ASSIGNMENT /TUGASAN

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NBNS3603
REFLECTIVE THINKING AND WRITING
SEPTEMBER SEMESTER 2021
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SPECIFIC INSTRUCTION / ARAHAN KHUSUS

1. Answer in MALAY or ENGLISH.

Jawab dalam BAHASA MELAYU atau BAHASA INGGERIS.

2. Number of words: 2500 – 3000 for EACH assignment excluding references.

Jumlah patah perkataan: 2500 – 3000 bagi SETIAP tugasan tidak termasuk rujukan.

3. Submit your assignment only ONCE in a SINGLE file.

Hantar tugasan anda hanya SEKALI sahaja dalam SATU fail.

4. Submit your assignment ONLINE.

Hantar tugasan anda secara ATAS TALIAN.

5. Submission date: 3 DECEMBER 2021.

Tarikh penghantaran: 3 DISEMBER 2021.

6. Each assignment accounts for 40% of the total marks for the course making a total of 80%.
Setiap tugasan menyumbang sebanyak 40% daripada jumlah markah untuk kursus ini
menjadikan jumlah sebanyak 80%.
 ASSIGNMENT QUESTION 1

OBJECTIVE:

This assignment is to appraise learners’ skills in writing reflectively on their learning

experiences.

SYNOPSIS:

Reflection is associated with “looking back” and examining the past to learn from what
happened and perhaps not repeat mistakes. However, it is also increasingly associated with
reflecting “on-action” (Schon, 1983) and encourages an exploring of thoughts and feelings;
looking for insights; and maximizing on self-awareness (Lacan, 1977). Effective reflection will
facilitate continuous professional learning and develops practitioners capable of demonstrating
their progression towards required learning outcomes and standards.

TASK:

Critically reflect on continuing nursing education (CNE) session you attended and enter this
experience in your reflective journal by responding to the following questions:

▪ “What was the most important thing you learned in the session?”
▪ “How do you determine what you learned in the session is relevant to your
profession?”

[Total Marks: 40]

 PRESSURE INJURY AND ITS IMPACT ON
PATIENT AND HEALTH CARE INDUSTRY
In recent years, continuing education has been highlighted in most healthcare professionals, more so
among nurses. According to American Nurses Credentialing Center’s (ANCC) Commission on Accreditation,
continuing nursing education (CNE) “builds upon the educational and experiential bases of the Registered
Nurse for the enhancement of practice, education, administration, research, or theory development, to the
end of improving the health of the public.”

The purpose of continuing education is to ensure that nurses stay abreast of current industry
practices, enhance their professional competence, learn about new technology and treatment regimens, and
update their clinical skills. In this reflective journal will be looking back on a recent CNE session where I
participated in. The session discussed pressure injury, its impact on patient outcome, how wound care
management evolved from the past, and the role of nursing in zero tolerance for pressure injury.

As nurses, we must never forget our role as their advocates and protector. We must be able to
provide quality care for our patients and support them through health and illness. When a patient suffers
from impaired wound healing the patient also suffers from pain, distress, embarrassment, anxiety, prolonged
hospital stay, chronic morbidity, or even death.

Hence, it has become imperative that nurses not only enrich themselves with the knowledge and
skills of managing a patient’s illness. As nurses, we must also polish our skills in preventing our patients from
developing pressure ulcers during the in-patient experience.

Before our session began, all the participants were greeted by two alternating slides. The first slide
was a quote by Florence Nightingale on pressure injuries was displayed. She said, “If a patient is cold, if a
patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault
not of the disease, but the nursing.” This statement made by Nightingale has struck me quite significantly not
only at the beginning of the session but throughout the end.

To be honest, this made me look back on how I was delivering patient care. Questions then popped
into my mind, “Was this the case? Is it not generally the fault of the patient’s illness, but instead of nursing?”
Perhaps, this may just be the difference in time. Perhaps, the lack of medical and nursing breakthroughs in the
past may have been the cause.

