2.

REFLECTIVE PRACTICE WRITE UP

2.1.DESCRIPTION

In the second week of 8th November 2017, around 7am I was in the general

operation theater in hospital K. I was placed in Plastic Surgery Room. On that

day, there were two procedures that scheduled in the operating theatre. First

case was Right Cleft Lip and Alveolus for Right Lip Repair Surgery then the

second case was Tuberous Sclerosis Forehead for Serial Excision Surgery. I

asked for the permission from the surgeon and the sister incharged to scrubbing

in the case.

Right Cleft Lip and Alveolus for Right Lip Repair Surgery was my first experience

as a scrub nurse in operation theatre. About 7.00am I and the scrub nurse X

prepared the operating room and necessary instrument for the lip repair surgery.

Around 8.00am the patient was pushed in into the operating room then the

patient was transferred to the operating table to be given a general anesthetic.

General anesthesia (GA) is the state produced when a patient receives

medications for amnesia, analgesia, muscle paralysis, and sedation. An

anesthetized patient can be thought of as being in a controlled, reversible state of

unconsciousness. Anesthesia enables a patient to tolerate surgical procedures

that would otherwise inflict unbearable pain, potentiate extreme physiologic

exacerbations, and result in unpleasant memories according to Press, D. C.

(2015).

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Around 8.30am I and scrub nurse X went to surgical scrubbing and put on sterile

gowns before preparing the necessary instruments during the surgery. I was a

second scrub nurse with a scrub nurse X and assisted by a circulating nurse M.

We were using the plastic surgery set. I provided infiltration injection using dental

syringe and dilution for infiltration adrenaline 0.5ml and added with sterile water

9.5ml for child below 20kg to reduce bleeding during incision. According to

Goranovic, T,. Pirkl, I. & Parazajder, D. (2011). Use of vasoconstrictors (e.g.

adrenaline) to reduce the nasal blood flow and optimize the surgical field in the

surgical procedure on nasal field provides good haemostasis, improves visibility

of a surgical field and decreases blood loss. Before the incision, the doctor uses

the skin marker and caliper to mark and measure the lip and doctors give

injection infiltration after marking and start making incision on the lip.

When closing the mucosa, the doctor using vicryl 4/0 round body and braided

absorbable and stitched the skin with monosyn 6/0 cutting and absorbable. There

is long standing disagreement among facial plastic surgery surgeons as to the

ideal suture material for closing the skin wound of the face. Many surgeons

believe that nonabsorbable suture material is preferable, as it is easier to tie, is

unlikely to break prematurely and elicits a minimal inflammatory response.

Others feel that these issues are of minor importance and prefer absorbable

suture because they do not have to be removed, thus saving the surgeon time

and decreasing patient anxiety and discomfort according to Parell, G. J (2003).

After that, they cleaned the wound first near the incision site then away from

incision site. Scrub nurse X discarded the first glove before applying the wound

7
dressing to avoid contaminating the wound. Aseptic technique is also important

when cleaning the surgical wound before applying dressing as it also affects

wound healing according to Rowley, E. A. (2010). Surgical aseptic technique is a

method employed to maintain asepsis and minimize the risk of introducing

pathogen into surgical wound. According to Philips, N. (2013). It protects the

patient from the impact of healthcare associated infection such as delayed

recovery, longer hospitalization, increased pain and increased morbidity.

The circulating nurse M gave me a Melolin Non-Adherent of dressing, usually I

used Primapore dressing at my workplace before and I was wondering why they

used the type of Melolin dressing to be placed in the surgical wound of the

patient and the nurse told me that the type of Melolin dressing suitable for plastic

surgery because it did not cause an irritation effect or damage to regenerate

tissue. According to Robb, W. A. T (1961) the results of a clinical trial of a new

type of wound dressing Melolin are reported. Its non-adherent quality with

consequent comfort to the patient and avoidance of trauma to the wound is

impressive. The absence of any irritant effect or damage to regenerating tissue

promotes the natural process of wound healing.

Before applying the dressing, the scrub nurse X applied the Chloramphenicol

(CMC) ointment on the surgical site wound. According to Heal, C. F,. Buettner, P.

G,. Cruichshank, R,. Graham, D,. Browning, S,. Pendergast, J,. & Drobet, H.

(2009) state that add good evidence to the common plastic surgery plastic (in the

UK) of chloramphenicol ointment on cutaneous wound, to prevent surgical site

infection.

