Knowledge And Practice Of Vacuum Assisted Closure Management Among Nurses In Riyadh Hospital

To determine knowledge and practice on management of Vacuum Assisted Closure (VAC) among nurses in Riyadh.
Specific Objective
1. To determine the level of knowledge on management of Vacuum Assisted Closure (VAC) among nurses in Riyadh.
2. To identify the standard of practice management of Vacuum Assisted Closure (VAC) among nurses in Riyadh hospital.
3. To identify the relationship between knowledge and practice on management of Vacuum Assisted Closure (VAC) among nurses in Riyadh hospital.

1.4 Research Question
1. What is the level of knowledge on management of Vacuum Assisted Closure (VAC) among nurses in Riyadh.
2. What is the standard of practice management of Vacuum Assisted Closure (VAC) among nurses in Riyadh.
3. What is the relationship between knowledge and practice on management of Vacuum Assisted Closure (VAC) among nurses in Riyadh.There is a relationship between knowledge and practice on management of Vacuum Assisted
Closure (VAC) among nurses in Riyadh.

Gender Differences in Nursing Profession

Statistical results reported in the previous section provide evidence for the fact that there is lack of any correlation between the level of knowledge among the nurses and their VAC practice, who work in a tertiary hospital at Riyadh. The study results indicated that majority of the nurses were females (74 of them) that accounted for an estimated 92.5% of the participants, while only 6 of them were males (7.5%). This likely suggests that the proportion of female nurses is greater, when compared to male nurses working in Riyadh.

This significant difference can be accredited to the nature of the profession that is more associated with women. The results of the study are also congruent with that of Kouta and Kaite (2011) who elaborated on the existing gender differences in the nursing profession where males who embark on their journey as a nurse often encounter a range of barriers that restrict their specialties and makes them being stereotyped or labelled. Hairr, Salisbury, Johannsson and Redfern-Vance (2014) also conducted a study where there were more number of female nursing respondents ((n=59; 84.3%), compared to males (n=15; 21.4%). Hence, the nursing profession has been predominantly established to recruit women staff.

The results also indicated that approximately 49 nurses belonged to the age group of 32-42 years and accounted for 61.25% of the total participant population. There are different studies that have illustrated the predominance of middle aged nursing professionals across healthcare settings. Furthermore, with an increase in age of the nurses, they have also been found to be affected by different musculoskeletal disorders in the lower back, neck, knees, and shoulders (Heiden, Weigl, Angerer & Müller, 2013).

Additionally, the research study also indicated that there were only 15 nursing staff (18.75%) in Riyadh who were aged more than 43 years of age. This result was not in accordance with the 2008 National Sample Survey of Registered Nurses survey findings that stated the mean age of U.S nurses ranged from 45-59 (HHS, 2010). The survey established 50 years as the overall mean age of all registered nurses in the United States. Furthermore, results from the survey also stated that the average age of all registered nurses who were entering their practice was 30 years. Conversely, this research found that there were an estimated 16 nurses (20%) of the age group 21-31 years who worked in the health care setting. Therefore, it can be stated that in Riyadh, the nursing professionals begin their practice at quite young ages.

Age and Educational Attainment of Nurses

The results of the study also indicates that there were more number of single nursing professionals (41 single; 51.25%), in comparison to their married counterparts (39 married; 48.75%). However, Brewer, Kovner, Greene, Tukov?Shuser and Djukic (2012) argued that there were 910 and 741 married and single nursing professionals in a study that aimed to determine the actual turnover of nursing staff in United States hospitals. More than half (55%) of the nominated nursing sample had nursing bachelor degree, while 45% of the sample reported having nursing diploma.

This was confirmed by Hairr, Salisbury, Johannsson and Redfern-Vance (2014) who found that 15.7% participants in their study had a master’s degree in the specialty, compared to 5.7% of the participants, who had a non-nursing master’s degree. Owing to the fact that the research was conducted across surgical wards in a hospital in Riyadh, they are expected to cater for different patients who undergo a plethora of complex and general surgical methods (LeMone et al., 2015).

Furthermore, the nursing professionals working in the surgical ward also have the duty of caring for all patients, while managing their post-operative complications, besides wound care, pain management, and nutritional requirements. Hence, the nursing staff are expected to have higher educational attainment such as bachelor’s degree in their speciality.

