A study to assess the effectiveness of Banana Leaf Dressing (BLD) among patients with partial thickness burns in selected hospitals at Karnataka

Ms. Jifi Antony¹, Mrs. Anitha Victoria Noronha², Prof. Sheela Williams³, Mrs. Janet Mathias⁴, Mrs. Usha Thomas⁵

¹M. Sc(N); Department of Medical Surgical Nursing, JSS College of Nursing, Mysore, Karnataka.

²Assistant Professor; Department of Medical Surgical Nursing, JSS College of Nursing, Mysore, Karnataka.

³Prof. cum Principal; Department of Medical Surgical Nursing, JSS College of Nursing, Mysore, Karnataka.

⁴Associate Professor; Department of Medical Surgical Nursing, JSS College of Nursing, Mysore, Karnataka.

⁵Associate Professor, Department of Medical Surgical Nursing, JSS College of Nursing, Mysore, Karnataka.

Corresponding Author Email: kdeepsin@yahoo.co.in

ABSTRACT

Burn injuries rank among the most severe types of injuries suffered by human beings with an attendant high mortality and morbidity rate. Majority of the burns patients experience pain and discomfort and many types of burn wound dressings are very difficult to remove and its removal may cause re-injury of the wound which results in pain and delayed wound healing. The present study was aimed to assess the effectiveness of Banana Leaf Dressing (BLD) in terms of reduction in discomfort, decrease in pain and easy removability of BLD among patients with partial thickness burns. A quasi experimental non-equivalent control group pre test and post test design was selected for the present study. Forty four patients with partial thickness burns (22 each in both experimental and control group) were selected by adopting non probability purposive sampling technique. The findings revealed that the post test discomfort and pain scores were significantly lower than the pre test discomfort and pain scores at before dressing, during dressing and 20min after dressing which was tested by using repeated measures of ANOVA and Bonferroni correction which were significant at 0.05 level of significance. The significance of difference between the mean post test discomfort scores at before dressing, during dressing and 20min after dressing of experimental and control group which were statistically tested by using independent ‘t’ test was not found to be significant at 0.05 level of significance. The majority of the burns patients who underwent Banana Leaf Dressing experienced easy removal of BLD in all days.

Thus it is concluded that Banana Leaf Dressing is effective in terms of reduction in discomfort, decrease in pain and easy removability among patients with partial thickness burns.

KEY WORDS: Banana Leaf Dressing, discomfort, pain, removability and patients with partial thickness burns.

BACKGROUND OF THE STUDY:

Skin plays an important role in maintaining overall health and well being. The major physiological impact of impaired skin integrity occurs in burns.¹ An acute burn wound is a complex and evolving injury. Extensive burns produce systematic consequences in addition to local tissue damage.²

A wound care revolution with emphasis on a team approach has occurred over the last five decades. In the 1960s, moist wound healing was discovered and coupled with advancements in wound dressing materials and it changed wound care practices dramatically. Some wounds heal quickly and uneventually, others are present for years.³

The primary goals of acute burn wound management are prevention of infection and the promotion of optimal wound closure by reepithelialisation which results in minimal aesthetic and functional impairment. Increased understanding of the cellular and molecular mechanisms of cutaneous wound healing has led to the development of new therapeutic agents and wound dressings.⁴

OBJECTIVES

The objectives of the study are:

1. To assess the wound depth of the burns patients before Banana Leaf Dressing among control group and experimental group.

2. To assess the discomfort and pain of burns patients at before, during and after Banana Leaf Dressing among control group and experimental group.

3. To assess the removability of wound dressing among control group and experimental group.

4. To evaluate the effect of Banana Leaf Dressing in terms of decreasing discomfort and pain reduction among experimental group.

METHODOLOGY:

Research approach/ design: Quasi- experimental nonequivalent control group pre test-post test design.

Variables of the study:

1) Dependent variable: Banana Leaf Dressing

2) Independent variable: Pain, discomfort and removability of wound dressing among patients with partial thickness burns.

3) Personal variables: age, gender, cause of burn injury, type and duration of receiving pain medication, affected burn surface area and percentage of burns.

Setting of the study: JSS Hospital, Mission Hospital and K.R. Hospital in Karnataka.

Sample & sample size: Forty four patients were selected for the present study, 22 each in experimental and control group.

Sampling technique: Non- probability purposive sampling technique.

