Frustrated

[sillyang]

I am frustrated at work. I have a co-worker that gives me the impression that she believes she knows everything, and is supperior to everyone else (I think she can even smell when a doctor is present). background info is she assists the wound nurse sometimes in the clinic. I have a patient that has a resolved by scar tissue stage III ischial tuberosity pressure wound. The patient has become weak through the long healing process. The patient has been working on transfers with PT (oh yea parapalegic) and the inadequate strength and shear has created one intact bullae and one that ruptured each 1cm diameter. I am not a wound nurse yet but I am currently in school for certification. I called and got an order to cover area with tegaderm, rational being it will keep a proper moist wound healing environment, provide protection/skin barrier and will be easy to visibly monitor. I applied dressing, had 2 days off and return to a patient with a 3 cm long 1.5 cm wide denuded area on the ischial PU scar. My frustrating co-worker had the order changed to butt paste. I was irritated because the patient has had a long road of healing and didn't need this set back. I called the doc explained the wound and asked what dressing he wanted. Once again I write an order for tegaderm. Over the next couple of days the wound made visible progress, smaller. The patient was then moved from my hall to make room for a new patient. The same day as the patients move my frustrating friend changed the order back to butt paste. I know I can be critical of Ms. Frustrating because there seems to be a personality conflict but come on. The second order for butt paste was written to be applied before patient is up in chair and leave wound OTA while in bed. That would just create a bigger wound from washing the butt paste off. I have seen Ms. Frustrating do similar things to other nurses. How do you deal with a person who needs to be so important? Or is it just me and I should shut up and just go to work.

[Asystole RN]

Is this the same Doc changing the orders back and forth?

Sometimes when there are conflicts with orders I have the primary Doc write an order and specify not to have it changed without notifying him personally.

[sillyang]

It is the same doc. He is the house doc too. I'm not sure she is calling for the order.

[JBudd, MSN]

Is she writing the order in his name? or under her own authority as a wound nurse (although I thought you said she just assisted sometimes)?

Get the doc involved if she is writing false orders in his name, this is a matter for your BON and your facility's ethics committee.

Have you spoken to the wound nurse directly? What does she recommend?

[sillyang]

Ms. frustrating is good buddies with the wound nurse yet she is not wound nurse. I did ask the wound nurse in general if she thought tegaderm was appropriate for an area of denuded skin with minimal exudate and she did agree that it was acceptable. The wound nurse is not highly regarded at work because she acts like she is a doc and talks down to everyone. I can't prove that Ms. frustrating is writing orders under the doc's name without a verbal order but i have witnessed stranger things.

[opensesame]

I am not a CWOCN but I have sat on my hospital-wide skincare committee for 6 years.

It is my understanding that Tegaderm is generally not used anymore even for small, superficial wounds, with the rationale being that when the dressing is removed, any healing skin is ripped off with the dressing. The adhesive on the Tegaderm can also cause damage to intact, fragile skin on it's own. It has been a few years since my hospital has completely stopped using Tegaderm for superficial wounds like shear injuries and ruptured bullae (as was your problem.) We now use a petroleum-based barrier cream -- probably similar to your "butt paste."

I have a feeling that "Ms. frustrating" is just as frustrated with you as you are with her, because I think you are doing the wrong thing, actually, and she is trying to correct you.

[csadam]

Second that, I completley agree with PP.

[hcox1975, BSN, RN]

I think the issue here is that this other nurse is trying to show some superiority and seeing how you would react. Her intentions are not based on the patient's care, they are based on power.

Either way, if she thinks the butt paste is better, and she sees you changing the order, she needs to come to you and tell you the rationale behind her using the butt paste.

The whole point here is the way the other nurse is handling the situation, not focusing on patient care.

[opensesame]

The whole point here is the way the other nurse is handling the situation

But didn't the OP do exactly what "Ms. Frustrating" did? It sounds to me like she went behind her and had the order changed back. Looks to me like she is handling it exactly the same way.

If that is the case, I'm not sure what OP is complaining about.

Is this not just a turf war?

[sillyang]

Not a turf war, I actually care about the end results of my patient. I considered leaving her order the first time because I really try not to play a part in the catty part of nursing. The wound was obviously worse, I didn't make the call I left that for the physician, I asked what dressing he would suggest. It has been stated in this thread that the tegaderm was the wrong tx. I can accept feedback. Butt paste is a zinc paste which is hard to remove and makes the wound difficult to assess on a regular basis, doesn't provide protection either, the tegaderm did show effective results right or wrong, I'm just learning.

[tyvin, BSN, RN]

You should have left it alone for the patients sake IMO. It is common practice for nurses to be able to write wound orders per a docs standing orders or even if they have a close relationship with the doc and the doc is OK with signing the orders later. Having said that I agree that the tegaderm is not the best wound treatment.

I am not wound certified but I have done many, many SCI patient assessments and advice for treatment of these types. Has your facility ever looked into or has any patients do NPWT aka wound vac? Promising results whenever I've seen or got an order for it.

[Tait, MSN, RN]

Maybe you just need to talk to the other nurse and discuss her rationale for the cream vs tegaderm?