Most of the nurses were from the Philippines (48.75%), followed by Malaysia (41.25%), South Africa (3.75%), and other countries. This is in accordance to the fact that the Philippine nursing schools often bear the load of safeguarding employability of the future nurses (Ortiga, 2014). Another significant finding from the statistical results is that majority of the staff selected for the research were registered nurses (78 RN; 97.50%), while only 2 of them were clinical nurse (2 CN; 2.50%).

This can further be attributed to the theory that adult medical surgical registered nurses have the responsibility of managing the complete care of patients who expect general surgical procedures to be operated upon them. In the words of Williams and Hopper (2015) patients admitted to the surgical departments are in continuous need of general assessments that are related to their health condition, registered nurses are likely to be involved in their care. Additionally, surgical RNs were also found in greater proportion in the study setting since they are also found to specialise in pre-operative care of all patients,

during which they are involved in handling a range of surgical tools, and intervening under situations where complications occur (De Meester, Van Bogaert, Clarke & Bossaert, 2013). Furthermore, there is mounting evidence for the role of a clinical nurse that comprises of diagnosis of illness and their treatment, based on the specific area of expertise (Moore & McQuestion, 2012). Thus, the complexity of surgical settings accounted for the higher proportion of RNs.

Nationalities and Job Titles of Nurses

While 11 of the nurses were found to have an experience of less than 5 years (13.75%), 36 of the sample had experience less than 10 years (45.00%). Lucchini et al. (2014) also conducted a retrospective analysis and suggested that the Nursing Activities Score (NAS) for patients was found to be 65.97%, NeuroICU 59.33%, and GICU 72.55%. Nursing experience has also been found to range from 6 months-16 years in another study, where most of the participants reported having experience of 2-5 years (n=19; 27.1%) (Hairr, Salisbury, Johannsson & Redfern-Vance, 2014).

Relationship has also been established between the level of competence among nurses and their clinical expertise length. O'connell, Gardner and Coyer (2014) suggest that the capability development of nursing professionals may be categorised by two distinguishing periods: a fast growth phase that is followed by steady periods. Nevertheless, the modality of development may be dissimilar subject to the dimensions of nursing competence that are placed in focus (Cleary, Horsfall, Muthulakshmi, Happell & Hunt, 2013).

It was found in this research study that 42 nurses were frequently involved in handling patients, while demonstrating adequate knowledge/practice of VAC (31.25%). While 25 nurses handled such patients always (31.25%), only 13 nurses handled them on an occasional basis (16.25%). Implementation of vacuum-assisted closure (VAC) wound therapy have been found beneficial in treatment of deep sternal wound infections and has also proved effective in reduction of mortality rates. VAC has also been linked with reduced recurrence of mortality rates (RR?=?0.34, 95% CI: 0.19–0.59) (Falagas, Tansarli, Kapaskelis & Vardakas, 2013). Further evidences have also established the fact that there occurs a general lack of consistent training that is provided for the nursing professionals.

Although nurses enrolled in other studies have demonstrated an awareness of elementary evidence behind use of VAC as a treatment option, they have often cited the need for additional support in the practical areas (Cray, 2017). This report complements the findings of the research that has been conducted in Riyadh. The responses suggested that only a handful of nurses (20%) had received adequate training on VAC use and its implementation. Approximately 64 nurses (80%) reported lack of any training on the same. In addition, the training was conducted in the form of demonstration among 78 nurses (97.5%), and verbally amid 2 nurses (2.5%).

A common difference that might have arisen while imparting training in a verbal manner was due to the existing cultural differences between the sender and the nurses belonging to different ethnicities. Owing to the fact that the nursing workforce at the Riyadh hospital was comprised of people belonging to different nationalities and culture, they might have found it difficult to understand the colloquial phrases that were used, in relation to VAC application.

Experience of Nurses

Verbal communication also has the primary disadvantage of short longevity, where the nurses are generally expected to forge the information that is being imparted, on the important concept of VAC (Knapp, Hall & Horgan, 2013).  While 63 nurses (78.75%) attended the wound care training sessions for a time period that extended for more than 12 months, 14 of them attended sessions that ranged between 6-12 months (17.5%), and 3 were subjected to sessions that lasted for less than 3 months (3.75%). This establishes the fact that training with VAC is obligatory for correct handling and deterrence of surgical complications.