8
I had learned the similarities and differences that I had observed from our

practices back home and from what I was practice here. I noted the different

types of dressing used and the different surgery regarding management of

wounds care. There are a multitude of dressings to choose from and selecting

the right one is crucial to promoting healing, as the wrong dressing can

significantly hinder a wound from healing. A good understanding of how wounds

heal, the dressings available and how they work should enable nurses to make

an appropriate selection according to Hampton, S. & Collins, F (2015).

9
2.2.FEELING

2.2.1. Before Experience

I am feeling excited because before this I never followed or seen how lip repair

was done for patients with cleft lip and alveolus. I also feel lucky can assist the

surgery along with plastic team assigned to be there and I was feeling curious

how the doctor will perform the surgery.

2.2.2. During Experience

I was feeling determined because that was my first experience to scrub in for lip

repair surgery. When preparing the instrument, I feel lucky and learned

something new like providing infiltration injection, according to Goranovic, T,.

Pirkl, I. & Parazajder, D. (2011). Use of vasoconstrictors (e.g. adrenaline) to

reduce the nasal blood flow and optimize the surgical field in the surgical

procedure on nasal field provides good homeostasis, improves visibility of a

surgical field and decreases blood loss. I also learned to recognize the

instrument in the plastic surgery and I have opportunity to know how the surgery

is done.

2.2.3. After Experience

I feel surprising when the staff nurse told me the purpose of melolin dressing,

before this I never used melolin dressing for plastic surgery. According to Robb,

W. A. T (1961) the results of a clinical trial of a new type of wound dressing

Melolin are reported. Its non-adherent quality with consequent comfort to the

10
patient and avoidance of trauma to the wound is impressive. The absence of any

irritant effect or damage to regenerating tissue promotes the natural process of

wound healing.

The whole practical gave me the opportunity to know types of the dressing each

procedure to use for wound care when performing procedures of managing

surgical wound. Every time I finish assisting any surgery, I learned a lot of

different types of dressing wound with different surgery. I feel relieved knowing

that I am enhancing my skill in this aspect more and more and knowing that I am

more self- assured with the experience I’ve had. According to Hampton, S. &

Collin, F. (2013) state that in order to heal quickly and cleanly, wounds need an

optimum healing environment at all these stages nurses can achieve this by

selecting and applying the right dressing at the right time.

According to Broussard, C. K. & Power, J. G (2013) appropriate wound dressing

selection is guided by an understanding of wound dressing properties and an

ability to match the level of drainage and depth of a wound. Wounds should be

assessed for necrosis and infection, which need to be addressed prior to

selecting an ideal dressing. Moisture-retentive dressings include films, hydrogels,

hydrocolloids, foams, alginates, and hydrofibers and are useful in a variety of

clinical settings. Antimicrobial-impregnated dressings can be useful in wounds

that are superficially infected or are at higher risk for infection. For refractory

wounds that need more growth stimulation, tissue-engineered dressings have

become a viable option in the past few decades, especially those that have been

approved for burns, venous ulcers, and diabetic ulcers. As wounds heal, the ideal

11
dressing type may change, depending on the amount of exudate and depth of

the wound thus, success in wound dressing selection hinges on recognition of

the changing healing environment.

I will become more confidence for providing patient education and focus on

principle on wound care, hygiene and prevention of complication and surgical site

infection. Aseptic technique is always applied whenever I touch the patient

wound to prevent infection. Every time I come in contact with the patient’s

surgical wound, I always keep these principles in mind. According to Stephen, C.

(2017) aseptic technique aims to prevent pathogenic organisms, in sufficient

quantity to cause infection, from being introduced to susceptible body sites by the

hands of staff, surfaces or equipment. It protects patients during invasive clinical

procedures by utilizing infection prevention measures that minimize the presence

of micro-organisms.

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2.3. EVALUATION

2.3.1. Positive Aspect

The whole experience gave me a lot of positive aspect for me. I understood more

about topics such as wound assessment and wound care and I was more familiar

with the different dressings commonly used in different discipline of the surgery.

There are a multitude of dressings to choose from and selecting the right one is

crucial to promoting healing, as the wrong dressing can significantly hinder a

wound from healing. A good understanding of how wounds heal, the dressings

available and how they work should enable nurses to make an appropriate

selection according to Hampton, S. & Collins, F (2015).