Data collection technique and instrument:

· Interview schedule

- Selected personal variable

- Discomfort assessment scale (Visual Analogue Scale for discomfort)

- 0-10 Numeric Pain Intensity Scale

· Observation

- Wound depth assessment tool

- Tool for the assessment of removability of wound dressing

- Wong Baker Face Scale

Sampling criteria

Inclusion criteria:

§ Burns patients who got admitted in selected hospitals at Karnataka.

§ Patients who got admitted with below 50% burns.

§ Patients who were willing to participate in research study.

Exclusion criteria:

§ Burns patients who got admitted with co-morbid illness and wound complications.

Data collection procedure:

Ethical clearance was obtained from the institution. Formal administrative permission was obtained from the administrators in the selected hospitals at Karnataka. The patients with superficial partial thickness burns were selected as per sampling criteria and by using Wound depth assessment tool. A written consent was obtained from the participants. Banana Leaf Dressing was done for the experimental group and routine gauze dressing was done for the control group.

TABLE 1 Mean, median, range and standard deviation of pre test and post test discomfort scores of burns patients in experimental and control group at before dressing, during dressing and 20min after dressing.

n₁₊n₂=44

	EXPERIMENTAL GROUP				CONTROL GROUP
	Mean	Median	Range	S D	Mean	Median	Range	S D
Pre test Before Dressing During Dressing 20min After Dressing	6.09 8.14 4.95	6 8 5	4- 8 6-10 2-8	±1.192 ±1.246 ±1.588	6.59 8.36 5.73	7 9 6	4-9 5-10 2-9	+1.436 +1.649 +1.667
Post test 1 Before Dressing During Dressing 20min After Dressing	4.68 7.27 4	5 7 4	3-6 5-9 2-7	±0.945 ±1.279 ±1.345	5.09 7.36 4.82	5 7 4	3-7 5-10 2-8	+1.306 +1.497 +1.532
Post test 2 Before Dressing During Dressing 20min After Dressing	4.05 5.91 3.23	4 6 3	3-6 4-8 2-5	±0.785 ±1.065 ±0.973	4.41 6.55 3.95	4 7 4	3-6 4-8 2-6	+0.959 +1.143 +1.290
Post test 3 Before Dressing During Dressing 20min After Dressing	3.18 5.14 2.82	3 5 3	2-5 3-7 1-5	±0.958 ±1.037 ±0.958	3.73 5.32 3.36	4 5 3	2-5 3-8 2-5	+0.935 +1.086 +1.093
Post test 4 Before Dressing During Dressing 20min After Dressing	2.73 4.36 2.09	3 4 2	1-4 2-6 1-3	±0.767 ±1.293 ±0.526	2.86 4.05 2.32	3 4 2	2-4 2-6 1-5	+0.834 +1.327 +0.995

It is evident that most of the burns patients experienced more discomfort during dressing.

TABLE 2 Mean, median, range and standard deviation of pre test and post test pain scores of burns patients in experimental and control group at before dressing, during dressing and 20min after dressing.

n₁+n₂=44

	EXPERIMENTAL GROUP				CONTROL GROUP
	Mean	Median	Range	S D	Mean	Median	Range	S D
Pre test Before Dressing During Dressing 20min After Dressing	6.59 8.82 5.55	7 9 6	4-9 7-10 3-8	+1.221 +1.006 +1.654	7.36 9.23 6.36	8 10 6.5	5-9 7-10 3-9	±1.293 ±1.020 ±1.497
Post test 1 Before Dressing During Dressing 20min After Dressing	5.05 8.14 4.77	5 8 4.5	4-7 6-10 3-8	+0.844 +0.941 +1.343	5.91 8.36 5.23	6 8 5	4-8 6-10 3-8	±1.151 ±1.002 ±1.193
Post test 2 Before Dressing During Dressing 20min After Dressing	4.36 6.77 3.91	4 7 4	3-6 5-9 2-6	+1.002 +1.232 +1.109	5.09 7.45 4.5	5 7 4	3-7 5-9 3-7	±0.971 ±0.963 ±1.012
Post test 3 Before Dressing During Dressing 20min After Dressing	3.82 6.05 3.23	4 6 3	2-5 5-8 2-6	+0.853 +0.999 +1.270	4.23 6.27 3.5	4 6 3.5	3-6 4-8 2-5	±0.922 ±1.202 ±1.012
Post test 4 Before Dressing During Dressing 20min After Dressing	3.14 4.95 2.77	3 5 2.5	2-5 3-6 2-4	+0.889 +0.899 +0.869	3.73 5.14 2.86	4 5 3	2-5 3-7 2-5	±0.827 ±1.167 ±0.941

It shows that burns patients experienced more pain during dressing.

