ACE Star Model Of Knowledge Transformation In Management Of Malignant Wounds In Cancer Patients

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Importance of Star Model in Nursing Practice

One of the devastating complications of cancer is malignant tumor. They are difficult to cure and is known for the emission of exudates, blood along with the generation of malodor. This affects the quality of life of both the patients and their caregivers. The following report is based on the ACE Star Model of Knowledge Transformation of nursing care in order to evaluate the evidence-based practice in nursing care in the domain of MW management.

The ACE Star Model of Knowledge Transformation is a model that is used for understanding the cycles, characteristics and the nature of the knowledge that is cited in numerous stages of evidence-based practice (EBP). It is a simple 5-point star model that illustrates 5 major stages of knowledge transformation: discovery research, evidence summary, translation to guidelines, practice integration and process, outcome evaluation (Stevens, 2013).

The importance of Star Model in Nursing Practice is it organizes both old and new concepts of developing care while providing a framework under which the approaches of EBP is organized. Via applying Star Model, the nurses get a detailed insight about the flow of relevant information via evidence based practice and thereby increasing the ability of the nurses in suggesting the cause and effect relationship and subsequent clinical implementation of that relationship (Stevens, 2013).

The main practice issue highlighted in the report of Ramasubbu et al. (2017) is the devastating effect of malignant wounds in advanced stage cancer patients and possible antibiotic therapy to treat associated symptoms of otherwise incurable malignant wounds. Malignant wound is a problem because they are difficult to cure. The main symptoms of malignant wound include exudates, pain, malodor, pain and risk of hemorrhage. These wounds mostly occur during the last six month of life of cancer patients in breast, chest wall or heck neck regions (Ramasubbu et al., 2017). According to the American Cancer Society (2012), there were approximately 12 million new cancer cases globally in the year 2007. This said number is expected to double by the end of 2050. With the advancement in the domain of chemotherapy and/or radiotherapy, the survival rate of cancer has improved considerably. However, malignant wounds (MW) which affects 5 to 10% of all cancer patients in the western countries, throw a significant challenge for the nurses in the cancer care (Lo et al., 2012).  Lo et al. (2012) further opined that since MW occurs in the head-neck region, the wounds are mostly not visible and generate social and psychological problems for patients. Therefore patient with MW require both palliative care and wound management in order to control their physical symptoms along with other physiological, spiritual, psychological and social problems (Lo et al., 2012).  According to Probst, Arber and Faithfull (2013), patients with uncontrolled symptoms of wound experience breakdown in the surface of the bodies and this associated with loss of self and social identity when their outer appearance becomes irreversibly unbound. This cast a huge impact on the healthcare professionals as they face immense difficulty in managing these end-of-life care patients. Moreover, patients of MW also receive inadequate specialized professional help (Probst, Arber & Faithfull, 2013).

Practice Issue and Best Treatments

Stakeholders

1. The registered nurse
2. The change nurse
3. The occupational therapists
4. The medical officer
5. The pharmacist
6. A psychologist
7. Palliative care nurse 

The change nurse will be important to reduce the bleeding via using non-adherent dressings and subsequent cleansing via irrigation and not via swabbing. This will help to reduce traumatic bleeding from wound. A registered nurse will help in wound cleansing, exudates management, odor management and pain management (Wai-man & Hospice, 2014). This will be done via application of antibiotics Metronidazole (Ramasubbu et al., 2017). The pain management will be done via the appropriate use of the analgesic and non-adherent dressing. The application of analgesic will be co-ordinated by the medical officer. The drugs prescribed by the medical officer for pain management will be order from a registered pharmacist (Wai-man & Hospice, 2014). A pharmacist will also give advice on medication and dressing products. The psychosocial care of patients and their family members is also important to reduce stress. According to Probst, Arber and Faithfull (2013), MW is associated with decrease in self-esteem. It will be the duty of a psychologist to interact with this palliative care patients suffering from MW in order to understand their psychological problems and provide effective treatment via counseling or other interactive sessions (Wai-man & Hospice, 2014). An occupational therapist will help the patients with strategies like pressure management, health management, mobility, surrounding environment, mental status, activities of daily life and other ancillary ancillary services (Kumar, 2015). A palliative care nurse will help to manage other symptoms and vital signs of the patients in relation to wound management and disease progression.

The systematic review on the randomized control trial conducted by Ramasubbu et al. (2017)  on a single study at high risk of bias  highlighted that metronidazole leads to the reduction of malodor in patients with MW. However, the study conducted by Watanabe et al. (2016) on total 21 subjects showed that the success rate of metronidazole in deodorization of malodorous fungating tumors is 95.2%. They used 0.75 % gel metronidazole. The results conducted by Fromantin et al. (2014) also provide promising results with metronidazole as an antibiotic in treating malodorous wounds resulting out of the presence of anaerobic bacteria. They tested the efficacy of metronidazole among breast cancer patients. Other approaches proposed by Fromantin et al. (2014) for the effective management of MW careful cleaning of wounds and proper control of exudates via the application of non-adherent dressings. The treatment of the malodor and proper management of exudates can be done further via the use of silver dressings. According to the reports published by Lian et al. (2014), antimicrobial property of silver dressings is useful in treating microbial activity while reducing septic phenomena and malodor.