Othman (2012) identified several issues that were related to the application and continuance of negative pressure wound therapy through the use of VAC, in primary care. Some of the commonly recognised barriers included premature referral of patients who require negative pressure wound therapy, absence of training of staff and community patients, intricate community funding conduits, and absence of coordination amid primary and secondary care. Other research evidences have also emphasised on the need of training for all new nurses in VAC implantation, alteration and secondary closure, besides formulation of a uniform guideline that can be followed by all professionals (Fleck & Fleck, 2014).

Despite 63 nurses attending training that encompassed a time period of more than 12 months, upon enquiring whether they were capable of applying VAC to patients, with proper physician order, all of them suggested that it was not the case. An estimated 93.75% of participants that accounted for 75 nurses stated that they always check the orders from a physician, prior to beginning the procedure, and try to implement it as early as possible. However. 6.52% of them stated that they never checked with the physician’s order. Kim et al. 92015) illustrated the importance of checking the orders from a physician, in relation to the kind of topical wound solution and its dosage.

This can be accredited to the fact that most of the parameters that are related to VAC therapy are usually developed by the physicians in the operation theatre. Thus, consultation with a physician is utmost essential before the application of VAC therapy, with the aim of preventing contraindications. Owing to the fact that the certain risks namely, (1) disconnection of the trac pad, (2) untying of drape, (3) unfilled battery of VAC pump, and (4) breaking of connection seals have been encountered by nursing professionals,

Frequency of Nurses Handling Patients with VAC

taking into account the order from the physicians might help in averting the risks and preventing further health problems (Fleck & Fleck, 2014). Thus, the handful of nurses in the setting who do not check the orders should be made aware of its necessity. All the respondents were accurate in stating about the shrinkage of the dressing, wrinkles in the film dressing, and its firmness.

Research evidences have elaborated on the association between PRP and VAC and their effectiveness in reduction and shrinkage of abdominal defects (Domenichelli, Straziuso, Sabatino & Federici, 2015). Swelling of the dressing fabric have long been allied with greater extent of their shrinkage. Thus, the nurses had adequate knowledge on the same (Balasubramanian, Balasubramanian, Babu, Devika & Rajendran, 2013). Additionally, 100% of the nursing participants demonstrated adequate knowledge on the fact that 1000ms canister cannot be used on patients who present with increased risks of bleeding or are incapable of tolerating a large fluid volume loss.

They were also aware of the fact that VAC therapy should not be implemented in cases that involve non-infected wounds and unstable chest. However, Back, Scheuermann?Poley and Willy (2013) suggested that extent of risks for infection for non-infected traumatic wounds can be determined by deciding if the wounds are (i) severely traumatic such as, open fractures, soft tissue wounds, (ii) highly contaminated and penetrating injuries, and (iii) bite wounds from humans, dogs and cats. Momentous reductions were also observed in another study in both non-infected and infected groups that compared the effectiveness of vacuum assisted-closure (VAC) therapy with suction applied (GSUC) (Dorafshar et al., 2013).

96.25% nurses or 77 of them gave responses that suggested that the patuents can shower, while the dressing is held in its place. 97.5% also demonstrated knowledge on efficacy of VAC therapy in controlling odor of the wounds, while the remaining did not have any knowledge on the same. There is mounting evidence for Negative Pressure Wound Therapy (NPWT) being considered the mainstay treatment for different wound types. All healthcare professionals who work with these NPWT dressings usually report a substantial number of wounds that subsequently develop an odor that is commonly referred to as “VAC stink.” Thus, VAC therapy are used for addressing the warmth found in the wound and/or periwound regions, strong odor, and purulent discharge (Ottosen & Pedersen, 2013).

The results also indicated that all nursing participants (100%) agreed for the use of wound VAC dressing kit, syringe, scissors and measuring cards during change of a VAC dressing. Furthermore, all of them also demonstrated adequate knowledge in stating the difference between wound dressing and VAC, thus demonstrating their awareness on the phenomenon that is being investigated. 93.75% nurses held the notion that -125mmHg to -75mmHg pressure is permissible for application to patients, while using VAC therapy.