TABLE 3 Repeated Measures of ANOVA for Tests of Within-Subjects Effects across days in discomfort n=44

Source	Before dressing			During dressing			20min after dressing
	df	F	Sig	df	F	Sig	df	F	Sig
Days(5)	4	170.413	.000^*	4	147.721	.000*	4	73.079	0.000*
Days(5)*Group (Experimental and Control group)	4	0.579	0.679	4	1.657	0.162	4	0.735	0.569
Error(Days)	168			168			168

F_(4,168):(p<0.05);*– Significant

TABLE: 4 Repeated Measures of ANOVA for Tests of Between-Subjects Effects across days in discomfort

Source	Before dressing			During dressing			20min after dressing
	Df	F	Sig	df	F	Sig	df	F	Sig
Groups (E and C)	1	2.461	0.124	1	0.292	0.592	1	4.976	0.031^*
Error(Days)	42			42			42

n=44 F_(1,42) :(p<0.05);*– Significant

The pre test was done on 1^st day of admission by using Discomfort Assessment Scale (Visual Analogue Scale for discomfort) and Pain assessment tools (Wong Baker Face Scale and 0-10 Numeric Pain Intensity Scale) at three times – before, during and 20min after dressing. Post test was done on 2^nd, 3^rd, 4^th and 5^th day for three times – before, during and 20 min after dressing by using Discomfort assessment scale, Pain assessment tools and Tool for the assessment of removability of wound dressing.

RESULTS:

The findings of the present study showed that majority of the samples(65.9%) were in the age group of 20-40years and 70.5% of them were females. The cause of burn injury was thermal. Majority (90.9%) of the samples in the experimental group received non-opioid analgesics only whereas about half of the samples in the control group were administered combination of drugs such as opioids and nonopioid analgesics. Majority of them had burn surface area of more than one area and had burns of 10-20% and followed by 30-40%.

Repeated measure of ANOVA is done to see the significant difference in discomfort and pain across days in each observation- before dressing, during dressing and 20min after dressing.

The table 3 shows that there was significant difference in discomfort scores across days at before dressing, during dressing and 20min after dressing since the p value< 0.05 but, there was no interaction between days and groups.

Table 4 shows that there was significant difference in discomfort scores at 20min after dressing between the experimental and control group since the p value < 0.05. Since there was significant difference in discomfort scores at before dressing, during dressing and 20min after dressing across days, further Bonferroni comparison was done and it was evident that there was significant difference in discomfort scores at before dressing, during dressing and 20min after dressing in most of the parameters since p<0.05. It indicates that Banana Leaf Dressing is effective in reduction in discomfort at before dressing, during dressing and 20min after dressing.

TABLE : 5 Repeated Measure of ANOVA for Tests of Within-Subjects Effects across days in pain n=44

Source	Before dressing			During dressing			20min after dressing
	Df	F	Sig	Df	F	Sig	Df	F	Sig
Days(5)	4	225.656	.000^*	4	504.975	.000^*	4	93.691	.000^*
Days(5)*Group (E and C)	4	0.933	0.447	4	1.127	0.345	4	1.173	0.325
Error(Days)	168			168			168

F_(4,168):(p<0.05);* – Significant

TABLE: 6 Repeated Measure ANOVA for Tests of Between-Subjects Effects across days in pain

n=44

Source	Before dressing			During dressing			20min after dressing
	df	F	Sig	Df	F	Sig	Df	F	Sig
Groups (E and C)	1	6.880	0.012^*	1	1.839	0.182	1	2.477	0.123
Error(Days)	42			42			42

F_(1,42):(p<0.05);*– Significant

The table 5 shows that there was significant difference in pain scores across days at before dressing, during dressing and 20min after dressing since the p value< 0.05 but, there was no interaction between days and groups.

In the above table, since the p value <0.05, there was significant difference of pain scores between experimental and control group at before dressing. But, there was no significant difference of pain scores between experimental and control group at during dressing and 20min after dressing at 0.05 level of significance.

Since there was significant difference in pain at before dressing, during dressing and 20min after dressing across days, further Bonferroni comparison was done and it was evident that there was significant difference in pain scores at before dressing, during dressing and 20min after dressing in most of the parameters since p<0.05. It is inferred that Banana Leaf Dressing is effective in reduction in pain at before dressing, during dressing and 20min after dressing.

Independent t test was done to see the significance of difference between post test discomfort and pain scores of burns patients among experimental and control group at before dressing, during dressing and 20min after dressing. The study findings shows that there was no significant difference between the mean post test discomfort and pain scores of burns patients among experimental and control group at before dressing, during dressing and 20 min after dressing.