To begin with, we have agreed that in most healthcare settings we find that the prevention of
pressure ulcers has been one of the hallmarks of excellent nursing care. After all, not all patient enjoys the
benefit of acute treatment and be discharged with a clean bill of health in just a few days. Some may take a
few days while others may need treatment modalities that can span from a few weeks to several months.
Some may even take more than a year depending on their prognosis.

The second slide contained an intriguing question. It asked, “Do you know what happened to
Superman?”

My contemplation on how to best manage pressure injuries came to a halt. I then became more
interested as my attention was shifted. How is Superman related to pressure injuries? Did he make an impact
on the prevention and management of pressure injuries? More questions were raised, and these have
increased my expectations on our session along with the idea that indeed an effective CNE is where theories
support application thus creating efficient evidence-based practice,
These two slides, a quote, and a question captured the interest of most if not all participants. At the
beginning of our session, we were all asked about how we felt about the Lady of Lamp’s statement. A few
agreed, some reasoned out that a patient developing pressure injury becomes inevitable especially those who
underwent major cardiac surgery, or the patient strongly refused. Some would say that due to lack of staff,
some of the nursing interventions are somehow delayed. Some then stated, that given the situation we have
done our best. However, hearing all these statements, I was reminded of all my self-doubt. Perhaps we have
not done our best yet if the patient still developed pressure injury.

Our instructor then let us contemplate and asked us to somehow remember our doubts. Which led
me to write my thoughts into my notes. I was expecting that all these questions will be resolved at the end of
our session. When our instructor moved to the second slide, “Do you know what happened to Superman?” My
curiosity was partially satisfied after learning his cause of death. Although it was briefly mentioned, I still
wanted to know more about how he impacted the prevention and management of pressure injury

In my curiosity, I was directed to an article published on Science Daily in 2006, “Even Superman
Couldn’t Win Battle With Pressure Ulcers.” It was revealed that the late Christopher Reeve, widely known as
“Superman”, passed away in his early 50’s due to complications associated with an infected pressure ulcer.
Before that, he suffered from a severe cervical spinal injury during his horseback riding accident in May 1995.
This left him paralyzed from the neck down, which made him rely on a wheelchair and ventilator for the
remainder of his life.

In another article by Jannete Brisby, “Pressure Injuries in the Healthcare Setting: Even Superman Is
Not Immune,” she contemplated that if Reeve, whose wealth enabled him to receive state-of-the-art medical
care and round-the-clock nursing, could succumb to a pressure injury, how can healthcare providers prevent
pressure injuries in vulnerable patients in the acute care hospital setting?

In the sad event of his passing in 2004, the sentinel consequence of pressure injuries was highlighted
and the world of healthcare. Indeed, the irony of “Superman” being defeated by severe infection, which is
ultimately related to having pressure injury, somehow hammered the idea that pressure injury can
potentially cause life-threatening consequences if not resolved or managed adequately. His case brought
about a significant impact not only in the healthcare profession but also allowed the public to grasp the idea
that pressure injury is not just a simple wound. Especially those who are vulnerable and at a high risk of
developing a pressure injury.

To help us better understand how large pressure injury impacts a patient, we had a brief session
wherein we brainstormed some if not most of the facts we know about the largest organ of the human body,
the skin.

We understand that the skin is a complex structure of the body designed as our first line of defense
against potential bacterial invasion and other external elements such as water, chemicals, UV radiation, and
other harmful elements. Our skin can make up about 2 square meters and receives approximately 1/3 of our
body’s blood volume. Aside from being our first line of defense against infection, it also helps us in preventing
excessive fluid and electrolyte loss; assist in the metabolism of calcium; allows us to “sense” the environment
such as pain, touch, pressure, temperature, etc.; maintains thermoregulation; and of course, it holds our body
in shape.

