Question:
Discuss About The Condition During Postoperat Complications?
Wound healing is an essential prerequisite for ensuring the speedy recovery of patients with hand surgical wounds. Considering the adverse impacts of smoking, it has been found that it exert its negative influences in exacerbating the condition during postoperative complications as well. The outcomes are strikingly different in case of the smokers as opposed to their non-smoking counterparts who pose less threat than smokers do to encounter postoperative challenges (Haskins, Amdur & Vaziri, 2014). Therefore, it becomes increasingly difficult to tackle the situation for the healthcare professionals considering the extent of the symptoms exhibited by the patient. Smoking pattern data in the population of Hong Kong has highlighted on important aspects related to smoking cigarettes. The detrimental effects of smoking have not only been found to impact health status of the concerned individuals, but are also found to have certain adverse socio-economical consequences. Tobacco smoking is considered particularly harmful due to the presence of toxicants such as tar, nicotine and carbon monoxide that might culminate in causation of serious illnesses like that of cancers. The carcinogenic property of these components exerts strong influences and threatening the lives of the smokers to a great extent. Statistics with respect to average daily consumption of cigarettes among daily cigarette smokers for the year 2015 showed that it is 14.8 and is highest among the individuals belonging to the age range of 50-59 years. Data suggested that this incidence rate was higher compared to the 13.8 figure as reported for the year 2012. Overall, the average incidence rate was documented to be 13.1 (Healthyhk.gov.hk, 2017). Concomitantly evidences have shown that there occurs accentuated risk of acquiring surgical site infection because of smoking alongside increased risk for postoperative complications. Recommendations for abating surgical site infection have suggested in cessation of smoking (Chp.gov.hk, 2017). Hence, deeper investigation on the issue of wound healing needs to be conducted to combat the situation and ensure quicker wound healing in the concerned target individuals.
The study will aim to examine the impact of tobacco smoking with respect to wound healing for patients having hand surgical wound in contrast to the situation as observed in case of the non-smokers prior to undergoing hand surgery as well as in postoperative phase within the periphery of clinical setting.
The projected study will be helpful in exploring the impact of cigarette smoking on wound healing of patients with hand surgical wound. Remedies targeted to mitigate the adverse impacts of tobacco smoking may thus be streamlined with scope of offering suitable strategies to overcome the debilitating situation and accentuate speedy recovery for the affected individuals. Healthcare professionals may be well equipped and adequately informed about the effective management of wounds for those habituated to smoking by referring to the data and recommendations in accordance with the study outcomes. Proper training may be arranged for them to facilitate optimal healthcare delivery.
Wound care in healthcare sector has garnered considerable attention until date to safeguard the health of the patients and to foster speedy recovery for them. Unlike several adverse side effects of smoking, its impact on wound healing needs to be explored vividly for better understanding the association between the two.
A study conducted by Duchman et al., (2015) aimed to detect the differences pertinent to thirty days morbidity and mortality in response to primary total hip and total knee arthroplasty as per the smoking status and pack year history of smoking considering the fact that total joint arthroplasty is the most sought after orthopedic procedure in the USA. Patient identification was done by virtue of consulting the database for the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to retrieve information about those who underwent total knee or total hip arthroplasty between 2006 and 2012. Subsequently stratification of patients was done through acknowledgement of the smoking status and pack year history of smoking. Univariate and multivariate analyses were considered for comparing the outcomes related to thirty days rate of mortality alongside wound complications as well as total complications in the concerned population. Dearth of orthopedic specific outcomes beyond 30 days from the ACS NSQIP database restricts the scope of the study in elucidating both the short term as well as long term orthopedic specific outcomes relevant to cigarette smoking. Findings of the study are suggestive of the far-reaching implications that are of significance from both clinical as well as scientific perspectives. Results obtained from the study revealed that individuals who are into the habit of smoking are predisposed to an accentuated risk of acquiring wound complications in post arthroplasty session. On the other hand, risk of total complication is evident in case of both the current as well as former smokers during period that follows total knee or total hip arthroplasty. Therefore, as part of the nursing duties, the nurses must be well trained to be able to evaluate all wound complications in an effort to ensue prompt, adequate therapeutic interventions to combat the demanding situation.
