Surgical Site Infection Essay
Chapter 1
INTRODUCTION
Background of the Study
Surgical Site Infections (SSIs) are the most common nosocomial infection, accounting for 38 percent of nosocomial infections. It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million patients undergoing surgical procedures each year. The environment plays a big role whether or not the patient would develop Surgical Site Infections. (Brunner & Suddarth, 2008).
The postoperative period extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon. This may be as short as one week or as long as several months. During the postoperative period, nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient self-care. Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortable as possible. (Brunner & Suddarth, 2008). …show more content…
According to The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS, 30 years ago, approximately 90% of tonsillectomies in children were done for recurrent infection; now it is about 20% for infection and 80% for obstructive sleep problems (OSA).
The rise in the incidence of tonsillectomy is one of the major phenomena of modern surgery, for it has been estimated that 200,000 of these operations are performed annually in this country and that tonsillectomies form one-third of the number of operations performed under general anesthesia in the United States. There are, moreover, features in the age, geographical and social distribution of the incidence, so unusual as to justify the decision of the Section of Epidemiology to devote an evening to its discussion. (Glover,
2008)
The environmental aspects of Nightingale’s theory (ventilation, warmth, quiet, diet, and cleanliness) remains a significant component of current nursing care until today. These concepts, even from the 21st, showed significance as the global society encounters new issues of disease control. Like for instance, sanitation and water treatment somehow controlled sources of diseases and sickness. In places such as clinics and hospitals, the control for room temperature for an individual patient is also considered. Also, the same environment, though it contains technology that helps for recovery, may create uncomfortable noise that would affect the healing process.
Nightingale’s theory has been used to provide general guidelines for all nurse practitioners for a number of years. The universality of her concepts still remains relevant except for some specific activities. The concept of the nurse, patient and environment are still applicable and relevant in all nursing settings today. Florence Nightingale believed that disease was a reparative process; disease was nature’s effort to remedy a process of poisoning or decay, or a reaction against the conditions in which a person was placed. Nightingale did not provide a definition of nature. In her writings, she often capitalized the word nature in her writings, thereby suggesting that it was synonymous with God. However, when she used the word nature without capitalization, it is unclear whether or not the intended meaning is different and perhaps synonymous with an organic pathological process. Nightingale believed that nursing’s role was to prevent an interruption of the reparative process and to provide optimal conditions for its enhancement. Nightingale felt that nurses needed to be excellent at the observation of their patients and the environment. She also believed that persons desired good health and that they would cooperate with the nurse and nature to allow the reparative process to occur or alter their environment to prevent disease. Nightingale strongly believed that appropriate manipulations of the environment would prevent diseases; this concept underlies modern sanitation activities. (Octaviano & Balita, 2008)
As nursing practice moves toward a caring paradigm, nurses seek creative ways in which to create healing environments for their patients. Nurses look to nursing roots for guidance and knowledge. Nightingale’s environmental adaptation theory of mind-body-spirit integration with environmental factors, including auditory, visual, olfactory, sensory, tactile, and cognitive modalities, provides a framework for actualizing caring-healing practices in a transpersonal caring model. (Schmock, 2009)
As an infection control nurse of a regional hospital, the researcher was eager to know the effectiveness of Nightingale’s theory which is said that her approach could help fight infection in modern hospitals. She also intended to find out how such measures could be applicable in the present hospital setting. This study is aimed to apply environmental factors of Florence Nightingale for post-tonsillectomy patient in order to speed up the recovery, decrease expenses, and lower the chances of readmission.
Statement of the Problem
General
The study aimed to determine the application of Florence Nightingale’s Environmental Theory to a post-tonsillectomy patient on the month of September 2013.
Specific Objectives Specifically, the study sought to answer the following questions:
1. What is the comprehensive health history of the post-tonsillectomy patient?
2. What are the current situations of the environment of the post-tonsillectomy patient on the following aspects:
a. Ventilation & Warmth
b. Light
c. Cleanliness
d. Health of Houses
e. Noise
f. Bed & Bedding
g. Personal Cleanliness
h. Variety
i. Chattering Hopes & Advices
j. Taking Food
k. Petty Management
l. Observation of the Sick
3. What are the nursing and applied interventions designed in the aforementioned environmental aspects?
4. What is the influence of the aforementioned environmental aspects to the recovery of the post-tonsillectomy patient?
Significance of the Study The study is beneficial to the following:
Post-tonsillectomy Patient. This study will benefit the patient in a way that he will have faster recovery during a critical phase of his hospitalization. This will enhance his recovery in a natural way using environmental factors thus decreasing additional hospitalization costs.
Patient’s Family. Patient’s folks will benefit from this study as they will be educated on how to utilize their environment at the hospital and as well as at home to help in the recovery of their patient since they are the ones who have close encounter with the patient.
Healthcare Providers. This study will help healthcare providers to focus more on the improvement of external factors of the environment that could affect their patient and his healing process. This study would serve as a basis for patient’s care to help patients recover faster.
Nursing Educators. This study will aid in developing insights about environmental intervention that could greatly help in the patient’s optimum health recovery. This can also be helpful to future researchers as a basis of their study and to nursing instructors for their lectures.
Present Researchers. Researchers can benefit from this study as they can compare and correlate certain findings and recommendations that resulted from this paper whichever relevant to their own study.
Community Leaders. This study could be helpful to community leaders when it comes to concerns in their community’s health, sanitation and other environmental aspects that they are combating their community. Being educated with this study, they can also impart to the population groups in their area the importance of maintaining sanitation and good hygiene in their own houses and surroundings as well as to family members that would need hospitalization.
Hospital Administrators. It is important for hospital administrators to be knowledgeable enough of the ideal set-up of hospital wards that would be advantageous to the patients, which are considered to be the most important people in the institution.
Nursing Service Personnel. This study is very beneficial to the Nursing Service of hospitals since this is focused on nurses’ initiative in implementing the said theory in caring for the patients.