Another new experience for me when I was showed the scrub nurse using

Melolin Non-Adherent dressing to cover the surgical wound site after clean the

surgical wound at Plastic Surgery Unit. The results of a clinical trial of a new type

of wound dressing Melolin are reported. Its non-adherent quality with consequent

comfort to the patient and avoidance of trauma to the wound is impressive. The

absence of any irritant effect or damage to regenerating tissue promotes the

natural process of wound healing according to Robb, W. A. T (1961).

Wound dressings are designed to help healing by optimizing the local wound

environment. There is little evidence that any dressing is superior to another. The

main reasons that we apply dressings include the following to provide rapid and

cosmetically acceptable healing, to remove or contain odour, to reduce wound-

related pain, to prevent or treat infection, to contain exudate, to cause minimum

13
and distress or disturbance to the patient according to Edward, H,. Gibb, M,.

Finlayson, K. & Jessen, R. (2013).

Dressing selection is based on, the cause (aetiology) of the wound,

characteristics of the wound including location, extent of tissue damage (depth),

wound size, phase of healing, level of exudate, pain, odour and last infection.

2.3.2. Negative Aspect

The whole experience also gave me a little negative aspect as I did not

emphasize the use of wound dressing for patients according to the type of

surgery to be performed and I also did not try to understand how wound healing

affected the selection of wound dressing according to Hampton, S. & Collins, F

(2015) there are a multitude of dressings to choose from and selecting the right

one is crucial to promoting healing, as the wrong dressing can significantly hinder

a wound from healing. A good understanding of how wounds heal, the dressings

available and how they work should enable nurses to make an appropriate

selection.

If I have no knowledge in the selection of wound dressing, surgical wound in the

patient will be slowly healed or will cause worse wound condition. According to

Daley, J. B. (2017) advances in the technology of wound dressings meant to

accelerate wound healing times are supported by evidence that maintaining the

right wound environment, whether dry or moist, optimizes the natural healing

process. When improperly dressed, wounds of all severities may heal

14
inappropriately, producing negative effects that include infection, blistering, and

scarring that impede wound healing.

Optimal management of post-operative wounds in the community is important to

prevent potential complications such as surgical site infections and wound

dehiscence from developing. As such, general practitioners, who play an

important part in the sub-acute management of post-operative wounds, should

appreciate the physiology of wound healing and the principles of post-operative

wound care according to Yao, k., Bae, L., & Yew, W. P. (2013).

Optimal wound dressings will protect surrounding healthy skin, support autolytic

debridement, and absorb exudate. Unless wound dressings possess these

characteristics, problematic wound healing is likely to occur that could lead to

serious conditions such as necrosis and infection according to Daley, J. B.

(2017).

15
2.4. ANALYSIS

Looking at the whole experience had improved my knowledge about great deal of

learning about wound management. During the surgery I noticed that the scrub

nurse X practice aseptic technique when clean the wound. According to Philips,

N. (2013) surgical aseptic technique is a method employed to maintain asepsis

and minimize the risk of introducing pathogen into surgical wound. Besides that,

the scrub nurse X used normal saline to clean the wound. According to Beam, W.

J. (2006) many cleansing solutions have demonstrated safe and effective results,

whereas others may damage and destroy cells essential to the healing process.

Normal sterile saline is regarded as the most appropriate and preferred cleansing

solution because it is a nontoxic, isotonic solution that does not damage healing

tissues.

In addition, the scrub nurse X put the chloramphenicol ointment (CMC) on the

surgical site wound. According to Heal, C. F,. Buettner, P. G,. Cruichshank, R,.

Graham, D,. Browning, S,. Pendergast, J,. & Drobet, H. (2009) state that add

good evidence to the common plastic surgery plastic (in the UK) of

chloramphenicol ointment on cutaneous wound to prevent surgical site infection.

Chloramphenicol has a broad spectrum of activity against Gram positive and

Gram negative bacteria and anaerobes.

All nurses should have the knowledge of the choice of dressing according to the

type of wound and type of surgery to prevent the condition of the surgical wound

to worsen or cause surgical site infection and delay healing of wounds. Like all

16
wounds healing is affected by intrinsic and extrinsic factor that may result in

complication according to Baxter (2003). Surgical complications include infection,

dehiscene, evisceration or bleeding at the surgical site.