Research carried out by Haskins, Amdur & Vaziri, (2014) explored the independent effect of smoking on the bariatric surgical outcomes by virtue of utilizing the National Surgical Quality Improvement Plan (NSQIP) owing to the efficacy of the bariatric surgery as a feasible long-term treatment for morbid obesity. The study design comprised of identification of bariatric patients from 2005 to 2010 with respect to all types of bariatric procedures barring adjustable gastric banding. Chi square and t tests were employed for examining the univariate associations of the pretreatment variables with smoking. For the laparoscopic and open treatment groups, logistic regression was used to test for association of smoking with outcomes corrected for relevant covariates. Despite the strengths of the study, a potential limitation concerning the study refers to the ambiguity in definition of the smoker for identifying a patient as provided in the NSQIP that demarcates the patients based on their smoking habit of cigarettes only within the year preceding surgery. Thus others forms of nicotine such as that of nicotine patch, gums upon bariatric surgery results are essentially undermined besides providing no valid information about the last puff taken by the patient or whether the concerned patient is presently a smoker or not. Therefore, in order to mitigate adverse surgical outcomes pertinent to the patient, information regarding smoking of all kinds of nicotine in addition to detection of the preoperative duration of smoking cessation need to be considered. Conclusive evidences showed that heightened incidence of postoperative morbidity for both laparoscopic as well as open bariatric surgery occurs due to smoking that appears as a modifiable preoperative risk factor. Smoking cessation has been found to exert positive influence through mitigation of the postoperative morbidity following bariatric surgery thereby necessitating the nurses’ interventions for directing prudent actions in accordance with patient situation.
Another study conducted by Hatcher et al., (2016) assessed the tobacco use and surgical outcomes relevant to patients suffering from head and neck cancer. Use of tobacco has long been associated with the risk of harboring head and neck cancer with little focus on the postoperative outcomes as potential threat to the disease. As part of the research methodology 89 patients afflicted by head and neck cancer were recruited in before surgery condition for the study. Inclusion criteria for the study comprised of documenting self-reported tobacco use status as well as assessment of recent tobacco exposure through urinary cotinine on the day of surgery in the concerned patients. Both length of stay at the hospital in conjunction with complications were measured as outcome variables for the study. The study has been thwarted with potential limitations owing to relatively reduced incidence of specific types of complications, limited sample size and no acknowledgement of the human papilloma virus status of the tumor. Findings of the study confirmed the association of postoperative complications because of tobacco use status that might act to distinguish the at-risk patients. The self-reported tobacco use history was intimately associated with poorer surgical outcomes following head and neck surgery. The findings corroborated with the evidences suggesting the negative influences of tobacco in relation to clinical outcomes pertinent to head and neck cancer patients. Therefore, the implications of studies have particular significance with respect to clinical and scientific point of views. A crucial role that need to be attended by the nurses call for emphasizing the need for assessment of the improvement in surgical outcomes due to smoking cessation interventions in patients suffering from head and neck cancer alongside gaining information about the duration of cessation to procure optimal benefits. Nurses may thus act to implement risk mitigation strategies accordingly.