This is complemented by the fact that following sealing of dressing, the vacuum pump is usually set for delivering intermittent and continuous pressures, the range of which depend on the device that is being used. Furthermore, the patient tolerance level and material used for dressing govern the pressure range that varies between −125 and −75 mmHg (Lindstedt, Malmsjö, Hlebowicz & Ingemansson, 2015). In contrary. 95% nursing respondents argued on removal of the dressing, under conditions that involve an elevated blood amount from the wound in the canister and/or tubing.

This complements the fact that under situations where the NPWT device facilitates the delivery of fluids like antibiotics and saline for irrigating the wound, intermittent fluid removal aids the drainage and cleaning of the wound bed (Waltzman & Bell, 2014).

In addition, all the nurses (100%) knew that during the packing of a cavity wound, the contact between the complete wound bed and its edges with the foam. Furthermore, they also demonstrated adequate knowledge on the fact that compression of the foam usually prevents the negative pressure to reach the wound bed. Cross tabulation between the knowledge level and practice on VAC management 82.1% nurses provided correct answers to all questions, thus demonstrating presence of sound awareness and knowledge on VAC application.

Chi-square analysis revealed presence of a significant association between their level of knowledge and the practice that they demonstrated. The Pearson Chi- Square value was found to be .351 (p value > 0.05). Owing to the fact that the p value was not less than 0.05, the null hypothesis could not be rejected. Presence of a large chi square value signifies that the observed data was not able to fit with the expected results, thus indicating the absence of a definite relationship between the knowledge and actual practice. Also, there was no significant difference between the nurse age groups and their wound VAC knowledge and awareness.

The current study results focused on the fact that nursing practices that were related to wound VAC therapy were able to achieve an overall response (frequently). This specified that the nursing staff from the Riyadh hospital are involved in the application of wound VAC practices. Nonetheless, they are still not able to reach best responses in their patients.

The fact that the study results demonstrated that there exists poor positive connexion between the nurses’ total knowledge scores on wound VAC knowledge and overall wound VAC practice response directs that upon improving the nurses knowledge on wound VAC through training and education, their practice of VAC will also get enhanced. Hill (2011) agreed that increased knowledge and awareness among nursing staff is directly responsible for contributing to their retention, enhancing work satisfaction, and increasing their intent to remain in the nursing profession.

5.2 Limitation

One major limitation of the research can be attributed to the fact that all nursing staff from the hospital in Riyadh were not available during the recruitment procedure. This might prevent generalizability of the findings. Small sample size was another potential limitation that might have created an impact on the reliability of the responses to the questionnaire. Hence, the sample was decreasingly illustrative of the whole population. Restricting the research to surgical wards in King Abdullah Medical Centre might also prevent generalizability of the results.

6.1 Conclusion

Based on findings presented above, nurses were found to demonstrate adequate awareness and knowledge regarding VAC therapy. However, they fail to implement their knowledge in real time practice settings. Vacuum-assisted closure (VAC) is considered as one of the first-line of treatment modality that is commonly used for the treatment and management of chronic and acute wounds that are usually challenging to treat. The evidences presented above also suggested that VAC therapy is an efficient and safe adjuvant, frequently utilised for the management of austere intrathoracic infections allied with mediastinitis linked to esophageal leakages, lung resection, and/or necrotizing pleuropulmonary infections.

Previously conducted studies have illustrated that participating nurses often report insufficient knowledge on wound VAC therapy. Several reasons can be cited responsible for resulting in insufficient level of awareness and knowledge among nurses regarding the wound VAC therapy. Some of the most common reasons are lack of adequate support from the concerned wound care team and insufficient nursing education. Absence of support from the important companies that manufacture and deliver the VAC machines also contribute to a display on low level of knowledge. Absent of appropriate communication between the healthcare staff has often been cited as a major reason in poor level of knowledge and absence of accurate VAC practices.

This can be accredited to the fact that in a hospital environment, most nursing staff are found to learn from each other. The statistical results that failed to establish proper correlation between knowledge and VAC practice might have been influenced by the presence of multilingual nursing staff in the Riyadh hospital that is presumed to result in miscommunication about the importance, usage, and standards of VAC practice. The simple nature of wound VAC and its capability of managing multifaceted wounds with great effectiveness fluctuating from management of wounds with tendon, exposed bone, or hardware, to treatment of acute burn, promotes its use for wound management.