Scope of the Study
Definition of Terms
Chapter 2
REVIEW OF RELATED LITERATURE
In this chapter the theoretical framework, conceptual literatures and research studies that are relevant to the project paper are presented. It includes result of the researcher’s view of concepts and studies which are deemed significant to the present study in terms of content, methodology and procedures. The researcher’s readings of the reviewed materials also provided her basis in analyzing her own data as well as in coming up with interpretations of data and recommendations based on data results.
Conceptual Framework There were various literatures related to Nightingale’s Environmental theory. Her renowned nursing skills were honed on the dirty and chaotic battlefields of the Crimean war. But Florence Nightingale could still teach modern hospitals a thing or two about infection control, according to an expert. Dr Jack Gilbert, head of an international project to categorize all known bugs, said modern hospitals could lower rates of infection by being slightly less sterile. Sterile conditions in wards and operating theatres may be doing more harm than good by wiping out organisms that keep dangerous microbes at bay, he believes.
Opening windows and allowing fresh air into wards could boost populations of "good bacteria" which help keep harmful bug populations under control, he explained. Dr Gilbert said: "There's a good bacterial community living in hospitals and if you try to wipe out that good bacterial community with sterilization agents and excessive antibiotic use you actually lay waste to this green field of protective layer.
"Then these bad bacteria can just jump in and start causing hospital borne infections".
The theory mirrors advice from Florence Nightingale who her 1860 work "Notes on Nursing" wrote of the importance of keeping patients' windows open and allowing a breeze in.
A study published last month by University of Oregon scientists found that rooms in clinics where windows were left open had a wider range of bacteria, while those that were kept sealed had a higher proportion of potentially harmful germs. Prof Mark Enright, a microbiology expert from Bath University, said ensuring a good air flow in hospitals was important, but said that describing them as too clean would be "quite an extreme view". (Collins, 2013)
The concept of environmental influences on healing has been known since Florence Nightingale (1970), a nursing leader, cared for soldiers of the Crimean War. New generations of critical care units are being designed to promote healing in a humanistic manner that can meet the holistic needs of patients and their families. The interaction between humans and the different environments in which they are placed has long been known. Florence Nightingale was famed for her focus on sanitation and other aspects of the environment that contribute to the health and healing of the patients. She was not only a leader in improving sanitation and ventilation, but was also instrumental in bringing forth the body-and-mind connection. She understood that the environment played a central role in a patient’s healing of body and mind. Nightingale went on to influence the healthcare environment by varying the patient’s visual perspective, utilizing color and natural light more effectively, and eliminating excessive noise. This early nursing leader was passionate about the nurse’s role to create a milieu that would give a patient the best opportunity to heal.
Environmental Noise
“Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. Such unnecessary noises undoubtedly induced or aggravated delirium in many cases.” (Nightingale, 1970)
Noise is one of the most insidious environmental stressors found in the hospital environment. On any ward, noxious noises can include the hum of medical equipment; bubbling of chest tubes; staff conversations; pagers and intercom systems; ringing of telephones; opening and closing of doors, cabinets, and supply carts; and even the clattering sounds from the wheels of a passing cart. These unfamiliar and unexpected noises can startle anyone, but especially a patient already stressed from a physiological strain. Designing a critical care environment that supports a healing atmosphere by reducing ambient noises takes into consideration many design elements, such as flooring, ceiling material, and doors and nursing station placement (Mazer, 2002). Creating a culture among the staff that fosters a healing environment includes encouraging behaviors that decrease unnecessary noise, such as keeping hallway conversations low, especially at night; avoiding over-the-bed conversations; turning pagers to vibrate; avoiding the use of overhead paging; turning off unused biomedical equipment; and modifying or repairing unnecessarily loud equipment (Petterson, 2000).
Environmental Light
“Second to their need for fresh air is their need for light. . . it is not only light but direct sunlight. The usefulness of light in treating the disease is all important”. (Nightingale, 1970)
Light, like sound, can have both positive and negative influences on the human body and mind. All living things need light to exist, and light contrasted with darkness guides the tempo of the body’s 24-hour circadian rhythm. Providing natural light or full-spectrum light is the best choice. Light has healing properties, and light therapy has been instituted as part of the treatment plans of many diseases. Many forms of light exist, and a variety of therapies that use light are being studied. Photodynamic therapy is being tested at the Baylor Research Foundation in the treatment of viruses, and light therapy is being used to treat seasonal affective disorder and insomnia (Starkweather et al., 2005). Available lighting options are nearly endless, thanks to changing technology, miniaturization of components and systems, and the wide variety of lighting choices available. Meeting the lighting needs of patients and caregivers is not the difficult challenge it has been in the past.
Color in the Environment
“Little as we know about the way in which [we are] affected by form, by color, and by light, we do know this—that they all have an actual physical effect. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Variety of form and brilliancy of color in the objects presented to patients are actual means of recovery.” (Nightingale, 1970) The relationship between light and color dictates that neither can exist without the other. In fact, light and color enhance each other’s life and energy. There are seven colors in the visible spectrum of light: red, orange, yellow, green, blue, indigo, and violet; all of these colors are present in visible light. The response of the body and mind to color is influenced by cortical activation, the autonomic nervous system, and hormone activation. Color evokes emotional responses that produce feelings of serenity or agitation that can aggravate or alleviate stress Color can also affect an individual’s emotional state, inducing cheerfulness, agitation, or calmness (Starkweather et al.). Nightingale reportedly used brilliantly colored flowers as a therapy for recovery. Over the centuries, various cultures have used color for its healing powers. Color has electromagnetic energy that can influence healing in similar ways to sunlight. The field of chromotherapy uses color as a therapeutic tool in the treatment of various disorders (Fontaine et al., 2001). Science is in the beginning stage of investigating color’s healing nature. Color by design can be used to supplement the existing light in patient rooms and contribute to the healing milieu.