In a study undertaken by Nåsell et al., (2011) investigation was set in for gauging the impact of smoking on postoperative complications especially with respect to deep wound infections, in case of patients with operatively treated fractures. The study design was set to be a cohort study with prospective follow-up in a setting consisting of university-associated teaching hospital coupled with advanced trauma care. For the study, an overwhelming population of 906 patients who underwent operative treatment for an acute ankle fracture in course of 3 years period was detected. Patients were classified into 721 non-smokers and 185 smokers for performing the analysis. Departmental database was referred to for acquisition of relevant data, followed by review of the patient’s medical charts with postoperative complications as the main outcome measure. However, a major limitation in relation to the study may be identified with respect to the study design which is essentially a retrospective despite the complications that were being registered being prospective in nature. Thus, it posed threats in verifying the background information of patient specifically with respect to smoking habits. Moreover, the complications due to smoking have not been estimated satisfactorily in course of the study because of inadequate proportion of smokers employed in the study. The results generated from the study brought to the forefront a major issue that identified cigarette smoking as a potential risk factor capable of accentuating the risks of postoperative complications in patients operated for an ankle fracture. Hence, the study results are of paramount importance concerning the clinical and nursing practice. Owing to the adverse outcomes following surgery in case of the smoker individuals, the physicians, nurses and other allied healthcare personnel must act in coalition for encouraging the patients to quit smoking while under the regime of acute treatment for harboring optimal outcomes
Sweetland et al., (2013) in their study explored the incidence of venous thromboembolism with respect to smoking habits under two distinct conditions. One condition relevant to absence of surgery as well as other comprised of those during the first 12 postoperative weeks by means of a large prospective study of women residing in the United Kingdom to provide an insight on the effect of smoking in general related to the risk of venous thromboembolism apart from the postoperative period. Data were collected in course of the 6 years follow-up encompassing 1162718 women having mean age of 56 years, out of which 4630 were reported to have admitted to hospital or have encountered death due to venous thromboembolism. The novel study approach and topic of investigation act to render considerable strengths to the study thereby minimizing the chances of weaknesses associated with it. However, certain intrinsic limitations to the study that may be identified relate to restricting the study design to women only for understanding the association between smoking and venous thromboembolism. Moreover, information regarding the periods of immobility during follow-up and use of postoperative anticoagulation was missing that further limited the study design. Presence of other unmeasured confounders might also threaten the research. Further conclusion has been arrived at with respect to increase in incidence of venous thromboembolism for the current smokers both in absence of surgery as well as during the follow-up in the 12 weeks following surgery. Therefore, for patients undergoing surgery it is imperative to consider smoking as a vital factor for assessment of risk due to venous thromboembolism. Hence, the results hold vital potentials to deploy suitable tobacco control strategies as effective measures of combating disease as well as premature mortality. Therefore, the nurses and physicians must collaborate among themselves to identify the patient condition for effectively mitigating the risks of venous thromboembolism.
Smoking appears as a modifiable risk factor for patients undergoing surgery that can be managed properly if attended on time and requires active engagement of the healthcare personnel.
The study will be an exploratory one whereby necessary information will be procured from the relevant secondary data source regarding wound healing of patients with hand surgical wounds. Medical documents in liaison with the nursing assessment data will be utilized to gain a deeper probe into the issue of wound healing in case of the patients with hand surgical wounds from the concerned hospital authority (Creswell, 2013). Secondary source of data will be employed to procure information pertaining to wound healing in case of smoker patients afflicted by hand surgical wounds and admitted in hospitals to derive optimal benefits from the procedure. In this particular study, a cross sectional observational study approach will be followed to gather necessary information whereby data collected from the representative subset of the population are utilized at a specific point of time (De Vaus, 2013). No interference with the subjects will be made regarding the data collection procedure.
In course of the study, purposive sampling method that is considered as a subset of non-random sampling method will be employed considering that a specific purpose will be attended to. The proposed study will utilize a number of cases aligning with the projected objectives and hence purposive sampling will be decisive in elucidating the phenomenon of interest. Objectives of the study as well as the characteristics of the population will be taken into consideration while selecting the sampling method. The type and nature of the study will play a decisive role in making a choice for the sampling method. Selection will be made consciously to include a definite population for the study due to possession of certain unique characteristics that are of significance with respect to the conduct of the study (Etikan, Musa & Alkassim, 2016). Further, for the proposed study, a sample size of 200 patients will be chosen whereby documentation of data with respect to those will be kept for collection of most prudent data. Specific group of patients having hand surgical wounds and habituated to smoking will be selected for the study. Data will be accumulated for 200 respondents so that the large sample size might offer a better description being the representative of the population. Large sample size has been confirmed of better describing the population and potentially eliminates the chances of bias in data interpretation (Marshall et al., 2013).