Figure: 1 Frequency and percentage distribution of removability of wound dressing

Majority of the burns patients who had undergone Banana Leaf Dressing (77.3% - 100%) experienced removal of Banana Leaf Dressing very easy whereas in control group, burns patients who had undergone routine gauze dressing (72.7% - 86.4%) experienced difficulty in removing wound dressing.

DISCUSSION:

The findings of the present study showed that majority of the samples (65.9%) were in the age group of 20-40years and 70.5% of them were females. The cause of burn injury was thermal. Majority (90.9%) of the samples in the experimental group received non-opioid analgesics only whereas about half of the samples in the control group were administered combination of drugs such as opioids and nonopioid analgesics. Majority of them had burn surface area of more than one area and had burns of 10-20% and followed by 30-40%.

The computed repeated measure ANOVA for discomfort and pain scores across days within the group at before dressing, during dressing and 20min after dressing were significant at 0.05 level of significance. Thus, findings revealed that, Banana Leaf Dressing is effective in reduction of discomfort and pain at before dressing, during dressing and 20min after dressing across days. But, there was no interaction between days and groups.

The Bonferroni comparison of discomfort and pain scores at before dressing, during dressing and 20min after dressing were found to be significant at 0.05 level of significance which indicates that Banana Leaf Dressing is effective in reduction in discomfort and pain.

The mean differences between post test discomfort and pain scores of burns patients between experimental and control group at before dressing, during dressing and 20min after dressing were found to be not significant at 0.05 level of significance which is inferring that there was no change in discomfort and pain among burns patients after exposure to Banana Leaf Dressing. Because, burns itself causes some discomfort and pain as the pathophysiological phenomenon irrespective of experimental and control group. Also, majority of burns patients in control group received combination of opioids and non-opioid analgesics whereas in experimental group, majority of samples received non-opioid analgesics only.

Majority of the burns patients who had undergone Banana Leaf Dressing (77.3% - 100%) experienced removal of Banana Leaf Dressing very easy whereas in control group, burns patients who had undergone routine gauze dressing (72.7% - 86.4%) experienced difficulty in removing wound dressing.

IMPLICATIONS:

The findings of present study have implications for nursing practice, nursing education, nursing administration and nursing research. Nursing care can be offered to patients through conventional means in traditional settings or it can be practiced in domains labelled alternative or complementary therapy. The nurses should aware of Banana Leaf Dressing for a patient with partial thickness burns by conducting staff development programmes such as continuing education, In service education etc by the higher authorities. The nurse educators have the additional responsibility to up-date the students’ and nurses’ knowledge regarding alternative treatment for burns patients. The findings of the study can help the nursing students and nurses to enhance their knowledge and skills in practicing Banana Leaf Dressing and utilize that skill in their daily professional activities. The alternative therapy like Banana Leaf Dressing for a patient with partial thickness burns should be included in the curriculum and students should be taught regarding the Banana Leaf Dressing which provides benefits of early wound healing, reduction in discomfort and pain and easy removability of BLD. The nurse administrators can convince the authority to provide means to practice the intervention of Banana Leaf Dressing on patients with partial thickness burns in their respective organizations.

RECOMMENDATIONS:

1. Large scale study can be conducted to generalize the findings.

2. A similar study can be conducted by adopting true experimental design.

3. A similar study can be conducted among patients with various percentage of burns.

4. A similar study can be conducted to assess the effectiveness of Banana Leaf Dressing in terms of early wound healing along with reduction in discomfort and pain and easy removability of BLD.

BIBLIOGRAPHY:

1. Mike W. Watson’s clinical nursing and related sciences. 6^th ed. India: Baillieres Tindall publications; 2002.

2. Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness Burns. Cochrane Database of Systematic Reviews [homepage on the Internet].2010 [cited 2012 April 8] Available from:http://www.ncbi.nlm.nih.gov/pubmed/18843629

3. Sharon B, Elizebath AA. Wound care essentials, practice principles. Newyork: Lippincott Williams and Wilkins publications; 2003.

4. Harry SS, Adam JS. Initial management of minor burns. Israeli Journal of Emergency Medicine [Serial on the Internet].2005 [cited 2011 Nov 7]; 5(4) Available from: isrjem.org/Burnsoct05.pdf.

Received on 07.06.2013 Modified on 15.09.2013

Accepted on 02.10.2013 © A&V Publication all right reserved

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 15-19