This report and risk management package is aimed at patients who have had a surgery. It focuses on the risk of developing wound healing complications as a result of poor nutrition following surgery. The selection of this topic is based on the author's former placement experience of caring for patients on a surgical ward. Some of these patients had poorly healing surgical wounds but refused prescribed nutritional supplements because they did not fully understand why the supplements were given to them. For that reason, a risk management package was designed in the form of a leaflet for patients (see appendix). This report will begin with an overview of the method of enquiry. This will be followed by a discussion of the importance of appropriate nutrition in wound healing post surgery. The discussion will continue with presenting the effects of the risk in relation to patients' outcomes, impact on the National Health Service (NHS) and associated cost. The report will further provide an evaluation of the effectiveness of the package.
A literature review of published materials was carried out to identify and supply relevant evidence for the development of this report and risk management package. The literature search comprised of healthcare books, online healthcare databases, online nursing journal collections, government and other healthcare related publications and statics.
Appropriate nutrition is widely recognized to have a significant role in the wound healing process and a number of essential nutrients have been identified (Casey, 1998; Russel, 2001; Todorovic, 2002; Williams, 2002; Mandal, 2006). A balanced diet, containing foods from all of the five food groups is said to include these essential nutrients (Todorovic, 2002; The Food Standards Agency, 2009). Surgery involves cutting through several tissue layers, each has to heal by undergoing various stages of wound healing and all of these stages must be completed for a surgery to be successful (Vuolo, 2006). The last, maturation stage, may take up to one year (Vuolo, 2006). Therefore, patients need to be aware that they should pay attention to their nutritional intake in order to make a complete recovery from their surgery.
The risk management package is aimed at patients who have had a surgery because even if they are well nourished on admission being nil by mouth and the physiological stress that surgery induces may deplete the body's nutritional reserves (Fulham, 2004). Protein deficiency, in particular, has been suggested to be caused by the effects of cortisol during physiological stress, and it is linked with wound healing delay post-surgery (Hughes, 2004). Protein is also lost through exudates from wounds (Holmes, 2003).
Inadequate nutrition increases the chances of developing wound infection (Bistrian, 2007). Also, it may cause low tensile strength of the wound which increases the risk of dehiscence leading to prolonged wound healing (Russel, 2001). Prolonged healing may cause decreased mobility and potential complications such as pressure ulcers, deep vein thrombosis and pulmonary embolism (Hampton & Collins, 2004). Keloid scaring is another potential complication (Russel, 2001). Delayed wound healing may also affect patients' psychosocial well-being by contributing to developing of depression and lethargy causing even further reduction in appetite and food intake (Edmonds, 2007).
Wound healing complications post-surgery have serious cost implications to the NHS. The hospital stay of surgical patients who are inadequately nourished is 90% longer (Gallaher-Allred et al., 1996). In addition, longer hospital stay requires use of extra healthcare resources, such as increased staff level and medications, which further adds to the cost. Recent study (Russel, 2007) revealed that nutritional supplementation in surgical patients produced cost savings; for instance, abdominal surgery patients given nutritional supplements produced on average savings of ~ £700 per patient (Russel, 2007).
In recent years there has been an increased awareness of the problem of inadequate nutrition and its effects on patient's health. As well as other nutritional screening tools, the Malnutrition Universal Screening Tool was developed (British Association of Parenteral and Enteral Nutrition, 2003). In 2006, official guidance for nutritional screening and support was produced (National Institute for Clinical Excellence, 2006) followed by a Nutrition Action Plan (Great Britain. Department of Health, 2007) and the Nutrition Now campaign (Royal College of Nursing, 2008) all of which aim at improving nutritional standards for patients.
Despite the increased awareness and education for health care professionals there does not appear to be much published information for patients addressing the role of nutrition, especially in wound healing. The significance of that is that even if surgical patients receive good quality verbal advice, they might not be able to retain it because of anxiety (Spry, 2005). However, it has been suggested that if combined with written information it is easier to assimilate, patients can refer to it again at a preferred time and it can prompt them to make further enquiries (Walker, 2007; Caress, 2003; Dixon-Woods, 1998).
It has been found that good quality patient information could have a number of positive outcomes for patients, one of which is promoting self-care (Caress, 2003). The package is meant to be a part of high quality patient education. Its role will be to consolidate the nutritional advice given by health care professionals thereby acting as an incentive for patients to take control of their health. The leaflet is written in a simplistic style, and it is designed with eye catching colours and images because that was found to attract patients' attention to written information (Dixon-Woods, 1998). It is intended to be given to all patients after their surgery, so that they can focus on their successful recovery.
Once implemented, in order to evaluate whether the package has made a difference it would be necessary to undertake an audit on wound healing rates and length of hospital stay of surgical patients and compare the findings with earlier figures. This is needed to establish if the patients who had been given the leaflet recover faster and spend less time in hospital. In addition, a questionnaire on nurses' observation of patients' meal choice and compliance with nutritional recommendations would aid evaluation of the package. It is expected that the leaflet will motivate patients to consume a healthy diet, which would in turn improve wound healing and enhance recovery, thus reducing the cost to NHS and improving patient care.
Although it is acknowledged that poor nutrition is one of the many factors affecting wound healing (Pudner, 2005), it is anticipated that this risk management package will make a positive contribution not only to the recovery from surgery but also to the overall health and well-being of patients.