The projected study will necessarily invest in a set of preset questionnaire that will be circulated among the population of Registered Nurses (RNs) who have been appointed in the surgical unit of hospital setting in the city of Hong Kong. The RNs will be requested to share their experiences and opinions as encountered by them during their professional pursuit of dealing with smoker patients with hand surgical wounds. In research, questionnaire is generally considered as a valid instrument comprising of a series of questions by virtue of which information may be gathered from the respondents appropriately. Information collected in this manner generally helps in acquiring data in a quick fashion. Complete and accurate data that is essentially primary in nature will be obtained through questionnaire that in turn might be useful in corroborating with the secondary data that will be obtained by accessing the relevant documents from the hospital (Nardi, 2015). The responses and feedback as received from the nurses will be helpful in interpreting the data with regards to situation in case of smoker patients having hand surgical wounds. In course of the data collection procedure, the Vancouver scar scale will be utilized to collect necessary information related to assessment of the surgical wound in the smoker as well as for the non-smoker patients. The change in the appearance of the scar will be documented by virtue of this validated tool thereby providing succinct information related to the status of the wound as observed and noted by the RN in course of routine nursing assessment. The viability of the tool has already been confirmed through empirical findings. Report has suggested that higher is the score in the Vancouver scar scale, higher is the healing time for the concerned patient (Kandamany et al. 2016). Objective scar assessment is carried out effectively through this scale. Further, it has been seen that this scale is suitable for offering vital insight into the aspects pertaining to pliability, pigmentation, height and vascularity of the wound that are considered vital indicators of the wound healing process (Hachach?Haram et al., 2017). Hence, documentation made by the RNs in the Vancouver scar scale will offer greater insight into the issue and help in generating different themes with respect to the chosen topic.
Prior to undertaking actual data collection procedure, a preliminary study will be undertaken where a small-scale or pretest of the actual research will b done through utilization of resources such as that of the questionnaire tool. The study will be done in a way to evaluate the feasibility of the topic under investigation. In research, it is considered as a vital component of a good research design and is essentially a preparatory phase of the major research study. The feasibility of the approach that will be utilized in later hours for performing a full-fledged study on a greater scale may be indicated through conduct of this pilot study (Zainal, 2017). The extent to which the research may be translated on a greater level must be gauged through this valid measure. For the pilot study, 5-10 feedback will be sought from the RNs working in surgical wards so that wound healing issues as observed in case of smoker patients as opposed to the non-smokers prior to surgery as well as in postoperative conditions will be better understood.
Data collection procedure will essentially resort to secondary data accumulation whereby data that has already been collected for research purpose are retrieved from relevant sources to inform about the situation pertinent to the topic of investigation. Organizational records regarding the patient information as obtained from the concerned hospital authority will be sought. Valid medical documents and nursing assessments about patients identified as smokers and suffered hand surgical wounds will be taken into consideration (Palinkas et al., 2015). Further, prudent information with respect to the experience and opinions of the nurses will be sought through questionnaire survey. Precautions will be taken so that requisite number of respondents feedback may be obtained. Medical data relevant to 200 patients will be obtained for including in the study for analysis. Vancouver scar scale data for these patients will be also retrieved from the nursing assessments documentations available from the hospital records.