Environmental Landscape
“That they [patients] should be able, without raising themselves or turning in bed, to see out a window from their beds, to see sky and sunlight at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near to it.” (Nightingale, 1970)
Staring at the same four walls can have just as deleterious a consequence on a patient’s recovery as the chaotic environment produced in the critical care environment. Creating a healing milieu in the critical care environment necessitates that clear consideration be given to the design of the environmental landscape as well as the feelings and emotions of the individual enmeshed in that environment. A revolutionary study by Ulrich (1984) found that postsurgical patients recovered more quickly when exposed to a window view than did those without this view, suggesting that changing the healthcare landscape reduces stress and has a positive effect on medical outcomes, including speed of recovery, and reductions in length of stay and cost.
Air Quality
“The first essential to the patient, without which all the rest that you can do for him is nothing. Keep the air he breathes as pure as the external air.” (Nightingale, 1970) The human sense of smell is inexorably linked with the environments in which people live. The information received through the senses evokes physiological responses and feelings. Scents stimulate the olfactory system and can trigger an immediate response (Buckle, 2001). The sense of smell plays a significant role in how humans perceive and react to environments in which they are placed. The basic medicinal smells of a hospital environment evoke strong reactions without even considering the potential for additional noxious odors. Just the “hospital smell” can produce anxiety and increase heart rate and respiration, let alone the reactions to the smell of blood, vomit, feces, and infections. Other suggestions include removing offensive odors from the immediate environment as quickly as possible and providing other, more pleasant odors to supercede the noxious ones, such as vanilla, lavender, and mint.
A mounting body of research suggests that humanizing the environment in which medical and nursing care is provided improves healing and the healing process for patients, families, and providers. Meeting the challenges of reducing environmental stressors in the critical care unit will potentially avert the adverse effects of being a patient in the Critical Unit and reduce staff stress. (Rubert, 2013)
Research Literature
Synthesis
Chapter 3
METHODOLOGY
This study aims to use the Environmental Theory of Florence Nightingale to help a post-tonsillectomy patient attain faster recovery by utilizing the environment towards his optimum healing experience during implementation and nursing process.
Application of Nursing Process
Assessment
ASSESSMENT TOOL
Instrument
The researcher developed a checklist of canons that was directly derived from the Nightingale’s Environmental Theory (Nightingale, 1969). In keeping with Nightingale’s Environmental Theory fundamental principles, the goal of the interview is to assess the patient’s environment as to what extent it could be controlled to facilitate easy recovery and to assess patient’s preference especially being in the perioperative phase.
Table 1
Nightingale’s Environmental Theory
13 Canons of Nightingale
Nursing Process & Thought Done
(Nightingale, 1969)
1. Ventilation
-Check the patient's body temperature,
room temperature, ventilation & foul
odors. 2. Warmth
-Create a plan to keep the room well-
ventilated and free of odor while
maintaining the patient's body temperature. 3. Light
-Check room for adequate light. Sunlight is
beneficial to the patient.
-Create and implement adequate light in the
room without placing the patient in direct
light. 4. Cleanliness
-Check room for dust, dampness and dirt.
-Keep room free from dust, dirt and
dampness. 5. Health of Surrounding
-Check surrounding environment for
fresh air, pure water, drainage, cleanliness
and light.
-Remove garbage, stagnant water and ensure
clean water and fresh air. 6. Noise
-Check noise level in the room and
surroundings.
-Attempt to keep noise level in minimum. 7. Bed & Bedding
-Check Bed and bedding for dampness,
wrinkles and soiling.
-Keep the bed dry, wrinkle-free and lowest
height to ensure comfort. 8. Personal Cleanliness
-Attempt to keep the patient dry and clean
at all times.
-Frequent assessment of the patient's skin is
essential to maintain good skin integrity. 9. Variety
-Attempt to accomplish variety in the room
and with the client.
-This is done with cards, flowers, pictures and
books. Also encourage friends or relatives
to engage in stimulating activities.
-Avoid talking without giving advice that is 10. Chattering Hopes without a fact. & Advices
-Respect the patient as a person and avoid
personal talk. 11. Taking Food
-Check the diet of the patient. Note the
amount of food and fluid ingested by the
patient at every meal. 12. Petty Management
-This ensures continuity of care.
-Document the plan of care and evaluate the
outcomes to ensure continuity.
-Observe and record anything about the 13. Observation of the Sick patient. -Continue observation in the patient's
environment and make changes in the plan of
care if needed. NURSING PROCESS
Procedure
On September 16, 2013, first day of patient’s admission, a one-on-one interview was conducted at the Medicare Surgical Ward where the patient was confined. Assessment of the environment was done and the needed alterations were made since Mr. HM was scheduled for operation the next day, September 17, 2013.
Table 2
Assessment of the Patient’s Environment using Nightingale’s Environmental Theory
13 Canons of Nightingale
(Nightingale, 1969)
Current Situation
Alterations/Actions Made
Ventilation & Warmth
Some windows in the ward are open with fresh air coming in.
There are 2 ceiling fans in the room.
Patient’s temperature is within normal range – 37.2◦C
All windows were opened to maximize ventilation.
Patient’s folks were encouraged to bring additional electric fan for the patient.
Light
The room has 4 T5 fluorescent lights.
Windows allow sunlight to fill the ward.
Cleanliness
Few dusts and cobwebs were noted at the window panes and jalousies
The housekeeping personnel was asked to wipe dusts and clean the entire ward
Health of Surroundings
Clogged drainage in the comfort room is noted
Water used in comfort room underwent treatment
The garbage bins are almost full
The hospital engineering personnel was informed about the clog and made immediate actions to fix it
Housekeeping personnel emptied the garbage bins
Noise
Minimal noise noted from nurses station across the ward
Nurses were asked to avoid making irrelevant noise during patient’s stay
Bed and Bedding
Bed is clean; terminal cleaning performed before patient was placed.
