This paper will discuss wound care, the effectiveness of saline versus water when cleaning wounds, and the experience of patients undergoing long term wound care. The purpose of this report is to demonstrate understanding of evidence informed decision making, researchable questions, searching the available evidence and research designs.
Webster’s Dictionary by Guralnik (1970) defines a wound as “an injury, especially one in which the skin or another external surface is torn, pierced, cut, or otherwise broken.” Wounds can be acquired from accidents or from medical procedures such as operations or surgeries. Anytime a patient acquires a wound, the care given to the person and at the site of injury is an essential part in the healing process. Proper wound care can prevent further complications, infections, and preserve function. It involves cleaning, examining and bandaging.
Wound cleansing or “irrigation” the steady flow of a solution across an open wound surface to achieve wound hydration, remove debris, and to assist with the visual assessment. The irrigation solution is meant to remove cellular debris and surface pathogens contained in wound exudates or residue from topically applied products. Cleansing methods may differ between individual health care providers, institutions, or facilities but the irrigation solution chosen can have a significant impact on healing outcomes and therefore should be chosen carefully with supporting evidence.
Quantitative Study Design
The study design that provides the highest level of evidence to answer the identified quantitative PICO question is a Randomized Control Trial (RCT). According to McMaster School of Nursing (N.D), a RCT involves “individuals who do not have the outcome of interest in mind and are randomly allocated to receive the intervention or standard of care or conventional treatment (comparison group), or no intervention (control group) and followed forward in time to determine whether they experience the outcome of interest.”
This design was chosen because its strengths involve “gold standard to test the effectives of a treatment/intervention, and decreased bias through random allocation” according to McMaster University School of Nursing (N.D). Random allocation of participants within the experimental group is preferred as unbiased results can be achieved and which prevents the data from being skewed. Specifically in this case, if patients know their wounds are being studied for the outcome of infections, personal behaviors or hygiene techniques could be altered during this time, which may influence the results.
Qualitative Study Design
A phenomenological study design is most appropriate to answer the identified qualitative study question because it explores the “lived experiences of people” which are subjective according to McMaster University School of Nursing (N.D). In this case, phenomenological studies fit best as the answer being sought is the experience for wounded patients under going wound care.
A “Summaries” level study was found called “Emergency nursing resource: wound preparation” from the National Guideline Clearinghouse database. The “Summaries” level is found at the top of the 6S hierarchy pyramid of pre-processed evidence. A summary study was used because it was the first level to be explored and provided the highest level of evidence to fully answer the quantitative PICO question. Furthermore, when a relevant “Summaries” level study is found, there is no need to go further down the pyramid as the “Summaries” level contains essentially a summary of the information available at the lower levels. Regarding my research strategy, I first started looking at the RNAO Best Practice Guidelines. I began browsing by topics, however a topic on wound care was not available.
I proceeded to use the manual search bar where I intentionally used a broad search term of “wound care” with the quotations around it. This only yielded only one result, which was not relative to answering my question. I thought that even if I used a more specific search request, I would not find any different results as even the broadest term yielded nothing helpful. From there, I moved onto the National Clearinghouse Guideline database. This is where I found my first relevant study called “Emergency nursing resource: wound preparation”. I found that using asterisks, quotation marks, and capitalized ANDs helped me be successful in finding the research I needed.
Also using different combination of search terms and synonyms, I was able to refine my search to the point where I found my first relevant study. The exact terminology I used was “‘wound prep*’ AND ‘water’ AND ‘saline’”. This generated two results, which was beneficial as the results were focused and specific to what I was searching for. I found another summaries level study from the DynaMed database called “Laceration Management”. I was able to find this study on my first try using the term “wound irriga*”. Because irrigation could refer to either water or saline, I found it more effective to use the root of “irrigation” as it yielded better results. Please see Appendix A for a copy of the search history.
When conducting a search for my qualitative question, I first started at the “Synopsis of Single Studies” level of the 6S pyramid. I searched three databases from this level including Evidence-Based Nursing, Evidence-Based Healthcare and Public Health, and Evidence-Based Medicine. Unfortunately I was unable to find a phenomenological study to accurately answer my qualitative question for patients undergoing wound care. Since none of these databases had what I was looking for, I moved onto the next level of the 6S pyramid, which was “Single Studies”. I was much more successful here. The first database I checked was CINAHL. Using the entry of (MH “Phenomenological Research” AND “wound care”) I retrieved twenty results. From the list of results, I found two appropriate phenomenological studies, which accurately answered my qualitative question.
I can say with ease that I did not experience difficulty when conducting a search for this material. I found following the suggestions and guidelines that the EIDM module provided from the McMaster University School of Nursing was extremely helpful in successfully finding relevant research in a timely manor. Please see Appendix B for a copy of the search history.
Quantitative Study Discussion
For the quantitative discussion, there will be two articles addressed which will answer the following question: In patients requiring wound care, does tap water compared to normal saline reduce the number of infection incidents? The first credible resource is titled “Emergency nursing: wound preparation”. It is a guideline intended for nurses and doctors with the best recommendations for practice with evidence to support it. The objective of the guideline is to evaluate what method of wound preparation is most effective for promoting wound healing and reducing rates of infection for patients in the with acute lacerations. The interventions considered were portable tap water versus normal saline. Pooled data from the studies within the review identified a 37% reduction in the rate of infection in wounds cleansed with tap water compared to wounds cleansed with normal saline.
