Prevention of Post-Operative Blisters

Abstract

People undergo various surgical procedures for reasons of treating a particular health disorder or diagnosis purposes. These procedures range from C-sections to total knee and hip arthroplasties. After the surgery, the patient will need to receive optimal care that facilitates a faster wound healing process. Various dressings are used to prevent contain the area while ensuring an environment that facilitates the healing. However, some of these dressing methods have been found to lead to the formation of post-operative blisters. These are real threat to patients since they have to stay for a longer time at hospitals and incur more spending to take care of the complications. 13% to 35% of patients who have undergone surgery experience these blisters. This pilot project aimed at initiating a reduction in the occurrence of blisters through the use of Mepilex border dressing. To achieve this, a literature search was conducted to identify some of the advantages of this dressing method. It was found that it requires less changing times hence reducing the prevalence of blistering as well as improving the healing time.

Keywords: Post-operative blisters, Mepilex Border Dressing, optimal care

Chapter One

Introduction and Problem Statement

Most of the operative procedures are associated with blisters which increase the length of hospital stay after the surgical operative procedures as reported by Allegranzi et al. (2016). These blisters occur regularly in about 13% to 35% of all patients who undergo surgical procedures and can interfere with the patient’s overall quality of life. In fact, most of them have been found to occur only five or six days after the surgical operation, affecting the patients’ abilities to go on with their normal activities of daily living (Eastburn, Ousey & Rippon, 2016). There is a higher risk of developing blisters after operative procedures among the women compared to men and the overall expenses caused by the complications thereof may go up to $36,000 per case. A good example of such blisters are the tape ones which commonly occur in patients who undergo hip surgical procedures at the taped locations of the surgical dressings used to cover the surgical wounds (Steinberg, Chernofsky & Luria, 2015). The rupture of such blisters results in the formation of open wounds which resultantly create a suitable environment for bacterial growth. Furthermore, open wounds following surgical complications can cause prosthetic implant infections in addition to other complications at the superficial level. Leaking of the fluids from such wounds produces changes in the nature of the wound leading to an increase in the length of hospital stay and resultantly increased hospital expenditures. Blisters are among the most painful and unpleasant outcomes of a surgical; procedures as highlighted by Sellæg, Romild, and Kuhry (2012). Such pain and discomfort can be associated with the exposure of the nerve endings which occurs when the epidermis is lost to expose the underlying dermis after the rupture of surgical blisters.

Background of the Problem

People undergo surgical procedures for many reasons some of which are to correct medical conditions while others are for cosmetic purposes. Surgeons also perform a surgery in a bid to locate a medical problem or improve the functioning of the body through the removal of some malignancies, for example. The Centers for Disease Control and Prevention estimates the number of inpatient surgical procedures that were done in 2010 to be approximately 51 million. This is an increase when compared to the 48 million that were performed in 2009 as reported by the National Center for Health Statistics. In addition to the 51 million, the CDC records are further broken down as follows: 719000 total knee replacements, 332000 total hip replacements, 395000 coronary artery bypass graft, and 1.3 cesarean section. These estimates reveal an ever increasing rate of people who could be requiring surgical procedures for various reasons.

Significance of the Problem

Most of the surgical wounds are acute hence they heal slowly within the expected duration of time without the patient experiencing secondary complications. However, post-operative complications develop in some instances and prolong the wound healing process. The wounds could be a site of entry of disease-causing microorganisms hence the concept of surgical site infections. Improper management of the wound could lead to the development of such complications which could even lead to the death of the patient. Delayed healing also makes the patient incur more expenditures while at the hospital. This could be due to the need to treat the secondary complication or to improve the healing process.

Blisters that occur after a surgical procedure are responsible for the increased lengths of hospital stay and the resultant increase in the cost of medical care in these settings. For instance, a patient who has acquired a surgical site infection will have to spend approximately 7000 euros more on the healthcare cost. Existing literature has supported this finding, and the researcher has vast experience in handling these complications in the hospital care settings (Allegranzi et al., 2016). From such experience, it has been noted that the standard dressing materials used in post-operative surgical procedures in the orthopedic units increase the tendency to form blisters. For significant reduction of the costs of hospitalization after surgeries, the clinicians and caregivers need to understand the causes of blistering under such circumstances (Eastburn, Ousey & Rippon, 2016). Understanding the causes and reducing the rate of these blistering incidences automatically reduces the rate of microbial infections as well as nosocomial infections and as a result, reduces the length of hospital stay. This study proposes the use of an effective dressing among patients who undergo surgical procedures as a way of reducing blistering and resultant nosocomial infections (Sellæg, Romild & Kuhry, 2012). The studies about post-operative dressings were important in standardizing the positive outcomes after undergoing surgical operations. As such, prioritizing the use of newer and better methods of dressing post-operative wounds would increase the patient safety, reduce patient morbidity and mortality, and cut down the costs of hospitalization.

Chapter Two: Critical Appraisal of the Evidence

Introduction

This study was aimed at synthesizing evidence to decrease the number of blisters in post-surgical patients via the implementation of Mepilex border dressing compared with the current practice.

