D.O.N. tells me NOT to describe wound???

[nervousnurse]

Yeaaa, I know what you're thinking...WHAT??? I charted a resident's two Stage III decubiti like this: "previous dressing saturated and seeping. Drainage is yellow tinged with red with mild odor".....then continued with the cleaning, treatments, new dressing, blah blah blah.

Couple days later, D.O.N. tells me "you don't need to say the old dressings were "SATURATED" and you don't need to DESCRIBE the drainage....just chart "dressing changed".

My reply: "ummm, with all due respect, isn't part of nursing DESCRIBING what we see thoro

ughly....I HAVE to say what the drainage looks and smells like!"

And, if you feel like reading even MORE ridiculousness, the Full-Time wound nurse also questioned me giving this resident 0.5 ml of Roxanol before these HORRIFIC dressing changes!?!?! The res. is on hospice, and has NEVER been given the Roxanol before....Upon noticing her facial grimacing, tears, and (she can barely speak), saying "You're HURTING ME", I decided that the scheduled ONE Lortab she gets Q 6 hours was obviously NOT covering her for the pain of these dressing changes! (Ya THINK?!!??!)

And, she has more than just the two Stage IIIs to each ankle......horrible wounds. Wound Nurse says "I just make sure and do the dressings soon after she gets her Lortab".....Well, so did I, and she's crying and whispering that I was HURTING her....

Many other nurses I work with are anti-Roxanol because "Hospice is just trying to kill them off"......The ONLY order I could find from hospice was giving it for "Air Hunger".....I asked my DON if I could clarify the order and add "and/or for PAIN" without having to call this snobby Hospica company or the doc, and she said yes....( I had to be SURE that was okay, cuz God forbid I use my brain and just give it before I cleanse her and treat 2 cm deep wounds!!!)

Well, like I said, she NEVER gets it except when I do her dressing changes. Only TWO of my coworkers agree that she should get the Roxanol before these dressing changes, and one of them said "Ummm....if this resident was MY Mom, I'd WISH you were her treatment nurse!"

Looking forward to hearing what y'all think....thanks!

[amoLucia]

Many times the way that the floor nurses chart wounds messes up the MDS for the patient. The facilities where my wife has been the MDS they usually just have the wound nurse, or a designated nurse, chart on the wound in a prescribed manner. That way the terminology and method for wound assessments stays the same. Things can get real messy when 10 nurses chart different things on the same wound.

This is what I was trying to say. Just ONE well-versed description for documentation purposes. Continuity without variations.

[wyogypsy, RN]

Good for you for giving the Roxanol. Yes you should describe what you see. I describe the dressing and wound, I just don't use what Stage it is as I am not a wound care nurse so rarely use the Stages, I would rather just document what I observe. The only thing different we did in hospice is that the wound care was more to maintain the wound than to heal it, as the pt was already on hospice care and healing the wound was not the priority, but giving good wound care was important to prevent infection and hopefully not let the wound get worse.