Journal of Clinical Nursing 1992; 1: 233-236

Clinical Notes

Wound dressing use in theatre follow-ing hip surgery and haemorrhage riskHAZEL MORTIMER RGNAssociate Nurse, BUPA Gatwick Park Hospital, Povey Cross Lane,Horley, Surrey RH6 OBB, UK

While working on an acute orthopaedic ward wherenumerous patients underwent hip surgery (mainly totalhip replacement and repair of fractured neck of femur), thenursing staff observed that many patients haemorrhagedpost-operatively, requiring the application of pressuredressings on the ward.

From our observations it appeared that the type ofpatient who haemorrhaged were often tho.se who had theirhip wound dressed with a light dressing in theatre. Thiscomprised thin layers of gauze followed by elastoplast orMefix tape which often only just covered the patient'ssuture line.

The pressure dressing was composed of thick layers ofgauze followed by thick perineal padding or wool crepebandage and was covered with elastoplast or Mefix tapethereby sealing the whole wound area. Patients whosewound received thick-pressure dressing did not appear tohaemorrhage as frequently in the post-operative period asthose receiving a light dressing.

These observations raised several issues regardingpatient safety, comfort, nurses' time and cost implications.The risk of hypovalaemic shock for those patients receiv-ing a light dressing necessitated further investigation. Inan attempt to provide a more systematic estimate of theproblem a simple survey comparing the haemorrhage ratesfor patients receiving each type of dressing was conducted,in conjunction with medical colleagues. The findings ofthestudy will be presented elsewhere, however, there wereindications that patients with lighter dressings may wellhave a much greater of risk of haemorrhage following hipsurgery, compared to those with a thicker pressure dress-ing. The risk of those patients with a light dressing toinfection will also require examination.

The issue is raised here that the presence of a pressuredressing may itself exacerbate the patient's experience ofpain. As well as the effect on individual patients, thedelayed application of the pressure dressing until the time

when a wound haemorrhage occurred on the ward, addedto the responsibilities of nurses, particularly on night shift,and drew them away from nursing other patients duringthe emergency. The question is also raised as to whylighter dressings were being used in preference to pressuredressings and, if so, what were the relative costs involved.Apart from the human cost of using an inadequate dress-ing, the cost of prolonged hospital stay arising from a post-operative wound haemorrhage would make this a falseeconomy.

Communicating these observations to colleagues pro-vided a basis for investigating the problem more systemati-cally and, in the light of the findings, enabled me toparticipate in making the necessary changes to ensurepatient safety. ^ -.•,,;}..-i,:ft .rnyri

The events described occurred while working as a staff nurse at theKent & Sussex Hospital, Mount Ephraim, Tunbridge Wells, Kent.

Manpower planning to provide opti-mum health visiting in areas of socialdeprivationJILL BROWN RGN RHV

Neighbourhood Nursing Team Leader, Plymouth Community Services,NHS Trust, c/o Scott Hospital, Plymouth, Devon, UK.

As many studies have shown, poor health is related tolevels of social deprivation. In order to target health-visiting services towards those areas of greatest healthneed, it was necessary to find a method of measuringworkloads relative to areas of deprivation.

With the introduction of neighbourhood nursing teams,an integrated management structure had highlighted thevariability in the provision of health visiting in the formerthree divisions. Additionally, there was an over-establish-ment of 2-5 WTE health-visiting posts, which had for-merly been managed by holding vacancies for variableperiods of time and not covering for maternity or sickleave. Demographic and life-style changes resulted infewer vacancies and even less opportunity to recoup anyoverspend. With the need to ensure that both the budget

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234 Clinical Notes li-fJ.i A . mwV. \uv:

was balanced and that money was available to fulfil ourcontractual obligations for such cover, it was essential toreview caseloads.

Initially, health visitors were required to compile pro-files of their current practice to ascertain the level and typeof work currently undertaken. These showed that servicesprovided in areas of low deprivation were more compre-hensive than those in areas with greater need. In areas ofneed, child health work was given highest priority and aminimal service offered to other age-groups. It was,therefore, considered important to measure each caseloadaccording to the potential for work needed rather thanwork currently undertaken. With the pro-active nature ofhealth visiting, this potential work was seen to be therelevant factor in determining caseload sizes.

However, it was acknowledged that health visitors, evenif working with all age-groups, still had a partieularresponsibility for families with young children under 5 andthat much of their work involved that group. Comparingpractice populations did not reflect the differences betweenpopulations of under-fives, so under-five numbers werechosen in preference to practice size.

In this district many part-time health visitors areemployed. To allow for this in calculating work potential,the number of under-fives in each caseload, according tothe child health computer, were divided by the weeklyhealth visiting hours. For example, a health visitor with acaseload of 240 under-fives, working 26 h a week, wouldhave a factor of 240/26 or 9 23.

