I have been asked to submit a research based, essay on a Critical Incident Analysis, which occurred on the ward on which I was working during my return to nursing course this year.
After looking at the various models of reflection that are available (Gibbs’ Reflective Cycle, John’s Model of structured Reflection, Rolfe’s Framework for Reflective Practice), I have decided to use Gibbs’ Reflective Cycle. The choice of this model was based on the fact that I identified more with this style of reflection, and I felt that it would suit me better compared to the other two models available.
Feelings
Having worked with Gibbs’ Model in a previous essay, I feel that I would work better with this model as it is not only familiar to me but also easy to understand and apply.
I had encountered a patient who asked me about the practice of skin disinfection prior to administering an intramuscular injection. Prior to receiving the injection the patient suggested that I should not use an alcohol swab because it caused a sting on the skin every time that the patient had to undergo an injection. The patient’s perception about this was that alcohol evaporates so rapidly and thus, when used prior to an injection there is a possibility that the injection needle could facilitate its penetration into the body through the point of injection. Subsequently, the alcohol that penetrates into the body causes an uncomfortable stinging sensation.
Evaluation
Conventionally, the skin has contaminating organisms that cause pathological transformations when injected into the body during injection. On the basis of these assumption patients, nurses, trainee-doctors and medical students are trained to prepare the skin before injection. This procedure is administered through cleansing with an antiseptic to keep away any infections at the site of injection. Alcohol swab containing 70% isopropyl has been used since the 19th century. It is the oldest and most effective antiseptic for the preparation of the skin just before an operation or injection. Alcohol has no activity as far as fungal spores are concerned. However, it destroys most of the vegetative bacteria (Williums et al., 2000). To determine this, I decided to perform medical trials with my patient specifically for this aspect of the assessment. The patient agreed to participate in the exercise. I took the time to explain the possible risks, purpose and nature of the exercise at length before he could verbally accept to participate.
The exercise involved the clinical effects of avoiding skin preparation before injection and the effects of involving skin preparation before injection using 70% isopropyl alcohol. The patient first received IM-intramuscular injections after skin preparation with a 70% isopropyl alcohol swab and after six hours got another injection without skin preparation.
The skin around the injection site was thoroughly swabbed for about thirty seconds with 70% isopropyl and given time to dry for another thirty seconds before injection. I examined the injection site after six hours for any signs of formation of an abscess, fever, swelling, pain and erythema. A checkup was also performed to make sure that there was no tenderness, redness or any other abnormal signs in the injection area. The next injection at the injection site where no skin preparation was given was then administered. Six hours later I examined the injection site again, looking for any signs of abscess, fever, swelling, pain, erythema, tenderness, redness or abnormal signs.
At the beginning of the exercise I made sure that the patient had no co-morbidity or skin disease such as heart valve or immune-suppressed disease.
I took a swab for culture from the injection site as per the instructions of the microbiology department (swab showing CFU-the skin bacterial colony forming units per milliliter). This was done just before and after getting the alcohol swab wiping from the patient to assess the effects of using 70% isopropyl alcohol swab for skin preparation pathologically.
The fungal or viable bacterial numbers are all measured using the CFU. The CFU is responsible for measuring the viable cells, while the direct microscopic count measures all the living and dead cells. Generally it is utilized for the measurement of the number of microorganisms present on the sample or surface.
Analysis
The exercise illustrated the fact that preparation of the skin using an alcohol swab kills 47% of bacteria on the skin at the site. Lack of skin preparation with an alcohol swab just before an injection, did not show any clinical illustrative signs.
It is impossible to comment on the removal of skin bacteria mechanically considering that no comparisons were made between the placebos wipe and alcohol wipe.
The skin is the largest organ of the body. It serves the purpose of protecting against infection, injury, light and heat, as well as the storage of fats and water and the regulation of body temperature. The skin is a sensory organ capable of preventing the entry of bacteria and loss of water (Hutin et al., 2003). Many organisms reside on the skin and commence on the surface. The most common organism found is the staphylococcus epidermidis with the number of CFU ranging from 2-12CFU in an unclean skin site compared to 2-6CFU in a thoroughly clean skin surface.
When I consider a small area that is needed for injection site, it is clear that the number of injected bacteria in a site that is not clean is much lower than what is needed for the formation of the pass. This indicates that there are no strong reasons whether to clean or not to clean the injection site.
In a research study, Fleming had observed thirteen thousand insulin injections with and without skin preparation using alcohol and in both groups he did not find any infection signs at the injected site (Pratt, Hoffman and Robb, 2005). Similarly, in a period of six years Dann (2009) monitored over five thousand injections undertaken using all routes without any skin preparation processes. The researcher too did not find any sign of infection on the injection site of the skin. McCarthy conducted a study on fifty patients on whom he used insulin for skin preparation. He did a comparison of six hundred injections taken separately without skin preparation, six hundred with cotton soaked in tap water and six hundred with alcohol wipe on the three quarters of the abdomen. He came up with the conclusion that none of the patients involved in the exercise underwent any injection site complications from the three methods (Binswanger et al., 2009)
Studies in microbiology do not indicate that the use of antiseptic on the skin before intramuscular, intradermal and subcutaneous injections lowers the risk of infections. Felig and Kolvisto measured flora in skin bacteria after wiping for five seconds with 70% isopropyl alcohol swab and they discovered, a decrease in the count of bacteria by 82-91%. During the observation period of 3-5 months in this same study the comparison of 1700 insulin injections done without any skin preparation and with skin preparation using an alcohol swab showed no systemic or local infection at all (Williums et al., 2000).