In addition to this, the session also allowed us to find out some fun facts related to our skin. Knowing
that every minute of the day we lose about 30,000 to 40,000 dead skin cells off the surface and that we can re-
grow outer skin cells about every 27 days made me realize that my skin is capable of more things than I’ve
given it credit for. To think that a person has almost 1,000 new skins in a lifetime.

We also know that the skin has three layers:

a. Epidermis, the thin outer layer which contains 4 types of epidermal cells: Keratinocytes,
Melanocytes, Langerhans cells, and Merkel Cells
b. Dermis, the thicker and deeper layer of the skin composed mainly of connective tissue
containing collagen and elastic fibers. The cells mostly found in the dermis are fibroblasts and
macrophages; and the
 c. Subcutaneous Layer (hypodermis), which anchors the dermis to the underlying organs and
tissues

We must know the basic concepts of our skin as this will help us have a better grasp of the wound
healing process. Wound healing is a complex process generally divided into 4 distinct and overlapping
phases. The progress and speed of wound healing of the skin can be greatly affected by the type of wound it
has. It is essential to know the layers of the skin and how they function to identify the most suitable treatment
modality for a better outcome.

In a study by Guo, S., and DiPietro, L.A. (2010), “Factors affecting wound healing,” they have
described wound healing, as a normal biological process in the human body achieved through four precisely
and highly programmed phases: hemostasis, inflammation, proliferation, and remodeling. Furthermore, Guo
and Dipietro emphasized that for a wound to heal successfully, all four phases must occur in proper sequence
and time frame. As such, any factor that may interfere with one or more phases of this process can lead to
improper or impaired wound healing.

When a break in our first line of defense happens, blood vessels are injured when tissue damage
occurs. Hemostasis occurs within the first 5 to 10 minutes. In this phase, our body is protected from further
blood loss by vasoconstriction and the formation of fibrin and final blood clot, and exposure to possible
bacterial infection due to the involvement of our leukocytes and platelets.

Next on the wound healing cascade is closely followed by the Inflammatory phase, which begins at
the time of the injury and generally lasts about 3 to 5 days. It is quite normal to observe increased heat,
swelling, erythema, and pain during this phase. This is to facilitate wound healing by autolysis, our body's
natural response for removing or debriding foreign material. In this phase, the wound bed needs to be
“sufficiently” clean to properly commence with the proliferation phase. However, prolonged inflammation
must be taken into consideration as this can lead to tissue damage. Other factors including the presence of
dirt or other objects can extend the inflammation phase. This can lead to impaired healing leading to a
chronic wound.

Once the proliferation phase commences, it generally takes about 4 to 24 days depending on the
extent of tissue damage. During this phase, a process known as angiogenesis takes place. Wherein, the wound
undergoes cell regeneration to form new granulation tissue which covers the wound bed. An adequate supply
of oxygen and nutrients to the tissues is essential in this phase.

Finally, the last phase in the wound healing cascade of which can last from 3 weeks to 2 years or
longer, is the Maturation phase. The new tissue developed in this phase is known as scar tissue. However,
unlike the former tissue, the scar tissue is only capable of about 70% to 80% of the original tissue strength.

As we discussed further into the session, it has become apparent that the wound healing process not
only begins immediately after tissue damage it also follows an intricate cascade of steps to properly heal the
wound. As such, it is easy to infer that any number of factors may affect not only the speed of wound healing
but also disrupt the entire process leading to impaired wound healing

Impaired wound healing can lead to several complications not limited to delayed healing of acute and
chronic wounds to pathologic inflammation, ulcer, ischemia, etc. In 2006, studies showed that non-healing
wounds affect about 3 to 6 million people in the United States, with 85% of these events mainly accounted for
by persons above 65 years old. These result in enormous health care expenditures with an estimated total
cost of more than $3 billion per year (Mathieu et al., 2006; Menke et al., 2007)

With regards to impaired wound healing, let us now focus on pressure injury and how it greatly
impacts not only patient outcomes but also the health care system in general. What then is pressure injury?
To briefly discuss, pressure injury was once termed as a pressure ulcer, bedsore, etc. However, in 2016, the
National Pressure Ulcer Advisory Panel (NPUAP, 2007) officially replaced the taxonomy “pressure ulcer,” and
was then referred to as pressure injury.