Providing successful wound management has become the goal for all health institutions. Use of VAC therapy for different types of wound was identified by the recruited nurses to exert a range of positive outcomes on the patients being treated such as, improved healing and granulation tissue development, controlling exceedingly exuding wounds, and lessened dressing changes, in comparison to conventional dressings. Furthermore, VAC have also been allied with a reduction in the nurse time, associated healthcare costs, and enhanced quality of life.

Nursing professional who remain at the first line in delivering care to all patients with wound VAC therapy demonstrated a sound understanding of the speculative background of the VAC therapy, besides knowing about the ways by which VAC should be implemented in their clinical practice.

Nurses working across the surgical department are primarily accountable for the patients admitted with wounds, which fail to heal suitably, thus posing grave health concerns. This calls for the need of a precise level of proficiency and education for ensuring optimal wound care. Though, all health care facilities are often not able to provide the nurses with appropriate orientation and training on the new advancements in wound management. The research study also helped in gaining a sound understanding of the way by which the plastic membrane averts the entry of air and permits a limited vacuum to develop within the wound. Thus, the volume gets subsequently reduced, followed by facilitating the elimination of excess fluid.

The foam of VAC ensures that the complete surface zone of the wound is consistently visible to the negative pressure effect, thus thwarting occlusion of the punctures located in the drain by connexion with the edges or the base of the wound. This also eradicates the theoretical likelihood of localised zones of great pressure and subsequent tissue necrosis. The research was based on already established theories that nurses develop their skills and gain an understanding of client care, over time. This is usually achieved through a combination of personal experiences and appropriate educational foundation.

The researchers was accurate in focusing the study on the fact that nurses are capable of gaining skills and knowledge, without essentially learning any theory. This is generally described as “knowing how” lacking “knowing that” and is composed of the expansion and acquisition of knowledge over research and clinical experience. The responses were also collected based on the fact that progressive beginners often demonstrate satisfactory performance, and are also found to have gained prior understanding in real nursing situations. This facilitates the nursing staff identify recurring evocative components with the aim that the principles, which are based on prior experiences, are able to express for guiding necessary nursing actions.

The research also focused on the fact that capable nurses usually have at least two or three years of experience in their field. The researchers also expected such nurses to be more aware of their goals, and are able to gain a sound perspective from their own actions. However, responses provided by the nurses working in Riyadh suggested that despite having adequate experience in their domain, they were unable to apply their knowledge while performing the VAC procedures adequately across the surgical settings. This revealed that increased knowledge among the nursing professionals is not essentially related with effectual management of applied skills in VAC wound dressing.

6.2 Recommendations

The practice of nurses regarding wound VAC therapy should be improved for accomplishing maximum benefits to the participants. The present study can act as a guideline for the development and formulation of specific hospital procedures and policies on wound VAC therapy. The hospital administrators must encourage all nurses working with surgical patients to regularly attend workshops, and courses, in order to continue their education and subsequently enhance their knowledge and succeeding practice on wound VAC therapy.

Provisions for educational support must also be created such as, establishment of an educational team in the Riyadh hospital. Opportunities for comprehensive wound care training courses and facilitating easy communication between the concerned healthcare professionals might help in improving their practice. There is a need to conduct future research to determine the effectiveness of the educational sessions and trainings on VAC practice.

References

Back, D. A., Scheuermann?Poley, C., & Willy, C. (2013). Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions–when, where and how to use: what does the evidence show?. International wound journal, 10(s1), 32-42

Balasubramanian, E., Balasubramanian, V., Babu, G., Devika, S., & Rajendran, R. (2013). Moist Wound Dressing Fabrications: Carboxymethylation of Antibacterial Cotton Gauze. Journal of Engineered Fabrics & Fibers (JEFF), 8(4

Brewer, C. S., Kovner, C. T., Greene, W., Tukov?Shuser, M., & Djukic, M. (2012). Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. Journal of Advanced Nursing, 68(3), 521-538.