New and clean bed cover and pillow case used by patient
Instructed folks to keep the bedding wrinkle-free and to change it if become soiled
Personal Cleanliness
Patient is dry and clean with good skin integrity maintained
Instructed patient and folks to maintain personal cleanliness of the patient
Variety
The bedside table is occupied with alcohol and other medical supplies
Different kinds of fruits were arranged in the bedside table to add color
Chattering Hopes and Advices
Advice given to the patient were factual and relevant to his condition
Taking Food
Patient complies with the diet ordered to him
Encouraged to continually eat foods within his ordered diet and ingest adequate amount
Petty Management
Patient’s data and progress are recorded accordingly
Observation of the Sick
Patient and environment is being observed and visited by the researcher daily during his hospital stay
Evaluative Phase
The assessment tool was used in determining the client’s environment and its relevance to the patient’s condition as a postoperative patient. Through this phase, the nurse assisted to evaluate the client’s environment towards his condition. Evaluation of patient’s response was gathered at his last day of hospitalization.
Chapter 4
DISCUSSIONS AND FINDINGS
A. Demographic Profile of the Participant
Name: HM
Age: 38 years old
Gender: Male
Civil Status: Married
Occupation: Jeepney Driver
Educational Attainment: College Level
Ethnic-Group: Visayan-Negrosanon
Religion: Roman Catholic
Language: English, Tagalog, Hiligaynon
Chief Complaint: Pain upon swallowing
Medical Diagnosis: Chronic Hypertrophic Tonsillitis
Operation: Tonsillectomy Bilateral with Pharyngoplasty
B. Comprehensive Health History
This study was conducted when the client was confined in the hospital where he was admitted and treated. The nurse-researcher and patient interaction happened in the Medicare Surgical Ward of the institution.
The first interview was done upon patient’s admission last September 16, 2013 at 11 o’clock in the morning with the client himself as the primary informant.
The client, Mr. HM, 38 years old, male, married and a father of 3, Filipino, a native and a resident of Victorias City and works as a jeepney driver in his city. Mr. HM is a serious type of person. He is not that fond of chitchatting with the people around him. He prefers to watch television or read the newspaper rather than socializing. The patient is an occasional drinker and doesn’t smoke. Based on the information provided by the client, he is fond of eating sweet foods and has had a history of recurring sore throat infections over the last 3 years. Despite of such conditions, he didn’t seek consultation instead he just gargles with water and salt every time the condition occurs.
Last September 13, 2013, Mr. HM experienced sore throat again and verbalized, “grabe bi day ang init tapos gulpi lang ma ulan naman, gaka ambihan ko kung naga drive, daw malain naman dayon pamatyag ko kag ga askad dayon tutunlan ko.” Upon experiencing this, he just gargled again with water and salt. On the next day, when he was eating his lunch at home, he felt that his sore throat worsened. He finds it very painful to swallow his food. Then the family and the patient decided to go to a doctor for a check-up on September 14, 2013 until he was diagnosed to have Chronic Hypertrophic Tonsillitis. He was then advised to have his tonsils removed. He and his wife decided to go for the operation as soon as possible.
Discussions
Since postoperative patients are in a critical phase of their recovery and are in need of careful and meticulous care by the nurses, the physical environment of the patient should not be ignored. There are a lot of factors in the environment that could certainly affect the patient’s healing process.
A complication that should be avoided in this phase is infection that would cause to worsening of the case and even death if not treated as early as possible, and the environment is one of the sources of infection. Nurses need to secure the patient’s surrounding to be free of such factors that could hinder the patient in recovering fast and well.
Findings
It was found out that after using the Canons based on Florence Nightingale’s Environmental Theory, the patient have attained fast recovery and has been free from postoperative complications such as infection upon being discharged in the institution. In general, nurses should be holistic in caring for patients which includes his surroundings and physical environment. This is one area in which nurses should give emphasis too. In the case of this study, the goal was met in the nursing process within the target timeframe.
Chapter 5
CONCLUSION AND RECOMMENDATIONS
Conclusion
In conclusion, Florence Nightingale’s Environmental Theory is deemed effective especially when applied to postoperative patients. Since patients in the postoperative phase had already breaks in their skin, which serves as a primary defense for pathogens, the surrounding environment should be free from harmful pathogens that would penetrate the patient’s wound and would cause severe damage and complications thus hindering the patient’s fast recovery and healing.
Recommendation
Based on the abovementioned conclusion, it is recommended that:
Patient. It is important that wards for postoperative patients should be kept clean and adheres to standard environment that is expected to have for patients recovering from surgery.
Patient’s Family. The family should be educated enough on how it is to properly care for hospitalized members and the environment where the member is placed.
Healthcare Providers. It is strongly recommended for healthcare workers to know and apply proper care to the healthcare environment and adhere to rules and regulations set by organizations and committees in order to attain a clean and hygienic patient environment.
Nursing Educators. Nursing educators need to impart and emphasize to students on how the environment would affect the patient’s condition and recovery. It is good that as early as during their student days that nursing students are inculcated on how to care for the environment to benefit their patients.
Present Researchers. Researchers should really study Florence Nightingale’s theory since it is really applicable until now, during the Modern Nursing era. It has always been helpful with regards to patient’s recovery stage.
Community Leaders. Community leaders should also apply this theory even in their own environment. Since this is where the patient would stay after hospitalization, it is still recommended to maintain the sanitation and cleanliness where the patient is.
Hospital Administrators. Hospital administrators should be strict in implementing standards when it comes to the cleanliness of the environment. The Infection Control Committee of the institution which aims to minimize infections within the hospital should be strongly backed-up by the administration.
Nursing Service Personnel. Since nurses are the frontiers in caring for the patient, the Nursing Service should be responsible in educating their nurses in integrating Nightingale’s Environmental Theory in caring for patients.