Computer application will be used to store and manage data, whereby all the necessary and relevant documents and data will be kept in safe custody of the laptop belonging to the PI. Data will be secured with password and restrictions will be imposed regarding handling of the data. People of the research team will only be allowed to handle the data and no other unauthorized persons will be permitted to access the data (Helander, 2014). Data management will be prioritized so that improper handling or misuse of data may be prevented to certain extent. Moreover, data management will ensure prompt storage and retrieval of data in later hours whenever required. All data obtained through the hospital records will be subjected to rigorous statistical operations for deriving meaningful conclusion from the results. Statistical calculations will ensure that the data obtained are of particular significance in reality rather than being a mere theoretical representation. Student’s t-test will be computed to analyze the population parameters with respect to the two populations concerning the smokers and non-smokers. Specifically, paired t-test will be employed to compare the two population means and understand whether the differences that might have occurred in the population are of significance or have taken place due to some chance factors. The presence of significant differences between population means is indicated through this t-test (De Winter, 2013). Thus, differences in wound healing or wound management for smokers and non-smokers will be detected by incorporating t-test as part of the statistical analysis. Further, in the study Chi square test will be employed for the sake of assessing the goodness of fit between a set of observed values with respect to those expected theoretically (Schumacker & Tomek, 2013). Computer based knowledge on the part of the researchers will be valuable in this context. Statistical Package for Social Sciences (SPSS) software will be used for the sake of doing all the statistical analysis of the data obtained.
The study will essentially follow all the legal and ethical dictums necessary to conduct the research. All the necessary guidelines will be followed so that confidentiality and authenticity of the data extracted may be maintained appropriately ((Neuman & Robson, 2014). While deriving necessary information from the documents maintained by the concerned hospital authorities, precautions will be taken so that no data leakage occurs. Care will be taken so that no information regarding the patient data is shared with any third party other than the researchers and the principal investigator (PI). Further, data collection through questionnaire survey from the RNs will safeguard the data acquired by allowing the data to be kept in safe custody of the PI. Necessary approval will be sought from the concerned hospital authority to utilize the data obtained for research besides seeking permission for participation in the study for the RNs. Data will be stored safely with secured password in the laptop of the PI so that no one other than the research team might get access to the data. It is crucial to undertake research in an appropriate fashion so that there remains no ambiguity and all the virtues related to privacy, safety, authenticity and confidentiality is well maintained (Best & Kahn, 2016).
Smoking toxicants across several studies has lead to revelation of consistent findings that they might cause adverse health impact to various bodily tissues attributable to the interaction among the separate components that are present in cigarettes. Because of smoking, deterioration of overall health condition of the smoker has been confirmed that in turn jeopardize the wellbeing of the affected individual (Jha & Peto, 2014). Pertinent studies have stated that tobacco smoking is intimately associated with impaired wound healing and aggravation of symptoms that underlie the postoperative complications thereby raising the concern that it will take longer for the smokers to heal hand surgical wounds compared to non-smokers due to smoking.
For the proposed study, no direct observations will be undertaken. All the necessary information will be retrieved from secondary sources. No primary data will be acknowledged in the data collection process that in turn might pose significant threats to the study outcomes. The authenticity and reliability of data may be threatened due to increased reliance on secondary data source. Dearth of appropriate primary data findings might lead to inappropriate interpretation thereby decreasing the authenticity. Lack of cooperation from the Registered Nurses in gaining their feedback on the topic that is imperative to proceed further with the study might hinder the outcomes. Funding restrictions and time constraints might further limit the progression of the study significantly.
Conclusion
Smoking has been unanimously presented as a potential modifiable risk factor that accentuates the risk for postoperative complications in the patients manifold compared to their non-smoker counterparts. Duration of smoking cessation prior to undergoing surgery has been considered vital to gauge the relative risk of wound healing in the concerned patients. Healthcare workforce must work in coalition appropriately to mitigate the issue so that exacerbation of symptoms may be abated to some extent. Advocacy for tobacco control strategies must be implemented rigorously so that the adversities in the form of disease onset, morbidity and premature mortality may be averted considerably.
The study will be conducted over a span of 7 months, commencing in the month of January 2018 and will end in the month of July 2018.
