what would you have done

[nursegreenbean]

I am a new nurse I work part-time float PRN any shift. When getting report I was told that all charting and treatments were done. When we were going over the residents I was told that rsdt. x was fine. About 1 hour before my shift was up the aide asked me to come look at rsdt x's bottom that there was an open area that was bleeding. I found a pressure ulcer about the size of my palm on the coccyx area with minimal bleeding. I asked the aide if she took any bandages off of it and she said there was none on it. I checked the tx book and the only tx for it said " apply silvercell". It didnt say to clean it with anything or to apply a dry dressing. It was only to be changed on one shift which was the next shift in 1 hour. I wasnt sure what to think so I tried asking another nurse but the nurse was to busy to help. I decided to hold off doing anything since the order did not seem complete and i knew the nurse taking over for me wrote the order so that nurse would know why it was written that way and it was due to be done on that shift. i explained all this to the aide. What I forgot to do which I will be the first to admit I should have was ask about it in shift report. The next day when getting report from the off going nurse I asked about the tx and was told they new nothing about it but it didnt sound right to them either so i made a note to ask the nurse when i gave report bc it was again the same nurse who wrote the order. when giving report that evening i was not given the chance to ask. The oncoming nurse asked the aide if rsdt x had a bandage on that it was ridiculous that the rsdt had been left without 1 the night bf. Now we all new the comment was directed at me. I explained myself and was told that the order didnt come from the WCC and that is why it wasnt detailed that it was just common sense to clean with NS and apply a dry bandage. Now if I had wrote the order I would have wrote all the details bc to me that is common sense but i didnt write it and that is not how it was written. I didnt know if there could have been a reason that they werent putting a dressing on it like location. But again I was told that it was absolutely ridiculous of me. So i was wondering what some of you would have done.

[CT Pixie, BSN, RN]

To the OP, I would have cleaned the wound with NSS, put on the ordered cream/ointment and then covered it by putting a clean dry dressing on it (most likely a gauze). I'd get that patient off their bottom and make sure that T&P was being done. And then charted the info about the wound (size, area, treatment done etc).

In my facility unless specifically stated, all wounds are covered with something..be it a clean gauze or op site, or whatever best suits the area/wound. All our docs will state specifically leave open to air or do not cover if they don't want it covered. I can't recall any recent ones that were left to air.

[CapeCodMermaid, RN]

There is no way a nurse in LTC would be able to do a head to toe skin assessment on every resident. That's why the C.N.A.s are SO important. They'll see most of everyone's skin every shift. Rely on them to tell you if someone has a skin issue. I would have covered the wound and then I would have called the MD for a more specific order.

[jesskidding, LPN]

There is no way a nurse in LTC would be able to do a head to toe skin assessment on every resident. That's why the C.N.A.s are SO important. They'll see most of everyone's skin every shift. Rely on them to tell you if someone has a skin issue. I would have covered the wound and then I would have called the MD for a more specific order.

I agree with you, but I wouldn't trust every CNA to inspect each pt or resident thoroughly. They are not trained to do that, at least not here in NC. I am currently a CNA and in nursing school, but if I was the RN, I would rather see each patient for myself rather than relying on what a CNA did or did not notice.

That said, I have never worked LTC only acute care so I have no idea on how assessments are performed in LTC.

[LoveMyBugs, BSN, CNA, RN]

The OP didn't state that she was in LTC, but yes in LTC you don't do skin assessments every shift, they are done every week and the CNAs need to alert to new skin issues.

If the OP is in a LTC you should have some kind of standing orders for wounds.

What did you need clarfication on for the wound? How to clean it?

Well there is usually NS or wound cleanser, the order read for applying cream before.. so had the wound changed to where it is now open? Usually applying cream is for intact skin, so now the wound is open therefore it needs a bandage over it and you should have looked in the chart for the intial assessment of the wound to see if it was intact and it had changed.

However open skin is risk for infection, and would need to be cleaned and covered.

[I<3Nursing]

Everyone has provided excellent feedback on what to do next time. I would agree that if you didn't feel comfortable with the order clarification is necessary. Another issue that needs addressed is the order that was written ineffectively, and not appropriately passed in report. Policies for orders in addition to what is routinely discussed in report need to be addressed. The event has passed, learn from it :) and fix it so it doesn't happen to another nurse and another patient again. I give you props for owning the issue, I hate making mistakes, but the pressures of being a nurse sometimes cloud our judgement. I bet it won't happen again.

[xtxrn, ASN, RN]

The term "resident" means LTC to me...hospitals hardly keep them long enough to be 'drive-thru customers' . LTC nurses don't do full assessments on every resident every shift. On SNF/Rehab- there are better assessments.... but that's not there in the op either.

Where I've worked, yes- we needed orders. Specific, including "until healed", or the state can actually ding a facility for not doing a treatment on an area (even if healed) if the order has not been officially d/c'd. Stupid- but that's the way it is (at least in TX and IL).