Stakeholders

For holistic management of the MW among the end-stage cancer patients it recommended to use 0.75% of gel metronidazole (Ramasubbu et al., 2017; Watanabe et al., 2016). It will help to reduce colonization of the anaerobic bacteria and thereby reducing the emission of malodour. For the proper management of the bleeding and exudates from the MW while treating the malodor, silver dressings will be used. Silver dressing in the non-adherent form will help to control the discharge the blood, other exudates, and thereby preventing the emission of malodor (Lian et al., 2014). Application of metronidazole and silver dressings will be provided along with effective cleaning of wound (Fromantin et al., 2014).

Action Plan

Process, Outcomes Evaluation and Reporting

Desired outcomes: Decrease in malodor

Measurement of malodor: the medical officer and registered nurse will measure the success rate via odor score of 0 to 1 after 2 weeks of gel metronidazole treatment.

Report results to the key stakeholders: Here the key stakeholders include hospital authorities, multidisciplinary team of palliative care unit and family members of the patients. The results will be reported via poster presentations or power point presentation.

The implementation of the plan on the larger scale will include proper evaluation of nursing care plan for treating MW and subsequent framing of policies for the optimized implementation of the therapy in malignant wound management of palliative care. In order to make sure that the implementation becomes permanent, proper nursing education in the domain of palliative care will be done and this will help to increase the understanding behind the use of metronidazole behind MW and subsequent odor control.

I will communicate the findings within the organization via the use of posters attached in the front of palliative care unit or oncology unit. In order to communicate the findings outside the organization, I will provide PowerPoint presentations to the group of palliative care professionals from different organizations.

Conclusion

Thus from the above discussion it can be stated that the main discovery of the research in the domain of MW control among palliative care patients application of metronidazole. The evidence-based summary revealed that use of gel metronidazole helped in the significant reduction of malodor among the patients with MW. The clinical practice guidelines include proper formation of multidisciplinary team for procurement of care. Proper practice integration will be done via providing group based power point presentation and poster presentations. the evaluation of the successful outcome in the domain of malodor control among Mw patients will be based on odor scale of 0 to 1 which will measured after 2 weeks of therapy procurement.

References

Fromantin, I., Watson, S., Baffie, A., Rivat, A., Falcou, M. C., Kriegel, I., & de Rycke, Y. (2014). A prospective, descriptive cohort study of malignant wound characteristics and wound care strategies in patients with breast cancer. Ostomy Wound Manage, 60(6), 38-48. Retrieved from: https://pdfs.semanticscholar.org/7718/1d51525bdcf73a82ce28b1adef69504b68a1.pdf

Kumar, S. S. (2015). Occupational Therapy Perspective in Wound Care Management in Geriatric Persons. International Journal of Medical and Health Research ISSN: 2454-9142 www.medicalsciencejournal.com Volume 1; Issue 5; December 2015; Page No. 40-42

Lian, S. B., Xu, Y., Goh, S. L., & Aw, F. C. (2014). Comparing the effectiveness of green tea versus topical metronidazole powder in malodorous control of fungating malignant wounds in a controlled randomised study. Proceedings of Singapore Healthcare, 23(1), 3-12. Retrieved from: https://www.researchgate.net/profile/Eugenia_Vlachou/publication/231864218_Comparison_of_foam_dressings_with_silver_versus_foam_dressings_without_silver_in_the_care_of_malodorous_malignant_fungating_wounds/links/569e784508aee4d26ad01f47.pdf

Lo, S. F., Hayter, M., Hu, W. Y., Tai, C. Y., Hsu, M. Y., & Li, Y. F. (2012). Symptom burden and quality of life in patients with malignant fungating wounds. Journal of advanced nursing, 68(6), 1312-1321. https://doi.org/10.1111/j.1365-2648.2011.05839.x

Probst, S., Arber, A., & Faithfull, S. (2013). Malignant fungating wounds–the meaning of living in an unbounded body. European Journal of Oncology Nursing, 17(1), 38-45. DOI: https://doi.org/10.1016/j.ejon.2012.02.001

Ramasubbu, D. A., Smith, V., Hayden, F., & Cronin, P. (2017). Systemic antibiotics for treating malignant wounds. The Cochrane Library. DOI: 10.1002/14651858.CD011609.pub2

Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), 4.

Wai-man, M. C. K., & Hospice, B. (2014). Management of malignant wound: nursing perspective. Retrived from : https://www.hkspm.com.hk/newsletter/Newsletter%202004%20Sep%20_11%2012%2013%20Malignant%20wound.pdf

Watanabe, K., Shimo, A., Tsugawa, K., Tokuda, Y., Yamauchi, H., Miyai, E., ... & Nakamura, S. (2016). Safe and effective deodorization of malodorous fungating tumors using topical metronidazole 0.75% gel (GK567): a multicenter, open-label, phase III study (RDT. 07. SRE. 27013). Supportive Care in Cancer, 24(6), 2583-2590. doi:  10.1007/s00520-015-3067-0