According to NPUAP, a pressure injury is defined as “injured intact skin usually localized over a bony
prominence as a result of pressure, or pressure in combination with shear and/or friction and/or moisture
over some time. Furthermore, NPUAP also classified pressure injuries into the following:

a. Category/Stage I: Nonblacheable Erythema

b. Category/Stage II: Partial Thickness Skin Loss
c. category/Stage III: Full Thickness Skin Loss
d. Category/Stage IV: Full Thickness Tissue Loss
e. Unstageable: Depth unknown
f. Suspected Deep Tissue Injury: Depth Unknown

To be honest, I must agree that the change in the new staging terminology provided a more accurate
description of pressure injuries to both intact and ulcerated skin. To be honest, I remember being confused
back then on how to properly identify pressure injury. Before 2016, where such skin injuries were called
pressure ulcers, it was quite common that two nurses would have some differences in how they identify and
stage the pressure ulcer.

Furthermore, the additional terms presented by NPUAP such as “medical device-related stress
injury” and “mucosal membrane pressure injury” further created a clear differentiation between staged
pressure injury and other types of pressure-related injuries.

Looking back in the years of development, constant improvement in patient care, and continuous
innovations brought about by evidence-based practice, we might say that we have truly come a long way in
providing quality patient care. Several studies conducted over the years helped us to increase our knowledge
and understanding of the wound healing process. Thus, allowing us to enhance our skills and critical thinking
in efficiently managing both acute and chronic wounds. Continuous improvements on how to better manage
pressure injuries were made. Constant innovations were established. Indeed we have come a long way from
simple bandages to silicone dressings, antibiotics, and other advanced treatment modalities such the
hyperbaric oxygen therapy.

Comparing these developments and the questions that I have previously noted, I was again reminded
of the quote at the beginning of our session. Indeed, for over 100 years we have come a long way and yet the
problem of pressure injury is still apparent. What can be improved? Did it concern staffing issues? These
questions made me doubt myself. Perhaps these were just excuses? Until I reminded myself of our Unit
Pressure Injury Incidence. We have yet to have an incidence of pressure injury for the last 4 months. But the
question remains, was this enough? Why does pressure ulcer persistently remain a significant problem? How
does this impact the healthcare industry?

In November 2019, Bruin Biometrics CEO Martin Burns and the UCLA team of researchers presented
their findings before the 2019 International Guideline Launch of the National Pressure Ulcer Advisory Panel
in Los Angeles. Their findings showed that pressure injuries presented a major health issue for providers and
kill more patients a year than any single cancer except lung cancer. Furthermore, The U.S. spends about $26.8
billion a year on treatment costs for pressure ulcers.

In a study published by Agency for Healthcare Research and Quality, “Preventing Pressure Ulcers In
Hospitals”, it was revealed that each year, more than 2.5 million people in the United States develop pressure
ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care
utilization. The study also implied that pressure injury affects over one in ten adults admitted to the hospital.
To estimate, the cost of patient care for an individual with pressure injury may range from $20,900 to
$151,700 per pressure injury.
 In another study conducted by the Centers for Disease Control (CDC), it is estimated that about two
million patients suffer from hospital-acquired infections (HAIs) every year with a 5% mortality rate. This
results in up to $4.5 billion in additional healthcare expenses annually.

This alone can give a picture of how much resources are needed for treating pressure injury alone. If
we can prevent the patient from developing a pressure injury, such cost may be directed to other causes.
Perhaps hospital management may be able to extend budget allocation in other avenues, such as better
facilities, state-of-the-art medical equipment, investing in additional medical and healthcare staff, and maybe
the possibility of an increased salary for healthcare workers.

According to Burns (2019), with the right care, about 95 percent (of pressure injuries) are
preventable. To think that there is a possibility of redirecting at least $20 billion a year. The possibilities are
endless.