In a different study, seventeen patients re-used a total of one hundred and eleven insulin syringes for a record two thousand three hundred and sixty three times and there were no signs of infection on the site of injection. Just like the piercing of contaminated skin, infections are more or less likely to arise from infected injecting solutions and infected needles and syringes. With skin cleansing the danger of drug users getting skin infections would be much lower, however the virulence and numbers introduced on skin bacteria is smaller than the minimum infectious dose of the formation of pus.
Some studies warn the use of cleaning material for the alcohol swab could leave traces on the needle causing irritation to the site of the injected area. Other research studies show that the site of injection should be cleaned in order to reduce the risk of getting an infection. Lodophors and ethyl alcohol are some of the commonest solutions used for the preparation of the skin before an injection ((Williums et al., 2000). Researchers view that the ongoing use of an antiseptic cannot work on time as what is normally expected in general practice as it does not guarantee for complete sterility.
The best practice according to scientists would be to clean the skin site thoroughly before injection in order to avoid the formation of an infection in the skin flora of the patient ((Williums et al., 2000)
In order to reduce the presence of pathogens, the most appropriate technique is swabbing the site of injection with 70% saturated alcohol swab for thirty seconds and giving the area an extra thirty seconds to dry. The time given for the site to dry sometimes does not prevent the stinging effect of the alcohol to the tissue upon needle entry.
However, nurses always put into consideration the legal implications in medicine and always choose to abide by the guidelines placed by the employer/health board as far as skin cleansing before injection is concerned.
It would be very hard to defend a case involving the injection of a patient’s skin without performing any cleansing of the area. The organisms that cause any abscesses at the intramuscular site are pathogenic in nature. It is however evident that in the last few years the debate on the importance of removing these pathogens from the skin just before an injection is an issue that will go on for a long time.
Despite the many research findings done over the years in a bid to discover the basics for cleansing of the skin just before the administration of an intramuscular injection, many nurses have been left in a dilemma regarding whether it is appropriate to perform this routine practice or not.
As much as the literature on this issue is not definite, many communities, individuals and institutions all over the world continue to advocate that the practice of cleansing of the injection site is important and should not be avoided.
Therefore, preparing a person’s skin for the injection is not necessary. Hence the preparation of the skin with alcohol is not a requirement. The practice of avoiding skin preparation before injection saves money and time and helps reduce the pain linked with the injection of alcohol that is not evaporated on the skin.
The exercise also shows that as much as there was a reduction in the skin-floral bacteria; there were no huge differences among the systemic/local effects and the clinical signs in the event of using or avoiding the skin preparation procedure
Conclusion
This exercise could play a role in making sure time and money are saved by not performing this practice, which from practice has been deemed as not entirely necessary. It also shows the importance of using procedures that are precise and at the same time maintaining hygiene.
The patient who had undergone this experiment, on a personal perspective found no difference whether alcohol was used to clean the skin or not. The patient felt that he would rather always have his say. While the patient’s views are always important, it is critical that they are in line with the health facility’s policies. Otherwise, the medical practitioner or nurse involved would be rendered to have acted against the expected code of ethics.
Action Plan
In such a case, in the future, I would not compromise on the guidelines and policies of the facility where I am positioned. Even at the request of the client, the professional and workplace ethics must be adhered to. This is specifically to avoid the legal implications that would be generated by a further complications arising from such a medical procedure. In the event of such a complication, one would be placed in a tough position for evading the organizational policies without consulting the facility authorities.
Works cited
Binswanger,I.A, Kral,A.H, Bluthenal, R.N, Rybold DJ, et al. High prevalence of abscesses and cellulitis among community-recruited injection drug users in San Francisco. Clinical Infectious Diseases 2000; 30(3): 579-81
Dann,T.C. Routine skin preparation before injection; an unnecessary procedure. Lancet 2009; 2(7611): 96-8
Hutin, Y,Hauri, A, Chiarello L, Catlin, M.,et al. Injection Safety Best Practices Development Group. Best infection control practices for intradermal, subcutaneous and intramuscular needle injections. Bull World Health Organ, 2003;81(7):491-500.
Pratt, R.J, Hoffman PN, Robb FF.The need, for skin preparation prior to injection. Point-Counter point. British Journal of Infectious Control 2005; 6(4): 18-20
Williums, R., Blowers, Garrod, L.P, Shooter,RA. Hospital infection.Causes and prevention. London: Lloyd-Luke, 2000;298-335.