If the doc for the resident had predictable orders, I probably would have put something on the resident and either faxed or called for clarification myself. I'll take the ding for putting on a dressing /ointment (and many stage 1-IIs can be treated with SOME barrier creams that don't need a rx-- still need an ongoing order, and report the decub- but in a pinch, an OTC is better than nothing). JMO.

[NoviceRN10]

I would have cleaned and dressed the wound and then clarified the order. Of course the previous nurse should have done the same thing .

[Altra, BSN, RN]

The OP states that there was an order to apply silvercel and that it was to be changed (daily?) by a certain shift. If the resident was found without the silvercel in place then the treatment plan was not being carried out.

The presence of the order indicates to me that the OP & CNA were not the first to observe/assess the resident's wound.

OP, it is a basic nursing measure to clean a wound during a dressing change. Now you know.

And while care of chronic wounds is not my specialty, it appears that silvercel is a self-contained dressing, so I'm not quite understanding the part of the thread discussing what to "cover" the silvercel with ... although it's never "wrong" to cover anything with gauze if it suits your preference, unless there are orders to the contrary. http://www.woundcareshop.com/SilvercelAlginate.aspx

Edited to add/clarify: OP, I wonder if that was what the CNA was trying to communicate to you -- that s/he found the resident without the ordered dressing on his/her wound. Also, it would probably have been better for you to go ahead and apply the silvercel while you were with the resident, and just pass on in report that you just changed it so it wouldn't need to be done by the next shift.

[CoffeeRTC, BSN, RN]

Yes...orders in LTC need to be specific and when I do change over or see these incorect orders I fix them with a verbal order/ fax to the doc.

Treatment orders for LTC need to indicate where the wound is, what to cleanse with, if there is a primary dressing..what that is, then the secondary dressing or cover and how to secure it. It should also state how often to change.

Sooo...for this dressing in question...I would think it should be something like this...

Cleanse stage 2 to coccyx with NSS, apply sivercell (we use aquacell Ag) cover with replicare and chage q 3rd day and prn.

This is our standard dressing. Since it only said sivercell..It would have been a guess as to what to do with it or how to cover that...this shouldn't be a guess and I'm willing to assume that you didn't get this in orientation?

[nursegreenbean]

Thank you for all your answers it has given me alot to think about. Special thanks to Michelle 126 I think you understand where I am coming from. LTC with 30 residents no head to toe assessment done daily. NO standing orders. Could not find a P&P book. On this shift there is no charge nurse.This was a 4 hour shift my aide was doing her job which was a q2h check and change when the area was noted. The resident was clean/dry and put on her side to relieve pressure. Since i was questioning the order and was limited on resourses The next best thing was to ask another nurse who was to busy to help which I dont hold against her. Yes I know all wounds are cleansed with someting normally normal saline. If they use silver cell in that facilty they usually cover with some type of dry dressing. This praticular residents family is very involved and particular. The nurse who wrote the order is an RN of 20+ years and I am a new nurse. I have done treatments at this facility before but they were "complete" orders so this one I questioned that maybe they could have wanted it open to air because it did not say otherwise. And we found the resident with no dressing on. Like i said I am also PRN so if they don't tell me in report and something like this comes up it is sometimes harder for me to figure out.I tried to use my critical thinking there was no order for a dressing and there was no dressing on the area so does that mean not to apply one. It was 10 pm and did not seem like something the doctor wound want called about. I do wish I had remembered to bring it up in report then the issue would have been taken care of the 1st night. Now i know that everyone is human and we've all forgotten to tell something in report at sometime. I don't remember 1 time saying I was annoyed. I only asked so that I can learn. My abbreviations are standard that I learned in nursing school I am sorry if you did not learn the same ones :) I didn't get orientation with the wound nurse and since hired we no longer have a wound nurse we do it ourselves. Thanks again

[nursegreenbean]

P.S. even though I was not annoyed I do not think it was professional for the other nurse to speak to me in that way and to involve an aide. The nurse is experienced and I am new it was definetly a teaching moment. If new nurses can't depend on the seasoned nurses for help and for them to do it nicely then where do we go. Maybe that is why so many new nurses quit in their 1st year. Telling me it was ridiculous and common sense only knocked me down a few notches maybe an explanation into the right way to do it with the whys and hows would have taught me something and I could have been better prepared. But instead I turned to all of you to teach me. Many big thanks :tku:

[maelstrom143]

[...] This was a 4 hour shift my aide was doing her job which was a q2h check and change when the area was noted. The resident was clean/dry and put on her side to relieve pressure.[...]

4h shift? Wow...that is barely enough time to catch your breath:eek:

Sorry. I did not understand the finite time you had to work with. Definitely makes it harder to deal w/some stuff. Even 5min check x 40 patients = 200 min...by that time your shift is almost over...yikes!!!