INTRODUCTION
Background of the Study
Surgical Site Infections (SSIs) are the most common nosocomial infection, accounting for 38 percent of nosocomial infections. It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million patients undergoing surgical procedures each year. The environment plays a big role whether or not the patient would develop Surgical Site Infections. (Brunner & Suddarth, 2008).
The postoperative period extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon. This may be as short as one week or as long as several months. During the postoperative period, nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient self-care. Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortable as possible. (Brunner & Suddarth, 2008). …show more content…
According to The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS, 30 years ago, approximately 90% of tonsillectomies in children were done for recurrent infection; now it is about 20% for infection and 80% for obstructive sleep problems (OSA).
The rise in the incidence of tonsillectomy is one of the major phenomena of modern surgery, for it has been estimated that 200,000 of these operations are performed annually in this country and that tonsillectomies form one-third of the number of operations performed under general anesthesia in the United States. There are, moreover, features in the age, geographical and social distribution of the incidence, so unusual as to justify the decision of the Section of Epidemiology to devote an evening to its discussion. (Glover,
2008)
The environmental aspects of Nightingale’s theory (ventilation, warmth, quiet, diet, and cleanliness) remains a significant component of current nursing care until today. These concepts, even from the 21st, showed significance as the global society encounters new issues of disease control. Like for instance, sanitation and water treatment somehow controlled sources of diseases and sickness. In places such as clinics and hospitals, the control for room temperature for an individual patient is also considered. Also, the same environment, though it contains technology that helps for recovery, may create uncomfortable noise that would affect the healing process.
Nightingale’s theory has been used to provide general guidelines for all nurse practitioners for a number of years. The universality of her concepts still remains relevant except for some specific activities. The concept of the nurse, patient and environment are still applicable and relevant in all nursing settings today. Florence Nightingale believed that disease was a reparative process; disease was nature’s effort to remedy a process of poisoning or decay, or a reaction against the conditions in which a person was placed. Nightingale did not provide a definition of nature. In her writings, she often capitalized the word nature in her writings, thereby suggesting that it was synonymous with God. However, when she used the word nature without capitalization, it is unclear whether or not the intended meaning is different and perhaps synonymous with an organic pathological process. Nightingale believed that nursing’s role was to prevent an interruption of the reparative process and to provide optimal conditions for its enhancement. Nightingale felt that nurses needed to be excellent at the observation of their patients and the environment. She also believed that persons desired good health and that they would cooperate with the nurse and nature to allow the reparative process to occur or alter their environment to prevent disease. Nightingale strongly believed that appropriate manipulations of the environment would prevent diseases; this concept underlies modern sanitation activities. (Octaviano & Balita, 2008)
As nursing practice moves toward a caring paradigm, nurses seek creative ways in which to create healing environments for their patients. Nurses look to nursing roots for guidance and knowledge. Nightingale’s environmental adaptation theory of mind-body-spirit integration with environmental factors, including auditory, visual, olfactory, sensory, tactile, and cognitive modalities, provides a framework for actualizing caring-healing practices in a transpersonal caring model. (Schmock, 2009)
As an infection control nurse of a regional hospital, the researcher was eager to know the effectiveness of Nightingale’s theory which is said that her approach could help fight infection in modern hospitals. She also intended to find out how such measures could be applicable in the present hospital setting. This study is aimed to apply environmental factors of Florence Nightingale for post-tonsillectomy patient in order to speed up the recovery, decrease expenses, and lower the chances of readmission.
Statement of the Problem
General
The study aimed to determine the application of Florence Nightingale’s Environmental Theory to a post-tonsillectomy patient on the month of September 2013.
Specific Objectives Specifically, the study sought to answer the following questions:
1. What is the comprehensive health history of the post-tonsillectomy patient?
2. What are the current situations of the environment of the post-tonsillectomy patient on the following aspects:
a. Ventilation & Warmth
b. Light
c. Cleanliness
d. Health of Houses
e. Noise
f. Bed & Bedding
g. Personal Cleanliness
h. Variety
i. Chattering Hopes & Advices
j. Taking Food
k. Petty Management
l. Observation of the Sick
3. What are the nursing and applied interventions designed in the aforementioned environmental aspects?
4. What is the influence of the aforementioned environmental aspects to the recovery of the post-tonsillectomy patient?
Significance of the Study The study is beneficial to the following:
Post-tonsillectomy Patient. This study will benefit the patient in a way that he will have faster recovery during a critical phase of his hospitalization. This will enhance his recovery in a natural way using environmental factors thus decreasing additional hospitalization costs.
Patient’s Family. Patient’s folks will benefit from this study as they will be educated on how to utilize their environment at the hospital and as well as at home to help in the recovery of their patient since they are the ones who have close encounter with the patient.
Healthcare Providers. This study will help healthcare providers to focus more on the improvement of external factors of the environment that could affect their patient and his healing process. This study would serve as a basis for patient’s care to help patients recover faster.
Nursing Educators. This study will aid in developing insights about environmental intervention that could greatly help in the patient’s optimum health recovery. This can also be helpful to future researchers as a basis of their study and to nursing instructors for their lectures.
Present Researchers. Researchers can benefit from this study as they can compare and correlate certain findings and recommendations that resulted from this paper whichever relevant to their own study.
Community Leaders. This study could be helpful to community leaders when it comes to concerns in their community’s health, sanitation and other environmental aspects that they are combating their community. Being educated with this study, they can also impart to the population groups in their area the importance of maintaining sanitation and good hygiene in their own houses and surroundings as well as to family members that would need hospitalization.
Hospital Administrators. It is important for hospital administrators to be knowledgeable enough of the ideal set-up of hospital wards that would be advantageous to the patients, which are considered to be the most important people in the institution.
Nursing Service Personnel. This study is very beneficial to the Nursing Service of hospitals since this is focused on nurses’ initiative in implementing the said theory in caring for the patients.
