicing correct aseptic technique and by identifying, questioning or stopping unsafe
behaviors.
Surgical wounds account for the vast majority of skin injuries. A study done by
Dhanasundari. G, 2018 estimated that more than 234 million major surgical procedures are
performed each year worldwide. In the United States, 750,000 gall bladder surgeries, 20
million hernia surgeries, 100,000 to 120,000 radical prostatectomy surgeries, one million
cholecystectomies, 150,000 gastric bypass surgeries were performed each year. Therefore, it
is believed that the use of aseptic technology is necessary to create a healthy environment in
medical institutions. Citation should be Dhanasundari (2018).
Various effects may lead to the occurrence of wounds, which may lead to the
immediate loss of all or part of the organ’s function, sympathetic stress response, hemorrhage
and blood clotting, bacterial contamination and cell death. Careful aseptic operation is the
most important factor in minimizing these effects and promoting successful wound care. Ms.
Anjumol. P.S, 2016 declared that it depends on the nurse’s knowledge and understanding of
normal wound healing physiology, closure methods and the optimal treatment of the wound
and with this knowledge, nurses can provide a systemic and holistic patient assessment, and
consider any potential complications related to the wound.citation should be Anjumol (2016)

2.1.2 KNOWLEDGE

Wound at surgical site can be prevent from infections if the student nurse’s
knowledge and skills adequate in performing dressing procedure. Imprevention of post-
surgical wound site infection high number of nurses having lack of knowledge and it was
conducted by a study by Nigeria, mentioned by Famakinwa, T.T, Bello (2014). Citation
wrong It was supported with the data collection which is the estimated cases on wound site
infection at Pakistan stated the high number of cases. From this we know, student nurse’s
understanding can prevent from infection of the wound site and it was supported by Haleema
Sadia (2017).

From Haleema Sadia (2017), point of view illustrated that nurses that low in
knowledge may one of the reason who transfer infection to the patient especially at the
wound site. Therefore, Darawad et al (2013), showed a research which is the majority
nursing students encounter lack of awareness, a helpful attitude thus average application on
disease control which is one of that is dressing procedure. The higher the frequency of
changing dressing the lower the risk of complications, Christina Lindholm, Searle (2016).
This is because high knowledge required in performing dressing procedure by maintaining
aseptic technique also it can reduce transmission of microorganism to the wound site.

Infection Control and Hospital Epideomology (2013) published an article which was
the data stated there are 4.5% to 5.7 billion patients every year was affected with infection
because of health professions does not maintaining aseptic technique while performing
dressing procedure. Poor knowledge in dressing procedure can affect the level of
performance in providing a good dressing and delay the wound healing process. Haleema
Sadia (2017), demonstrated that well organized knowledge will ease the patient health
condition thus reduce risk of getting infection at the hospital. Besides that, deficiency of
awareness in performing dressing might introduce new pathogens to the wound site therefore,
increase risk in developing secondary complications such as wound ischemia and purulent
pus. From this we can know that nurses are recognizing as captain of obstruction of disease.

2.1.3 ATTITUDE

A good attitude is essential for nursing students in learning process. As what MINK
(2019) said, maintain extraordinary effort until you do. It is necessary to study notes before
go to clinical practices as it is the responsibility of students to always get well-prepared with
knowledge. Nursing students should have a good learning effort in order to increase
competencies in dressing procedure to ensure proper effective dressing procedure can be
carried out and bring benefit to patient. Most student nurse or nurse which having good
attitude no matter in taking care of patient or performing procedure, it increases the rate of
healing and bring lot of benefits to patient such as promote granulation tissue formation,
decrease risk of infection and other which as what we learn during nursing ethics which is
beneficial. However, some nurses having poor attitude and practice on performing procedure
such as dressing on patient might bring a lot of chronic complication to patient such as
delayed wound healing, infection . Need citation

Dressing procedure not only need knowledge, it also need nursing students to have a
positive and proactive attitude. Nursing students should focus on taking care of patient
condition instead of taking crosses, this is because having a proper practice towards a patient
will not only increase the student performance but it will ensure the patient receive the
nursing care that they deserve. By implying this in clinical field, it will be very useful for
them to take care of patient when they start to work. Instead of that, at the same time by
doing a proper dressing procedure towards the patient it will ensure the patient can avoid
from any source of infection and secondary diseases cause by the wound.need citation

When the sterile field is contaminated, students should take it as a serious matter as it
may bring harm to patient and not just let it be. It is very vital for nursing student to
understand the importance of sterility because sterility involve the safety of patient, dressing
procedure is done on exposed wound this mean patient have high chances of carry infection
in much shorter period of time and also infection they will get can give negative impact
towards the patient. Other than that, this is also consider unethical because the student is
being negligence to patient. Hence, student is strictly not allowed to be negligence to patient,
this is stated by (lawhandbook, 2013) negligence is a failure to take reasonable care to avoid
causing injury or loss to a person.

2.1.4 COMPETENCIES

According to Zheng (2019), wound dressing is vital to promote wound healing

process. Delayed wound healing and growth of new tissue may increase the risk of exposure
to microorganism which can cause infection and worsen the wound condition. Effective
wound dressing can ensure good wound healing process. This statement is supported by Lei,
Sun, Li, Zhu, Lin et al (2019), mentioned that a good wound dressing will speed up wound
healing. Thus, nursing students must have adequate competencies in performing dressing
procedures as it will bring patient to hazard if not possess enough dressing skill.
 Students should know how to maintain sterile field such as always keep sterile hand in
sterile field to prevent contamination. Invasive microorganism may be introduced to patient’s
wound and cause infection if aseptic technique is not maintained. Wound contamination
results from failure in maintaining sterility will bring burden to patient physically, mentally
and economically. This statement is supported by Pieter (2020), who stated that post-
operative wound complication (PWCs) will increase morbidity, mortality and costs.
Complication such as sepsis will bring harm, stress and burden to patient as patient may
experience pain,suffer and face costly treatment. This condition may end up in amputation if
the infection not treated well.

Beside that, nursing students should also have the competencies in assessing wound
condition as it is part of documentation in dressing procedure. Before performing dressing
procedure, students need to assess wound condition by observing granulation of new tissue
and wound surrounding to determine wound healing process. According to Graves (2017),
presence of new tissue grow over the wound indicates that the wound starts to heal. Wound
assessment is important in dressing procedure because it enable health care provider to
determine the effectiveness of dressing. Students need to possess adequate competencies in
wound assessment so that able to sense any signs of wound infection, report to doctor and
change the type of dressing in order to promote good wound healing.

Hence, nursing students should have the responsibility to improve and maintain competencies
in performing dressing procedure to prevent any contamination and ensure wound healed in
well condition.