Optimal management of post-operative wounds in the community is important to

prevent potential complications such as surgical site infections and wound

dehiscence from developing. As such, general practitioners, who play an

important part in the sub-acute management of post-operative wounds, should

appreciate the physiology of wound healing and the principles of post-operative

wound care according to Yao, k., Bae, L., & Yew, W. P. (2013).

Figure 1: Melolin consists of a film of poly(ethylene terephthalate), onto which is

bonded an absorbent layer consisting of a mixture of cotton and polyacrylonitrile

fibres, backed with a layer of an aperture non-woven cellulose fabric. The plastic

film is present to prevent the dressing adhering to the surface of the wound, and

is perforated to allow the passage of exudate from the wound into the body of the

pad.

17
2.5. ACTION PLAN

When the circulating nurse M give the Melolin dressing, I ask the circulating

nurse M on the time what is the melolin dressing for and why? Then the

circulating nurse M replied it is use for dressing and suitable for plastic surgery

because it did not cause an irritation effect or damage to regenerate tissue. I

would be faced with more opportunities for learning, I would not hesitate to grab

them I should learn to be more assertive the next time and try my best to find

more ways of achieving professional development.

In the future, I will continue my learning about surgical wound management by

keeping myself up to date about topic and regularly reading new literature. I

would also want to know more about other types of dressings that I am not

familiar with and find more avenues of learning through trainings and knowledge

updates. According to Hampton, S. & Collins, F (2015) there are a multitude of

dressings to choose from and selecting the right one is crucial to promoting

healing, as the wrong dressing can significantly hinder a wound from healing. A

good understanding of how wounds heal, the dressings available and how they

work should enable nurses to make an appropriate selection.

Furthermore improvements for staff such as make continuous nurse education

(CNE) about wound care and the appropriate type of dressing according to the

type of wound. According to Williams, B. (2010) society demands continued

professional accountability for competence in an era of exponential knowledge

proliferation and technological change. One way to meet this demand is for every

18
practicing professional to engage in continuing professional nursing education.

For newly enrolled staff must follow the mentor mentee and it is the mentor's

responsibility to teach the mentee about dressing according to the type of

surgery. A mentor is an individual with expertise who can help develop the career

of a mentee. A mentor often has two primary functions for the mentee. The

career-related function establishes the mentor as a coach who provides advice to

enhance the mentee’s professional performance and development. The

psychosocial function establishes the mentor as a role model and support system

for the mentee. Both functions provide explicit and implicit lessons related to

professional development as well as general work–life balance.

Arrange workshops or courses on wound assessment and wound care for all

nurses so that nurses have knowledge in wound care. The formulary choice

should take into account cost as well as other required characteristics such as

size, adhesion, conformability and fluid handling properties according to Khatri,

S. (2014).

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 3. CONCLUSION

3.1. Discussion

Through this experience, I have utilized reflection to aid me in attaining an

optimum level of learning by not only focusing on my knowledge but most

especially on the positive changes that I’ve achieved with my skills due to this

learning experience. My clinical skill on surgical wound management was further

enhanced. To ensure proper healing, the wound bed needs to be well

vascularized, free of devitalized tissue, clear of infection, and moist. Wound

dressings should eliminate dead space, control exudate, prevent bacterial

overgrowth, ensure proper fluid balance, be cost-efficient, and be manageable

for the patient and/or nursing staff. Wounds that demonstrate progressive healing

as evidenced by granulation tissue and epithelialization can undergo closure or

coverage. All wounds are colonized with microbes; however, not all wounds are

infected according to Armstrong, D. G. (2017).

At the same time, reflection diary is useful for me to learn and learning new

things about the use of wound dressing. We as a nurse must have knowledge

about wound dressing before apply to patients according to type of surgical

wound and type of surgery and site of surgery. Aseptic technique is also

important when cleaning the surgical wound before applying dressing as it also

affects wound healing. Surgical aseptic technique is a method employed to

maintain asepsis and minimize the risk of introducing pathogen into surgical

wound according to Rowley, E. A. (2010). It protects the patient from the impact

20
of healthcare associated infection such as delayed recovery, longer

hospitalization, increased pain and increased morbidity according to Philips, L.

(2013).

In addition, the nurse needs to know how to use wound dressing according to the

location of the surgery wound and apply the appropriate dressing for healing and

avoid surgical site infection. Optimal management of post-operative wounds in

the community is important to prevent potential complications such as surgical

site infections and wound dehiscence from developing. As such, general

practitioners, who play an important part in the sub-acute management of post-

operative wounds, should appreciate the physiology of wound healing and the

principles of post-operative wound care according to Yao, k., Bae, L., & Yew, W.