In a journal published by Bokyo, Longkayer, and Yang, “Review of the Current Management of
Pressure Ulcers” in 2018, they have identified a critical issue. Indeed, despite an increase in the number of
therapies and other treatment modalities available in the market, none has demonstrated any clear benefit
over others and pressure ulcer treatment remains frustrating and time-consuming. They further concluded
that the prevention of pressure ulcers remains the most important step in the management of these wounds.
However, despite best efforts, pressure ulcers may develop if enough risk factors are present. Treatment of
pressure ulcers is necessary for patient comfort and to decrease the risk of systemic infection. 

As nurses, it has become an essential skill to properly assess our patients. This includes the proper
use of appropriate assessment tools to better plan our nursing care intervention and interdisciplinary plan of
care. Our most widely used tool is the Braden Scale Assessment Tool. This assessment tool is primarily used
to identify patients who are at risk of developing a pressure injury

During the session, we were then asked to complete the activity where we each use the Braden scale
tool to assess the patient’s risk of developing a pressure injury. It was quite interesting to note that the slight
differences in how we score the same patient. Of course, there will be differences in our respective clinical
judgment due to our own experiences and our field of expertise. It is also interesting to note that we all
generally agree that a higher risk score is more acceptable since we focus more on preventing the
development of pressure ulcers.

At the end of the session, I was able to reinforce my conviction of zero tolerance for pressure injury.
As we all went over our questions at the beginning of our session, we realized that indeed the wisdom of
Florence Nightingale on excellent nursing care rings true. Over the century, we have indeed come made
improvements in our delivery of nursing care. But we must not be lax and must maintain zero tolerance for
pressure injuries. Lastly, I have also realized that indeed we are doing our best to adhere to this policy. This is
evidenced by our achievement in our Unit Pressure Injury Incidence rate. 4 months is indeed a good record,
but we can still do better.
REFERENCES:
 Serena T. E. (2014). A Global Perspective on Wound Care. Advances in wound care, 3(8), 548–552.
https://doi.org/10.1089/wound.2013.0460

 DeMarco, S. (2017, June 14). Wound and Pressure Ulcer Management. John Hopkins Medicine.
https://www.hopkinsmedicine.org/gec/series/ wound_care.html

 Aawc, T. (n.d.). Wound Care Nurses: A long-standing tradition of specialized patient care. Association for
the Advancement of Wound Care. Retrieved November 30, 2021, from
https://www.aawconline.org/index.php?
option=com_dailyplanetblog&view=entry&year=2019&month=05&day=06&id=56:wound-care-nurses-a-
long-standing-tradition-of-specialized-patient-care-

 Dr. Suzanne Kapp, University of Melbourne. (2021, November 30). Under pressure. Pursuit.
https://pursuit.unimelb.edu.au/articles/under-pressure

 Li, Zhaoyu & Lin, Frances & Thalib, Lukman & Chaboyer, Professor. (2020). Global prevalence and
incidence of pressure injuries in hospitalized adult patients: A systematic review and meta-analysis.
International Journal of Nursing Studies. 105. 103546. 10.1016/j.ijnurstu.2020.103546.

 Boyko, T. V., Longaker, M. T., & Yang, G. P. (2018). Review of the Current Management of Pressure
Ulcers. Advances in wound care, 7(2), 57–67. https://doi.org/10.1089/wound.2016.0697

 Baycrest Geriatric Health Care System. (2006, August 23). Even Superman Couldn't Win Battle With
Pressure Ulcers. ScienceDaily. Retrieved December 4, 2021, from
www.sciencedaily.com/releases/2006/08/060822172344.htm

 Bisbee, J. (2020, March 17). Pressure Injuries in the Healthcare Setting: Even Superman Is Not Immune
| Patient Safety. Patient Safety.
https://patientsafetyj.com/index.php/patientsaf/article/view/pressure-injuries-superman