Scope of the Study
Definition of Terms
Chapter 2
REVIEW OF RELATED LITERATURE
In this chapter the theoretical framework, conceptual literatures and research studies that are relevant to the project paper are presented. It includes result of the researcher’s view of concepts and studies which are deemed significant to the present study in terms of content, methodology and procedures. The researcher’s readings of the reviewed materials also provided her basis in analyzing her own data as well as in coming up with interpretations of data and recommendations based on data results.
Conceptual Framework There were various literatures related to Nightingale’s Environmental theory. Her renowned nursing skills were honed on the dirty and chaotic battlefields of the Crimean war. But Florence Nightingale could still teach modern hospitals a thing or two about infection control, according to an expert. Dr Jack Gilbert, head of an international project to categorize all known bugs, said modern hospitals could lower rates of infection by being slightly less sterile. Sterile conditions in wards and operating theatres may be doing more harm than good by wiping out organisms that keep dangerous microbes at bay, he believes.
Opening windows and allowing fresh air into wards could boost populations of "good bacteria" which help keep harmful bug populations under control, he explained. Dr Gilbert said: "There's a good bacterial community living in hospitals and if you try to wipe out that good bacterial community with sterilization agents and excessive antibiotic use you actually lay waste to this green field of protective layer.
"Then these bad bacteria can just jump in and start causing hospital borne infections".
The theory mirrors advice from Florence Nightingale who her 1860 work "Notes on Nursing" wrote of the importance of keeping patients' windows open and allowing a breeze in.
A study published last month by University of Oregon scientists found that rooms in clinics where windows were left open had a wider range of bacteria, while those that were kept sealed had a higher proportion of potentially harmful germs. Prof Mark Enright, a microbiology expert from Bath University, said ensuring a good air flow in hospitals was important, but said that describing them as too clean would be "quite an extreme view". (Collins, 2013)
The concept of environmental influences on healing has been known since Florence Nightingale (1970), a nursing leader, cared for soldiers of the Crimean War. New generations of critical care units are being designed to promote healing in a humanistic manner that can meet the holistic needs of patients and their families. The interaction between humans and the different environments in which they are placed has long been known. Florence Nightingale was famed for her focus on sanitation and other aspects of the environment that contribute to the health and healing of the patients. She was not only a leader in improving sanitation and ventilation, but was also instrumental in bringing forth the body-and-mind connection. She understood that the environment played a central role in a patient’s healing of body and mind. Nightingale went on to influence the healthcare environment by varying the patient’s visual perspective, utilizing color and natural light more effectively, and eliminating excessive noise. This early nursing leader was passionate about the nurse’s role to create a milieu that would give a patient the best opportunity to heal.
Environmental Noise
“Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. Such unnecessary noises undoubtedly induced or aggravated delirium in many cases.” (Nightingale, 1970)
Noise is one of the most insidious environmental stressors found in the hospital environment. On any ward, noxious noises can include the hum of medical equipment; bubbling of chest tubes; staff conversations; pagers and intercom systems; ringing of telephones; opening and closing of doors, cabinets, and supply carts; and even the clattering sounds from the wheels of a passing cart. These unfamiliar and unexpected noises can startle anyone, but especially a patient already stressed from a physiological strain. Designing a critical care environment that supports a healing atmosphere by reducing ambient noises takes into consideration many design elements, such as flooring, ceiling material, and doors and nursing station placement (Mazer, 2002). Creating a culture among the staff that fosters a healing environment includes encouraging behaviors that decrease unnecessary noise, such as keeping hallway conversations low, especially at night; avoiding over-the-bed conversations; turning pagers to vibrate; avoiding the use of overhead paging; turning off unused biomedical equipment; and modifying or repairing unnecessarily loud equipment (Petterson, 2000).
Environmental Light
“Second to their need for fresh air is their need for light. . . it is not only light but direct sunlight. The usefulness of light in treating the disease is all important”. (Nightingale, 1970)
Light, like sound, can have both positive and negative influences on the human body and mind. All living things need light to exist, and light contrasted with darkness guides the tempo of the body’s 24-hour circadian rhythm. Providing natural light or full-spectrum light is the best choice. Light has healing properties, and light therapy has been instituted as part of the treatment plans of many diseases. Many forms of light exist, and a variety of therapies that use light are being studied. Photodynamic therapy is being tested at the Baylor Research Foundation in the treatment of viruses, and light therapy is being used to treat seasonal affective disorder and insomnia (Starkweather et al., 2005). Available lighting options are nearly endless, thanks to changing technology, miniaturization of components and systems, and the wide variety of lighting choices available. Meeting the lighting needs of patients and caregivers is not the difficult challenge it has been in the past.
Color in the Environment
“Little as we know about the way in which [we are] affected by form, by color, and by light, we do know this—that they all have an actual physical effect. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Variety of form and brilliancy of color in the objects presented to patients are actual means of recovery.” (Nightingale, 1970) The relationship between light and color dictates that neither can exist without the other. In fact, light and color enhance each other’s life and energy. There are seven colors in the visible spectrum of light: red, orange, yellow, green, blue, indigo, and violet; all of these colors are present in visible light. The response of the body and mind to color is influenced by cortical activation, the autonomic nervous system, and hormone activation. Color evokes emotional responses that produce feelings of serenity or agitation that can aggravate or alleviate stress Color can also affect an individual’s emotional state, inducing cheerfulness, agitation, or calmness (Starkweather et al.). Nightingale reportedly used brilliantly colored flowers as a therapy for recovery. Over the centuries, various cultures have used color for its healing powers. Color has electromagnetic energy that can influence healing in similar ways to sunlight. The field of chromotherapy uses color as a therapeutic tool in the treatment of various disorders (Fontaine et al., 2001). Science is in the beginning stage of investigating color’s healing nature. Color by design can be used to supplement the existing light in patient rooms and contribute to the healing milieu.