Data from one study showed a significantly higher rate of infection in the group that received normal saline; however, this could have been attributed to difference in the temperature of the irrigation solution (National Guideline Clearinghouse, 2012). The overall recommendation based upon the supporting evidence is that “potable tap water is equivalent and may be superior to normal saline for laceration cleansing and irrigation in patients across the lifespan” to promote wound healing and decrease rates of infection (National Guideline Clearinghouse, 2012). This evidence answers the quantitative questions clearly and concisely by alluding to the fact tap water is equivalent to normal saline in reducing infection rate in wounded patients.
The next “Summaries” level study that will be discussed is called “Laceration Management” (DynaMed, 2008). Here we see that based on 715 randomized trails of acute laceration cleansing, patients received either tap water or normal saline solution. Based on the 634 follow up cases 4% tap water versus 3.3% saline group had wound infections. Furthermore, in this review, findings show that warmed saline was preferred over room temperature saline.
So again we see the factor of temperature of the irrigation solution being considered as it plays a role in infection rate, similarly to the study findings discussed above. The overall bottom line of the review states, “tap water irrigation may not increase infection rate compared to sterile saline for simple lacerations” (DynaMed, 2008). This evidence therefore compliments the answer to quantitative question discussed above as again we see little to no difference in infection rates with tap water compared to normal saline in wound care.
Qualitative Study Discussion
There are two phenomenologic studies used to address the following qualitative question: What is the experience for wounded patients under going long term wound care? The first study is called “The Lived Experience A Chronic Wound: A Phenomenologic Study” (Beitz, & Goldberg, 2005). The methods used to obtain the data were interviews with open-ended questions and a brief questionnaire. The most commonly expressed concerns were grouped into the following themes: pain, mobility, freedom, and wound status. The constant experience of pain made life uncomfortable, mobility limitations decreased independence and freedom, and lastly lack of knowledge regarding wound status increased uncertainty, feelings of frustration, and decreased life quality (Beitz & Goldberg, 2005). The identified themes explicitly answer the qualitative question regarding experience of undergoing long term wound care.
The second study is called “A forever healing: The lived experience of venous ulcer disease” and it explores the life experiences of having a chronic wound from a patient’s perspective. Similarly to the “Chronic Wound” study discussed above, an interview method consisting of open-ended questions was used to collect data. Four common themes emerged from the analysis of experiences, which include: a forever healing process, limits and accommodations, powerlessness, and “who cares?” (Chase, Melloni, Savage, 1997).
The healing process for these patients with leg ulcers never ends as continual protection, attention and care is required, which is a lot of responsibility and commitment. Furthermore, the implications of the ulcers often left clients with decreased mobility and activity. The long-term duration of these circumstances in conjunction with the functionality loss led to a sense of powerlessness and hopeless. Ultimately clients admitted to developing a “who cares?” attitude toward their condition (Chase et al 1997). These common life experience themes identified within this study provides a view into the experiences of having a chronic wound, which answers the qualitative question.
In summary, both “Summaries” level studies conclude the same answer that tap water does not increase rate of infection in wound irrigation compared to saline solution. Solution temperature plays a role in wound healing and should be considered when preparing to cleanse. From a qualitative perspective, wounds can have major implications on life quality. As health care providers, the phenomenologic knowledge regarding living with a chronic wound is invaluable. It not only grants us the ability to better empathize with clients undergoing similar circumstances, but allows us to provide better care by helping persons cope and adapt to chronic wounds in healthy, positive ways (Beitz, & Goldberg, 2005).
The ways in which nurses can minimize negative components of chronic wounds include assessing pain frequently, working with physical therapists to optimize mobility and freedom, and lastly be forthcoming with explanations about procedures and wound status. When such things are accomplished, clients should feel more empowered and perhaps an improvement will be seen not only physical state, but also the mental and emotional state.
Beitz, J., & Goldberg, E. (2005). The lived experience of having a chronic wound: a phenomenologic study. MEDSURG Nursing, 14(1), 51.
Chase, S., Melloni, M., Savage A. (1997). A forever healing: The lived experience of venous ulcer disease. Journal of Vascular Nursing, 15(2), 73-78.
DynaMed. (2008, March 8). Laceration management. Ipswich, MA:EBSCO Publishing. Retrieved November 14, 2012, from http://search.ebscohost.com.libaccess.lib.mcmaster.ca/login.aspx?direct=true&db=dme&AN=129892&site=dynamed-live&scope=site. Guralnik, D. B. (1970). Webster’s New World dictionary of the American language (2d college ed.). New York: World Pub. Co.
McMaster University School of Nursing, (N.D). Research Designs [BScN EIDM Learning Modules]. Retrieved from Avenue to Learn. National Guideline Clearinghouse. (2012, July 2). Emergency nursing resource: wound preparation. Rockville MD: Agency for Healthcare Research and Quality.