NJprisonrn, MSN, NP 5,300 Views
Joined: Jul 7, '11;
Posts: 197 (28% Liked)
; Likes: 106
Normally, I would have knocked this deal because I don't like the money. But it's worth considering since it involves receiving specialty training---which isn't easy to get as a new grad these days. BUT, the training is for 4 months so why does he want to keep you at $60k for 2 additional months before increasing it to the $75k? Derm specialty services aren't cheap, and if you're going to be seeing 50 patients a day you're not going to have any problems with billing much more than $200k a year for this practice.
I would max practice expenses at 50%. I think that he could do better than that 25% that he's offering, but as long as what he's paying you is within the local market range then I suppose it's an acceptable sacrifice to make in exchange for the experience that you're going to get. Make sure that the contract is for one year only and that it doesn't include a non-compete clause. After you've done your year, if better opportunities call you can simply move on.
Congratulations, and good luck!
I have a patient who has a new end ileostomy. I am the only CWOCN in the hospital and I was gone on vacation when he was in the hospital. So the surgical floor did their best with his ostomy care. However, they were using the wrong pouch which caused leakage and the peristomal skin to become denuded. So, now I'm trying to heal the skin while also trying to stop further leaking - Yikes!
Here's the story -
New end ileostomy (temporary - previous primary anastomosis leaked causing the need for this diverting ileostomy). The stoma only measures 32mm or 1 1/4". It is just slightly oval in shape. Stoma is flush to skin with the opening in the middle. Patient has a fairly flat abdomen with no creases/skin folds/divots. Abdomen is mostly soft (normal-like..if that makes sense). Patient was sent home with a flat one-piece pouching system, had leakage throughout entire weekend and now skin is moderately denuded from about 3-9 o'clock and extends to his groin/thigh area. Upper skin is slightly irritated but I believe that's all from the pouch tape-border and barrier being removed every couple hours. Patient states that he's had to change his pouch 3-4 times a day. The denuded tissue weeps a little which causes it to break the seal on the pouch (at least I think that's the problem).
So this is what I've done so far. Keep in mind that my hospital is on the smaller side so I am limited on products. We are contracted with Hollister for our ostomy supplies so that's what I'll be referring to.
First attempt, I applied stomahesive powder to denuded area
Since patient had a supply of flat pouches, I added an adapt convex barrier ring to it due to stoma being flush to the skin. Skin barrier was flextend.
Patient came back next day and it was leaking and he had to change pouch about 2-3 times.
I then "crusted" the denuded area with stomahesive powder and skin barrier wipe
I placed a hydrocolloid sheet onto denuded area thinking that the pouch would have an easier time adhering to a dry surface (while the "crusting" and hydrocolloid worked on healing the denuded tissue)
I reapplied an adapt convex barrier ring to the flat 1 piece as before.
Again, leakage happened...
So I changed it up a little:
I "crusted" the denuded area and applied the hydrocolloid sheet again.
I switched to the Hollister New Image convex 2-piece pouch (hospital doesn't carry 1 piece convex for some reason) thinking that either the adapt convex barrier ring wasn't applying enough convexity, was applying too much, or was too soft for abdomen.
I also applied an ostomy belt for added support and "window-framed" pouch with paper tape (put tape around border). *Fingers crossed*
Patient empties bag frequently so that isn't the problem (he's doesn't want it to get too full/heavy and pull the pouch off). Patient's stool is pudding-consistency and he isn't having high output. Everywhere I've read says to do the crusting technique but I've also read that sometimes that interferes with the seal. I honestly don't think any pouch will stick to that denuded skin so I have to do something.
I'm not a fan of the ostomy paste because it's hard to get off skin or people use too much so I was trying to stay away from it, but is that something I should try if this last pouch change doesn't work?
This is where I need your help! I've only been doing this for about a year and my hospital only gets maybe 1-2 stoma patients per month so I'm not the most experienced. Since I'm the only CWOCN in the hospital, I don't have anyone to bounce ideas off of or take in with me to see the patient. I'm kind of at a loss now and it's only going to get harder the longer I can't obtain a seal. I don't think a stoma revision will be an option since it's temporary anyway.
Eventually, though, if I can't get it to stop leaking, I may refer him on to another stoma nurse who has more experience or works in a bigger hospital (more supplies available).
Thanks for any input, I greatly appreciate any ideas!
Remember to join your state NP association and your state chapter of AANP!
Apologies if this is not considered a "relevant" post as I am a new member/just a BSN student! I have been browsing this discussion board because of my professional but mostly personal interests.
My son had an emergency ileostomy at birth and was in and out of ICU for months. His electrolytes were out of whack, and his delicate skin was completely broken down over his entire abdomen at one point. The pediatric WOC nurse absolutely saved us. I can still remember our first conversation -- she asked how we were doing and I said "fine". She said "No, you're not. You are exhausted and scared." I fell apart! She was compassionate, knowledgable and creative when the doctors weren't -- she came up with an Ilex, Aquaphor and preemie diaper combination that allowed his skin to heal; she petitioned the docs to give the "go" for his reanastomosis. She became our therapist, advocate, and friend.
Anyways. I am not sure where my nursing career will take me -- I'm sure many students start out with a specialty in mind but end up with something else entirely. I would love to make a difference in wound/ostomy care the way our nurse did for us. But even if I end up somewhere else I just wanted to give a shout out to you all for everything you do!
Sorry if this was a little long (and a little mushy)!
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