In the three former Divisions, the mean caseload sizewas 7-75, 8 51 and 7 7 per hour health visitor time, withstandard deviations of 1 63, 115 and 114, respectively.

Relative deprivation was measured according to Censusstatistics. Ten contributory factors highlighted areas withfour relative levels of deprivation. These indicators were:• persons over 65;• pensioners living alone;• persons under 5;• one-parent families;• unskilled workers; ' • ' - • ' • ' 'n-''-'? •"

• unemployment;• lack of amenity;• overcrowding;• high mobility;• ethnic minorities.A score of 0-3 was added to each of the caseload sizes, thearea of greatest deprivation scoring 3 and the least 0, usinglocation of the GP surgery to set the deprivation level.

Another factor concerning impact on the work of thehealth visitor is the number of children in need ofprotection from abuse. Where figures are high, healthvisitors are unable to address health issues in other age-groups. Child protection statistics used at the time of thereview showed variations between 0-53 and 17'12/000ehildren between neighbourhoods. Scores of between 0and 4 were added to the combined caseload size anddeprivation scores.

The results were plotted on a bar chart, showing eachindividual caseload. These charts are not shown, butFigure 1 sbows tbe variations between neighbourhoodteams.

Such a wide variation needed addressing. It would notbe easy to tackle the whole problem in one attempt, as itwas important not to reduce services drastically. It was

r H Special Weighting

I Casetaod per Hour

(; u l j i v m q o l I f j t '

' K i ' j \>:r\tvr<'.'nn •xi l i t

Team

dim 'w^oiu oi qj - n t - i l l f i r ! - . j< : ( j t | ( ' i ( » A,'

Figure 1 Original distribution ofhealth-visiting hours betweenneighbourhood nursing teams.

Clinical Notes 235

Special Weighting

Caseload per hou

Figure 2 Revise of distribution ofhealth-visiting hours betweenneighbourhood nursing teams.

decided to concentrate on those caseloads where the scoreswere under 9 and over 12. As there had been a temporaryban on recruitment, use was made of the vacancy level tomake many changes, but some stall" were moved.

Suggestions of possible movements in line with theoverall aim were made to the Neighbourhood TeamLeaders and their local knowledge was taketi into accountwhen planning the specific changes. The proposals werefinalized and these are shown in Figure 2.

Believing that the co-operation and understanding ofthe GPs would be to the benefit of the service, thepropo.sals were presented to the Local Medical Committeebefore progressing. It gave its full support. Implemen-tation generally went fairly smoothly, despite sotne reluc-tance on the part of some staff" and individual GPs who, notsurprisingly, disliked any reduction in services.

Our aim of balancing caseload size with particular areasof deprivation and child protection need has shown amarked improvement in the spread of caseload sizes,although further development will be needed in future.

Caring for the Asian patientROSEMARY WEBSTER RSc, RGNClinical Nurse Specialist, Coronary Care Unit, Leicester GeneralHospital, Gwendolen Road, Leicester LE.^ 4PW, UK

Working in a hospital in a city where over one-third ofthepopulation can be classified as Asian, day-to-day practiceoften leads me to reflect on the care we give to this clientgroup.

I work in a coronary care unit, and, whilst it is well-

established that Asians are at increased risk of ischaemicdisease when compared to their non-Asian counterparts,(Balarajan, 1991) very little is known about the illnessexperience of Asian patients, in particular their expec-tations for, and the reality of, recovery and rehabilitation.Recent government initiatives, notably the Patient'sCharter, have emphasized the importance of the provisionof individualized care for all patients.

Respect for religious and cultural beliefs is one of thenine national charter standards identified by the Depart-ment of Health. With such incentives it is perhaps under-standable that many nurses appear eager to learn aboutAsian culture. However, such knowledge does not neces-sarily lead to itnprovements in practice. Much of which iswritten about culture and illness tends to be anecdotal andbased on the life-styles of Asians living in the Indiansubcontinent. Asians coming into bospital in tbis countryare likely to have acquired aspects of British culture andcast aside certain traditions and behaviours.

The Asian population itself is a diverse group, the term'Asian' refers to major groups of immigrants from theIndian subcontinent (India, Pakistan, Bangladesh) andtheir childtxn; plus political refugees from Kenya andUganda, descended from earlier immigrants from India.Information which classifies people according to religion islikely to be limiting and generalized. Transcultural nursingtbeory tends to be American and thus not necessarilyapplicable to British nurses (Leininger, 1978).

Some nurses, in an eflbrt to bring cultural aspects intotheir care, will respond to assumed but non-existentcultural differences. For example, I have witnessed nursesaddressing patients in loud monosyllabic tones, assumingthat the patient is unable to speak English, when in fact