Search Strategies and Yield

The search for literature related to the clinical question: “Will the use of Mepilex Border dressing and proper surgical site handling reduce the occurrence of blistering over a three month period?” was conducted from online databases. These databases included the Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Medline, PubMed and ProQuest, all with full text. The search criteria were governed by the use of search terms such as blister prevention, blisters or blistering, surgical patients, surgical dressings, Mepilex Border dressings, and surgical site handling. Blister prevention resulted in 1121 sources of evidence from all the databases while blisters or blistering produced 954 articles. Surgical patients on the other had produced a total of 111 sources of evidence while surgical patients produced 797 articles with the search term Mepilex Border dressings producing only 54 articles. Surgical site handling produced 769 sources of evidence, and all these articles (totaling to 3806) were later exposed to the inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

Only articles published in the English language were included in the final yield of the online academic database search considering that the researcher and the target population can proficiently understand this language. Based on this criterion, 1001 articles were eliminated leaving behind 2805 articles for further scrutiny and eliminative procedures. Another criterion selected to identify relevant materials for appraisal included selecting sources of evidence that were published between 2010 and 2016. This criterion was important in ensuring that the sources of evidence selected for appraisal were up to date, making the information thereof reliable and valid for generalization. Based on this approach, another 1028 articles were eliminated leaving behind 1777 articles for further subjection to exclusion and inclusion criteria. Further elimination was based on the specifics of the article context which entailed selecting only sources of literature that concentrated on blisters suffered by post-operation patients, eliminating another 1238 literature sources leaving behind only 539. The final selection was based on whether the articles addressed blistering as a problem and gave any form of alternative aimed at reducing the incidence of blistering and this process finally eliminated 533 and only six literature sources were found relevant for synthesis and responding to the clinical question. The six articles addressed the causes of blistering in post-surgical patients, impacts of post-surgical blisters, prevention of blistering and possible alternatives for standard dressing materials.

Literature Review Protocols and Hierarchy of Evidence

The Critical Appraisal Skills Program (CASP) was found useful in the synthesis of the selected literature using the ten critical questions as enlisted in Appendix A. Further, the Appraisal of Guidelines for Research Evaluation II tool was essential in the determination of the quality and strength of the selected sources of evidence. The hierarchy of evidence was also critical in classifying the selected literature in order of reliability and validity of the findings in levels. As such, one study was regarded as Level I since it was a systematic review in the form of qualitative literature review, two as Level II since they were randomized controlled trials, one Level III since it was a meta-analysis, and two as Level IV since they were case studies and reports as illustrated in Table 1. The strengths and limitations of all these studies will be highlighted in the discussion of the five themes garnered from the twelve articles and which form the backbone of responding to the clinical question for this study.

Prevention of Postsurgical Blisters

Steinberg, Chernofsky, and Luria (2015) described several recommendations that can be practiced with effectiveness to reduce the incidence or severity of blisters associated with surgery. For instance, these authors suggested that severe complications of the blisters could be unroofed following by adequate provision of care using silver sulfadine in a similar way to most burn injuries. Similar recommendations were suggested by the findings of Strauss et al. (2006) who investigated the preventive mechanisms of combined injuries including blisters associated with surgical procedures. Even though the use of silver sulfadine as suggested by these two cohorts is helpful in preventing the severity of the blisters, the method is still controversial awaiting further findings in its support. Some types of surgeries, however, rarely present with associated blistering, making it important to consider the safest surgical procedure before proceeding. For instance, such blisters are rarely reported in elective wrist surgeries, and when they occur, it is quite difficult to differentiate between real blisters and normal swellings following the surgical operation. Such blisters may also be confused with hematomas and wound dehiscence implying that they may not be as detrimental as blisters occurring during other surgical procedures like knee and hip replacement surgical operations. To prevent such blisters and complications thereof, Steinberg, Chernofsky, and Luria (2015) recommended the use of elevation and compressive garments specifically to patients with elective wrist surgeries considering that this case report was concerned with such injuries among three patients. In fact, one of the patients involved in the case analysis was sufficiently treated with an elevation within only two weeks since the blister-like swelling presented. There was no need to apply a compressive dressing on either of the three patients treated in this way, proposing a newer and better mechanism of preventing blister complications in patients after surgery. To limit the occurrence of such blister complications in the clinical settings, Steinberg, Chernofsky, and Luria (2015) also recommended the use of a clear film dressing containing high moisture vapor transmission rates.

Summary

In conclusion, this EBP will give significant insights in improving the clinical outcomes of patients who have undergone surgical procedures. This goal is in line with the anticipated output of every healthcare worker to improve the health of their patients. Patients who undergo surgery get their problems rectified through a painful process hence they need to be helped to heal faster. Subjecting them to secondary complications reduces their satisfaction and could impact on their general life. Their wounds should be allowed to heal faster and in a manner that does not subject them to pain, SSI or blisters. This project carried out a rigorous literature search that linked the use of dressing types to causing blisters. Mepilex border dressing has been recommended since it not only requires less changing times but also reduces the occurrences of these blisters around the wound area.

The dressing is aimed at reducing the formation of blisters due to the established reason o the friction and tension that occurs between the dermis and the epidermis during the removal of a dressing. Less changing times imply that these push and pull actions are minimized hence preventing the seeping of interstitial fluid into the space between the two layers of the skin. This project has based its evidence on the significant impact that can be realized I the prevention of blisters when the right dressing is used. Appendix E gives an overview of some of the factors that define an efficient dressing. In as much as the dressing should stay for up to a week without removal, it should be absorbent enough to prevent the build-up of exudate in the wound area, or the spilling of the exudate. These considerations were appraised in proving the role of the Mepilex border dressing in improving the quality of care for post-surgical patients. Traditional dressing has been replaced by modern ways which have more advantages that promote wound healing. It was my responsibility as my researcher to blend the factors and come up with a dressing that offers holistic care. My objective was to find a strategy that improved patient satisfaction by preventing the occurrence of the complications they previously had to undergo after surgery.