Post TKR infection which is a result of treatment in a hospital or a healthcare service unit, but secondary to the patient’s original condition. According to Fehring et al (2000), the diagnosis of infection depends on the clinical appearance of the patient is generally based on joint aspirates and cultures, laboratory results. [Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], radiography and clinical examination. The knee joint can present inflamed, red, swollen, tender on palpation, feeling warm and the patient can show clinical signs of systematic infection like fever, shivering, night sweating, etc. Sometimes the only complaint patients have is continuous pain. This should be considered as an infection until proven otherwise. Zimmerli W (2004) present most commonly cultured microorganisms are coagulase- negative staphylococci (30-43% of cases) and Staphylococcus aureus (12-23%), and followed by mixed flora (10-11%), streptococci (9-10%), Gram- negative bacilli (3-6%), enterococci (3-7%) and anaerobes (2-4%). No microorganism is detected in about 11% of apparent infection. Polymicrobial infections are reported in 12-19% of cases.

Many medical procedures bypass the body’s natural protective barriers. Routine use of anti-microbial agents in hospitals creates selection pressure for the emergence of resistant strains. According to Rutala et al (1983), investigating on Methicilin Resistant Staphylococcus Aureus (MRSA) outbreak, found that MRSA comparised 16% of all bacterial isolates sampled from the air and 31% of the isolates from elevated surfaces.

After knee surgery, infection is a major concern. A standard treatment protocol must be followed. All patients post TKR must treated with intravenous flucloxacillin and benzyl penicilin (erythromycin for penicillin allergic patients) for a minimum of 6 weeks. According to Lewis G (2006) antibiotic -loaded cement were also found to be efficient in reduced the risk of infection in the early post operative period. However, Joseph TN (2003) states high doses of antimicrobial agents may result in the bone cement has lower mechanical properties and there are also concerns regarding the allergic reaction to impregnated antibiotics and the potential for the emergence of antibiotic-resistant bacteria.

Knowledge is one factors contribute of infection. “Barriers to good hand hygiene include poor knowledge of infection control, time pressure, poor technique, inadequate facilities and inappropriate clothing and hand adornments. (NOA 2004: Department of Health (DH) 2005). Professional healthcare staff must have a good knowledge hand washing follow by standard precaution to prevent infection. It can decrease infection via hand among them. Gould et al (2008) thinks that infections in healthcare setting are spread by direct contact (cross infection) of health workers.

Normally in crowded with full patient’s orthopedic ward with 3-4 staff nurses per shift, this can cause the workload. It a high was too heavy and they have not enough time to carry out their job properly. It’s difficult to practice good hand washing hygiene before and after touch every patient. Infection can cause by the nurses while practicing nursing interventions via poor hygiene control and failure to maintain sterility in procedure especially do dressing to post TKR patient. When hand washing facilities are poor, it contributes to infection. Clinical hand wash sink are required in all areas where clinical activities are performed. Provision of adequate and appropriate facilities could be improved hand washing compliance. According to Harris et al (2000) stated that hindering factors and good and hand washing are lack of time, poor facilities and materials. From one study of compliance with hand washing (Girou and Oppein, 2001) state that 50% of healthcare workers’ did not wash their hands after procedure.

A nation review of nursing workforce predicts the demand for nurses will increases in hospital admissions. With many nurses hearing retirement, a national shortage of up to 40,000 nurses is predicted by 2010. Therefore recommend that the Department of Health require all hospitals to use the general workload calculation tool to assess the number of nurses needed in appropriate wards.

A compounding factor and one that is the cause of many post TKR infection in hospital, staff especially nurses they not able to practice proper hand washing technique as they have too many procedures to be settle before end of the shift staff nurses are always running out the time to manage all about patients including orders from doctor, they must manage pre and post operative patients too. Among crowded hospital populations and where poor infections control practices exits it may facilitate bacteria transmission. A commonly in ward, nurses have to follow ward round and carry out order from doctors such as taking blood, do dressing and sent patient for x-ray or physiotherapy. During ward round, staffs unable to wear proper mask, glove and apron before enter isolation room patient post TKR as an action from doctor which wants it to be fast. In this situation, nurses must be the best way to perform nursing role in whatever situation no matter it is a busy day, emergency situations or lack of staff. It is important the nurse to analyze and utilize the situation in work management. The Infection Control Nurses Association (1998) mention that commitments by managers to improved resources are important to prevent poor hand hygiene among healthcare and patients.

During ward round, staffs unable to wear proper mask, glove and apron before enter isolation room’s post TKR patient as an action from doctor which it to be fast. In this situation nurses must be the best way to perform nursing role in whatever situation no matter it is a busy day, emergency situation or lack of staff. It is important for the nurse to analyze and utilize the situation in work management. According to Hanssen AD et al (1999) the incidence of infection as cause of prosthetic failure varies depending on the joint involved with the rate of arthroplastis becoming infected being 1.7% of primary and 3.2% of non primary hip arthroplasties, 2.5% of primary and 5.6% of non primary knee arthoplasties and 1.3% of shoulder arthoplasties.

A nation review of nursing workforce predicts the demand for nurses will increase by over two percent a year due to expected increases in hospital admissions. With many nurses hearing retirement, a national shortage of up to 40,000 nurses is predicted by 2010. Therefore recommend that the Department of Health require all hospitals to use the general workload circulation tool to assess the number of nurses in appropriate ward.

Learning through reflection is more potent if there is an understanding of frameworks that encourage a structural process to guide the act of reflection. In this paper I would like to reflect about one cases happened in my work place. One old male patient about 80 years old develops deep infection after a two – stage revision of an infection post TKR. The ideal definitions of post operative wound infection remain problematic. A substantially higher audited rate of wound infection is produced by applying the clinical definition proposed by the Surgical Infection Study Group (SISG). After apparent early post operative wound infection in to patients, only three (4%) had definite ongoing wound problem or deep sepsis at 1 year.

As an experienced nurse, I feel upset if the infection is cause by the lacking of staff’s knowledge in wound management. Patient might be depressed as the result from infection and complication and need longer hospitalization period. They also must waiting and have maintain period of healing process.

Regarding this situation, I applying Gibbs Reflective Cycle, Nurses play a crucial role in the management of wounds. So they need to have good current knowledge and be more aware of their own wound care practice so to bring about more effective wound management. Professional Development in Nursing Time, (1994,p1), describes the nurses to be more observant of their patients’ wounds, increased their knowledge and skills on wound care and assisted them in acquiring more experience and skills in nursing research and get up on going frame work for improvements in wound management.

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