Environmental Landscape
“That they [patients] should be able, without raising themselves or turning in bed, to see out a window from their beds, to see sky and sunlight at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near to it.” (Nightingale, 1970)
Staring at the same four walls can have just as deleterious a consequence on a patient’s recovery as the chaotic environment produced in the critical care environment. Creating a healing milieu in the critical care environment necessitates that clear consideration be given to the design of the environmental landscape as well as the feelings and emotions of the individual enmeshed in that environment. A revolutionary study by Ulrich (1984) found that postsurgical patients recovered more quickly when exposed to a window view than did those without this view, suggesting that changing the healthcare landscape reduces stress and has a positive effect on medical outcomes, including speed of recovery, and reductions in length of stay and cost.
Air Quality
“The first essential to the patient, without which all the rest that you can do for him is nothing. Keep the air he breathes as pure as the external air.” (Nightingale, 1970) The human sense of smell is inexorably linked with the environments in which people live. The information received through the senses evokes physiological responses and feelings. Scents stimulate the olfactory system and can trigger an immediate response (Buckle, 2001). The sense of smell plays a significant role in how humans perceive and react to environments in which they are placed. The basic medicinal smells of a hospital environment evoke strong reactions without even considering the potential for additional noxious odors. Just the “hospital smell” can produce anxiety and increase heart rate and respiration, let alone the reactions to the smell of blood, vomit, feces, and infections. Other suggestions include removing offensive odors from the immediate environment as quickly as possible and providing other, more pleasant odors to supercede the noxious ones, such as vanilla, lavender, and mint.
A mounting body of research suggests that humanizing the environment in which medical and nursing care is provided improves healing and the healing process for patients, families, and providers. Meeting the challenges of reducing environmental stressors in the critical care unit will potentially avert the adverse effects of being a patient in the Critical Unit and reduce staff stress. (Rubert, 2013)
Research Literature
Synthesis
Chapter 3
METHODOLOGY
This study aims to use the Environmental Theory of Florence Nightingale to help a post-tonsillectomy patient attain faster recovery by utilizing the environment towards his optimum healing experience during implementation and nursing process.
Application of Nursing Process
Assessment
ASSESSMENT TOOL
Instrument
The researcher developed a checklist of canons that was directly derived from the Nightingale’s Environmental Theory (Nightingale, 1969). In keeping with Nightingale’s Environmental Theory fundamental principles, the goal of the interview is to assess the patient’s environment as to what extent it could be controlled to facilitate easy recovery and to assess patient’s preference especially being in the perioperative phase.
Table 1
Nightingale’s Environmental Theory
13 Canons of Nightingale
Nursing Process & Thought Done
(Nightingale, 1969)
1. Ventilation
-Check the patient's body temperature,
room temperature, ventilation & foul
odors. 2. Warmth
-Create a plan to keep the room well-
ventilated and free of odor while
maintaining the patient's body temperature. 3. Light
-Check room for adequate light. Sunlight is
beneficial to the patient.
-Create and implement adequate light in the
room without placing the patient in direct
light. 4. Cleanliness
-Check room for dust, dampness and dirt.
-Keep room free from dust, dirt and
dampness. 5. Health of Surrounding
-Check surrounding environment for
fresh air, pure water, drainage, cleanliness
and light.
-Remove garbage, stagnant water and ensure
clean water and fresh air. 6. Noise
-Check noise level in the room and
surroundings.
-Attempt to keep noise level in minimum. 7. Bed & Bedding
-Check Bed and bedding for dampness,
wrinkles and soiling.
-Keep the bed dry, wrinkle-free and lowest
height to ensure comfort. 8. Personal Cleanliness
-Attempt to keep the patient dry and clean
at all times.
-Frequent assessment of the patient's skin is
essential to maintain good skin integrity. 9. Variety
-Attempt to accomplish variety in the room
and with the client.
-This is done with cards, flowers, pictures and
books. Also encourage friends or relatives
to engage in stimulating activities.
-Avoid talking without giving advice that is 10. Chattering Hopes without a fact. & Advices
-Respect the patient as a person and avoid
personal talk. 11. Taking Food
-Check the diet of the patient. Note the
amount of food and fluid ingested by the
patient at every meal. 12. Petty Management
-This ensures continuity of care.
-Document the plan of care and evaluate the
outcomes to ensure continuity.
-Observe and record anything about the 13. Observation of the Sick patient. -Continue observation in the patient's
environment and make changes in the plan of
care if needed. NURSING PROCESS
Procedure
On September 16, 2013, first day of patient’s admission, a one-on-one interview was conducted at the Medicare Surgical Ward where the patient was confined. Assessment of the environment was done and the needed alterations were made since Mr. HM was scheduled for operation the next day, September 17, 2013.
Table 2
Assessment of the Patient’s Environment using Nightingale’s Environmental Theory
13 Canons of Nightingale
(Nightingale, 1969)
Current Situation
Alterations/Actions Made
Ventilation & Warmth
Some windows in the ward are open with fresh air coming in.
There are 2 ceiling fans in the room.
Patient’s temperature is within normal range – 37.2◦C
All windows were opened to maximize ventilation.
Patient’s folks were encouraged to bring additional electric fan for the patient.
Light
The room has 4 T5 fluorescent lights.
Windows allow sunlight to fill the ward.
Cleanliness
Few dusts and cobwebs were noted at the window panes and jalousies
The housekeeping personnel was asked to wipe dusts and clean the entire ward
Health of Surroundings
Clogged drainage in the comfort room is noted
Water used in comfort room underwent treatment
The garbage bins are almost full
The hospital engineering personnel was informed about the clog and made immediate actions to fix it
Housekeeping personnel emptied the garbage bins
Noise
Minimal noise noted from nurses station across the ward
Nurses were asked to avoid making irrelevant noise during patient’s stay
Bed and Bedding
Bed is clean; terminal cleaning performed before patient was placed.