Cleary, M., Horsfall, J., Muthulakshmi, P., Happell, B., & Hunt, G. E. (2013). Career development: graduate nurse views. Journal of clinical nursing, 22(17-18), 2605-2613.

Cray, A. (2017). Negative pressure wound therapy and nurse education. British Journal of Nursing, 26(15), S6-S18.

De Meester, K., Van Bogaert, P., Clarke, S. P., & Bossaert, L. (2013). In?hospital mortality after serious adverse events on medical and surgical nursing units: a mixed methods study. Journal of clinical nursing, 22(15-16), 2308-2317.

Domenichelli, V., Straziuso, S., Sabatino, M. D., & Federici, S. (2015). Vacuum Assisted Closure (VAC) and Platelet-Rich Plasma (PRP): A Successful Combination in a Challenging Case of Gastroschisis. Open Journal of Pediatrics, 5(03), 274

Dorafshar, A. H., Franczyk, M., Karian, L., Teven, C., Wroblewski, K., Gottlieb, L. J., & Lohman, R. F. (2013). A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device: a supplementary subgroup analysis of infected wounds. Wounds: a compendium of clinical research and practice, 25(5), 121-130. 

Falagas, M. E., Tansarli, G. S., Kapaskelis, A., & Vardakas, K. Z. (2013). Impact of vacuum-assisted closure (VAC) therapy on clinical outcomes of patients with sternal wound infections: a meta-analysis of non-randomized studies. PLoS One, 8(5), e64741

Fleck, T., & Fleck, M. (2014). Negative pressure wound therapy for the treatment of sternal wound infections after cardiac surgery. International wound journal, 11(3), 240-245.

Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the relationship to job satisfaction and retention. Nursing Economics, 32(3), 142-147. 

Heiden, B., Weigl, M., Angerer, P., & Müller, A. (2013). Association of age and physical job demands with musculoskeletal disorders in nurses. Applied ergonomics, 44(4), 652-658

Hill, K. S. (2011). Work satisfaction, intent to stay, desires of nurses, and financial knowledge among bedside and advanced practice nurses. Journal of Nursing Administration, 41(5), 211-217. doi: 10.1097/NNA.0b013e3182171b17

Kim, P. J., Attinger, C. E., Olawoye, O., Crist, B. D., Gabriel, A., Galiano, R. D., ... & Teot, L. (2015). Negative pressure wound therapy with instillation: review of evidence and recommendations. Wounds, 27(12), S2-S19.

Knapp, M. L., Hall, J. A., & Horgan, T. G. (2013). Nonverbal communication in human interaction. Cengage Learning.

Kouta, C., & Kaite, C. P. (2011). Gender discrimination and nursing: α literature review. Journal of Professional Nursing, 27(1), 59-63. 

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU. 

Lindstedt, S., Malmsjö, M., Hlebowicz, J., & Ingemansson, R. (2015). Comparative study of the microvascular blood flow in the intestinal wall, wound contraction and fluid evacuation during negative pressure wound therapy in laparostomy using the VAC abdominal dressing and the ABThera open abdomen negative pressure therapy system. International wound journal, 12(1), 83-88.

Lucchini, A., De Felippis, C., Elli, S., Schifano, L., Rolla, F., Pegoraro, F., & Fumagalli, R. (2014). Nursing Activities Score (NAS): 5 years of experience in the intensive care units of an Italian University hospital. Intensive and Critical Care Nursing, 30(3), 152-158.

Moore, J., & McQuestion, M. (2012). The clinical nurse specialist in chronic diseases. Clinical nurse specialist, 26(3), 149-163. doi: 10.1097/NUR.0b013e3182503fa7

O'connell, J., Gardner, G., & Coyer, F. (2014). Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing. Journal of advanced nursing, 70(12), 2728-2735.

Ortiga, Y. Y. (2014). Professional problems: The burden of producing the “global” Filipino nurse. Social science & medicine, 115, 64-71.

Othman, D. (2012). Negative pressure wound therapy literature review of efficacy, cost effectiveness, and impact on patients' quality of life in chronic wound management and its implementation in the United Kingdom. Plastic surgery international, 2012.

Williams, L. S., & Hopper, P. D. (2015). Understanding medical surgical nursing. FA Davis.