P. (2013).

3.2. Suggestion

Before we use or apply dressing wound we should make assessment on the

wound first, then surgical area of the wound, type of the wound and use

appropriate wound dressing according to the wound condition. According to

Hampton, S. & Collins, F (2015) there are a multitude of dressings to choose

from and selecting the right one is crucial to promoting healing, as the wrong

dressing can significantly hinder a wound from healing. A good understanding of

how wounds heal, the dressings available and how they work should enable

nurses to make an appropriate selection.

21
Care of the periwound skin, including its protection against mechanical injury

(such as tissue trauma caused by the removal of adhesive tapes and dressings)

and chemical injury (caused by products used on the skin, bodily fluids and

wound exudate), is an essential requirement for those providing wound and

dermatological care according to Lawton, S. (2009).

22
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Armstrong, D. G. (2017). Basic principles of wound management. Southwestern

Academic Limb Salvage Alliance (SALSA). Keck School of Medicine.
University of Southern California.

Baxter, H. (2003). Management of surgical wounds.1-7;99(13),66-8

Hinchingbrooke Health Care NHS trust, Cambridgeshire.

Beam, W. J. (2006). Wound cleaning: Water or saline?. Journal of athletic

training. 41(2).196-197. University of North Florida. Jacksonville. Florida.

Broussard, C. K. & Powers, G. J. (2013). Wound dressing: Selecting the most

appropriate type. American journal of clinical dermatology. Vol
14(6).449-459.

Edwards, H,. Gibb. M,. Finlayson, K,. & Jensen, R. (2013). Wound dressing
guide. Promoting healthy skin champion for skin integrity. Queensland
University of Technology. Brisbane.

Daley, J. B. (2017). General treatment of non-healing wounds. Wound care

treatment and management. Department of Surgery. University of
Tennessee Health Science Center College of Medicine.

Hampton, S. (2015) Selecting wound dressing for optimum healing. Nursing

times. 2-15;111(49-50),20-3.

Heal, C. F,. Buettner, P. G,. Cruichshank, R,. Graham, D,. Browning, S,.
Pendergast, J. & Drobet, H. (2009). Is topical Chloramphenicol necessary
to reduce wound infection?. Does single application of topical
chloramphenicol to high risk sutured wound reduce incidence of wound
infection after minor surgery? Prospective randomized placebo controlled
double blind trial. Queensland.

Goranovic, T,. Pirkl, I. & Parazajder, D. (2011). The effect of injection speed on
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Guo, S,. & Dipietro, L. A. (2009). Factors affecting wound healing. Center for
wound healing and tissue regeneration. Department of periodontics
College of Dentistry. Chicago. USA.

Grey, E. J,. Enoch, S. & Harding, G. K. (2006). Wound assessment: ABC of

wound healing. 332(7536). 285-288. Royal College of surgeon of England.
Cardiff University.

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Lawton, S. (2009). Assessing and managing vulnerable periwound skin. World
wide wounds. Queen's Medical Centre. Nottingham University Hospitals
NHS Trust. UK.

Parell, G. J (2003). Comparison of absorbable with nonabsorbable suture in

closure of facial skin wound. Arch Plastic Surgery. 5(6):488-90.
Department of Otolaryngology-Head and Neck surgery, University of
Florida Medical Center. Gainesville. Fla. USA.

Press, D. C. (2015). General consideration. General anesthesia. Department of

anesthesiology. Stanford University School of Medicine.

Philip, N. (2016) Surgical site management. Berry & Kohn’s Operating room
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Rice, J. (2009). Wound care. Retrieved from

https://www.ausmed.com/articles/wound-care-assessment/ @ 9/12/2017.

Robb, W. A. T (1961) Clinical trial of melolin: A new non-adherent dressing.

Journal of plastic, reconstruction and aesthetic surgery. Vol 14,p47-49.
Southern General Hospital, Glasgow formerly senior surgical registrar.
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Rowley, E. A. (2010). Wound care: principles of aseptic technique. Mental health

practice. Vol4(2). King’s College. London.

Yao, K,. Bae, L,. & Yew, W. P. (2013). Post-operative wound management. Vol
42(12),67-70. Orthopaedic Resident, Monash Health. Melbourne, Victoria.

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