New and clean bed cover and pillow case used by patient
Instructed folks to keep the bedding wrinkle-free and to change it if become soiled
Personal Cleanliness
Patient is dry and clean with good skin integrity maintained
Instructed patient and folks to maintain personal cleanliness of the patient
Variety
The bedside table is occupied with alcohol and other medical supplies
Different kinds of fruits were arranged in the bedside table to add color
Chattering Hopes and Advices
Advice given to the patient were factual and relevant to his condition
Taking Food
Patient complies with the diet ordered to him
Encouraged to continually eat foods within his ordered diet and ingest adequate amount
Petty Management
Patient’s data and progress are recorded accordingly
Observation of the Sick
Patient and environment is being observed and visited by the researcher daily during his hospital stay
Evaluative Phase
The assessment tool was used in determining the client’s environment and its relevance to the patient’s condition as a postoperative patient. Through this phase, the nurse assisted to evaluate the client’s environment towards his condition. Evaluation of patient’s response was gathered at his last day of hospitalization.
Chapter 4
DISCUSSIONS AND FINDINGS
A. Demographic Profile of the Participant
Name: HM
Age: 38 years old
Gender: Male
Civil Status: Married
Occupation: Jeepney Driver
Educational Attainment: College Level
Ethnic-Group: Visayan-Negrosanon
Religion: Roman Catholic
Language: English, Tagalog, Hiligaynon
Chief Complaint: Pain upon swallowing
Medical Diagnosis: Chronic Hypertrophic Tonsillitis
Operation: Tonsillectomy Bilateral with Pharyngoplasty
B. Comprehensive Health History
This study was conducted when the client was confined in the hospital where he was admitted and treated. The nurse-researcher and patient interaction happened in the Medicare Surgical Ward of the institution.
The first interview was done upon patient’s admission last September 16, 2013 at 11 o’clock in the morning with the client himself as the primary informant.
The client, Mr. HM, 38 years old, male, married and a father of 3, Filipino, a native and a resident of Victorias City and works as a jeepney driver in his city. Mr. HM is a serious type of person. He is not that fond of chitchatting with the people around him. He prefers to watch television or read the newspaper rather than socializing. The patient is an occasional drinker and doesn’t smoke. Based on the information provided by the client, he is fond of eating sweet foods and has had a history of recurring sore throat infections over the last 3 years. Despite of such conditions, he didn’t seek consultation instead he just gargles with water and salt every time the condition occurs.
Last September 13, 2013, Mr. HM experienced sore throat again and verbalized, “grabe bi day ang init tapos gulpi lang ma ulan naman, gaka ambihan ko kung naga drive, daw malain naman dayon pamatyag ko kag ga askad dayon tutunlan ko.” Upon experiencing this, he just gargled again with water and salt. On the next day, when he was eating his lunch at home, he felt that his sore throat worsened. He finds it very painful to swallow his food. Then the family and the patient decided to go to a doctor for a check-up on September 14, 2013 until he was diagnosed to have Chronic Hypertrophic Tonsillitis. He was then advised to have his tonsils removed. He and his wife decided to go for the operation as soon as possible.
Discussions
Since postoperative patients are in a critical phase of their recovery and are in need of careful and meticulous care by the nurses, the physical environment of the patient should not be ignored. There are a lot of factors in the environment that could certainly affect the patient’s healing process.
A complication that should be avoided in this phase is infection that would cause to worsening of the case and even death if not treated as early as possible, and the environment is one of the sources of infection. Nurses need to secure the patient’s surrounding to be free of such factors that could hinder the patient in recovering fast and well.
Findings
It was found out that after using the Canons based on Florence Nightingale’s Environmental Theory, the patient have attained fast recovery and has been free from postoperative complications such as infection upon being discharged in the institution. In general, nurses should be holistic in caring for patients which includes his surroundings and physical environment. This is one area in which nurses should give emphasis too. In the case of this study, the goal was met in the nursing process within the target timeframe.
Chapter 5
CONCLUSION AND RECOMMENDATIONS
Conclusion
In conclusion, Florence Nightingale’s Environmental Theory is deemed effective especially when applied to postoperative patients. Since patients in the postoperative phase had already breaks in their skin, which serves as a primary defense for pathogens, the surrounding environment should be free from harmful pathogens that would penetrate the patient’s wound and would cause severe damage and complications thus hindering the patient’s fast recovery and healing.
Recommendation
Based on the abovementioned conclusion, it is recommended that:
Patient. It is important that wards for postoperative patients should be kept clean and adheres to standard environment that is expected to have for patients recovering from surgery.
Patient’s Family. The family should be educated enough on how it is to properly care for hospitalized members and the environment where the member is placed.
Healthcare Providers. It is strongly recommended for healthcare workers to know and apply proper care to the healthcare environment and adhere to rules and regulations set by organizations and committees in order to attain a clean and hygienic patient environment.
Nursing Educators. Nursing educators need to impart and emphasize to students on how the environment would affect the patient’s condition and recovery. It is good that as early as during their student days that nursing students are inculcated on how to care for the environment to benefit their patients.
Present Researchers. Researchers should really study Florence Nightingale’s theory since it is really applicable until now, during the Modern Nursing era. It has always been helpful with regards to patient’s recovery stage.
Community Leaders. Community leaders should also apply this theory even in their own environment. Since this is where the patient would stay after hospitalization, it is still recommended to maintain the sanitation and cleanliness where the patient is.
Hospital Administrators. Hospital administrators should be strict in implementing standards when it comes to the cleanliness of the environment. The Infection Control Committee of the institution which aims to minimize infections within the hospital should be strongly backed-up by the administration.
Nursing Service Personnel. Since nurses are the frontiers in caring for the patient, the Nursing Service should be responsible in educating their nurses in integrating Nightingale’s Environmental Theory in caring for patients.