Are orders needed for dressing changes? QI project question

Posted
by JessicaLedford JessicaLedford (New) New

I am on a new unit in a new hospital for my clinical rotation and we have to do a QI project. I've run into an issue that I haven't seen in my previous clinical locations related to bandage changes. At previous locations I've always seen orders for bandage changes in the nursing orders. At this hospital I haven't found any. This past week I had 3 patients, one that has 2 bandages for pressure ulcers, two that had surgical incisions (one was one day post-op, the other a few days post op), two with freshly installed JP drains, and one with a bandage placed over a surgical incision that had spurted purulent material during morning rounds.... So a whole lot of bandages around. I couldn't find a nursing order for any of them. I asked my partner nurse and she said bandages are changed once a shift at assessment, unless soiled, then they are changed again. But there wasn't a specification for materials used, that was nursing judgement.I've been trying to find out if orders are legally required or if nursing judgement is within scope of practice and that has been very difficult to figure out. Can someone give my input on your experience? Or better yet, point me to legal regulations or best practice resources for this? I'm finding a lot about how to do a bandage change but not about orders or protocols to have consistency. Thanks.

Edited by traumaRUs

mrsboots87

mrsboots87

Specializes in Neuro, Telemetry. Has 7 years experience. 1,761 Posts

Sorry, I am of no help, but just wanted to say that that is a good question. Maybe it varies per state, have you tried reviewing your nurse practice acts to scope out wound dressing change protocol. I just know that I am a student in AZ that has been told we NEVER change a bandage without orders. THe orders can say to change bandages PRN, but will usually state what kind of dressing are required. We are also told we never remove post op bandages without specific orders from the surgeon and only after they have removed the initial dressing and viewed the incision site. However, I know they wound nurses do not need orders and use judgement when dressing a wound, so it does make me wonder if it is just facility policy that dictates dressing change protocol or law. HMM. Hoepfully someone has more info on this for you.

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 16 years experience. 224 Articles; 27,608 Posts

Every dressing change requires a physician's order at my place of employment, even if it is a skin condition such as a simple skin tear that would be covered by one of the standing orders.

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience. 1,761 Posts

All dressings are changed every 24 hours. No orders needed. We require a order to NOT change them. We have a few dressings the MDs like to change themselves.

Pilot2FNP

Pilot2FNP

Has 10 years experience. 49 Posts

ALL dressings should NOT be changed every 24 hours. Some, such as alginate dressings, are left in place from 3-7 days routinely.

Kuriin, BSN, RN

Specializes in Emergency. Has 6 years experience. 967 Posts

All dressings are changed every 24 hours. No orders needed. We require a order to NOT change them. We have a few dressings the MDs like to change themselves.

What? No. That is wrong. You change at specific times. The only time that you would actually actively change it is if it is soiled or wet from blood. Tegaderm can last longer than 24 hours.

Lev, BSN, RN

Specializes in Emergency - CEN. Has 7 years experience. 9 Articles; 2,802 Posts

At my place of employment nurses can put in wound care orders and consult the wound care nurse. This is done under protocol. The rule is before doing any dressing change there must be an order. This doesn't always happen. Also, patients will come up from the OR with a dressing over a surgical incision sometimes the surgeons will put in wound care orders and sometimes they won't. If they want staff the change the dressing they will put in an order. Otherwise they'll do the dressing change themselves.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 42 years experience. 4 Articles; 20,908 Posts

Usually the rule is....unless stated by policy...you do not change an original surgical dressing without surgeon approval....or it fell off. Pressure ulcers are usually a would care nurse driven order entry....this varies by facility policy on how to initiate the call.

As with most else in nursing find the policy and procedure information and look up that facilities policy.

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience. 1,761 Posts

Maybe I should have been more specific. I am not talking about specialty dressings. I'm talking basic dressings like chest tube dressings, island dressings etc. those are changed every day. aqua cel dressings etc are left until due to be changed. I'm also not talking about pressure ulcers etc dressings or special wound care dressings that are seen/changed by wound care.

JessicaLedford

JessicaLedford

6 Posts

Thank you for the input. I have checked the NC board of nursing site, but wasn't easily able to find it. Obviously bandage changes are in the scope of practice, but not about orders/no orders. Not to say it isn't in there!

I did find that wound care nurses (specialization) can and do put bandage change orders in - but I haven't yet found out if they can do it independently (which means it is in scope, with the training) or if they are operating with an MD that technically is doing the orders... I had no idea figuring something out like this would be so tough! :)

JessicaLedford

JessicaLedford

6 Posts

Sun0408 - in what state do you practice?

JessicaLedford

JessicaLedford

6 Posts

Eseme - I searched on the intranet at the hospital where I'm in clinicals & found lots of protocols for bandage changes, but not an umbrella policy for bandage changes in general. Not to say it wasn't there, but I wasn't able to easily locate it.