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July |
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Topic finalization |
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Layout formation for research work |
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Undertaking Literature Review |
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Formation of Research Plan |
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Selection of suitable research methodologies |
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Pilot Study |
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Data collection from secondary sources |
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Data analysis of the collected data sets |
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Interpretation of collected data sets |
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Concluding the Study |
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Designing a rough draft |
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Submitting the Research Proposal to Ethical Committee |
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Activity |
Expenditure |
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Pilot Study |
5000 $ |
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Stipend to four research scholars |
40,000 $ |
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Internet facility charges |
2000 $ |
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Paper and photocopy charges |
1000 $ |
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Other expenses |
2000 $ |
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Total |
50,000 $ |
Reference list
Best, J. W., & Kahn, J. V. (2016). Research in education. Pearson Education India.
Chp.gov.hk. (2017). Recommendations on Prevention of Surgical Site Infection. Chp.gov.hk. Retrieved 22 September 2017, from https://www.chp.gov.hk/files/pdf/recommendations_on_prevention_of_ssi.pdf
Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.
De Vaus, D. (2013). Surveys in social research. Routledge.
De Winter, J. C. (2013). Using the Student’s t-test with extremely small sample sizes. Practical Assessment, Research & Evaluation, 18(10).
Duchman, K. R., Gao, Y., Pugely, A. J., Martin, C. T., Noiseux, N. O., & Callaghan, J. J. (2015). The effect of smoking on short-term complications following total hip and knee arthroplasty. JBJS, 97(13), 1049-1058.
Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1-4.
Hachach?Haram, N., Bystrzonowski, N., Kanapathy, M., Smith, O., Harding, K., Mosahebi, A., & Richards, T. (2017). A prospective, multicentre study on the use of epidermal grafts to optimise outpatient wound management. International wound journal, 14(1), 241-249.
Haskins, I. N., Amdur, R., & Vaziri, K. (2014). The effect of smoking on bariatric surgical outcomes. Surgical endoscopy, 28(11), 3074-3080.
Hatcher, J. L., Sterba, K. R., Tooze, J. A., Day, T. A., Carpenter, M. J., Alberg, A. J., … & Weaver, K. E. (2016). Tobacco use and surgical outcomes in patients with head and neck cancer. Head & neck, 38(5), 700-706.
Healthyhk.gov.hk. (2017). Smoking Pattern. Healthyhk.gov.hk. Retrieved 22 September 2017, from https://www.healthyhk.gov.hk/phisweb/en/health_info/behav_risk_factors/smoking_pattern/
Helander, M. G. (Ed.). (2014). Handbook of human-computer interaction. Elsevier.
Jha, P., & Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 370(1), 60-68.
Kandamany, N., Kierath, J., Rea, S., Edgar, D., Finlay, V., Burrows, S., … & Wood, F. (2016). Increased Healing Time Is Associated With Higher Vancouver Scar Scale Score. Anz Journal of Surgery, 86, 16.
Marshall, B., Cardon, P., Poddar, A., & Fontenot, R. (2013). Does sample size matter in qualitative research?: A review of qualitative interviews in IS research. Journal of Computer Information Systems, 54(1), 11-22.
Nardi, P. M. (2015). Doing survey research. Routledge.
Nåsell, H., Ottosson, C., Törnqvist, H., Lindé, J., & Ponzer, S. (2011). The impact of smoking on complications after operatively treated ankle fractures—a follow-up study of 906 patients. Journal of orthopaedic trauma, 25(12), 748-755.
Neuman, W. L., & Robson, K. (2014). Basics of social research. Pearson Canada.
Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533-544.
Schumacker, R., & Tomek, S. (2013). Chi-square test. In Understanding Statistics Using R (pp. 169-175). Springer New York.
Sweetland, S., Parkin, L., Balkwill, A., Green, J., Reeves, G., & Beral, V. (2013). Smoking, Surgery, and Venous Thromboembolism Risk in Women: UK Cohort Study. Circulation, CIRCULATIONAHA-113.
Zainal, Z. (2017). Case study as a research method. Jurnal Kemanusiaan, 5(1).
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