Post-op amputation dressing changes LONG!

iluvivt, BSN, RN · Mar 12, 2009

Well you can bet on the fact that if something went wrong you would get blamed....I think I would have removed enough of it so I could assess the CSM as well. The order did not say leave in place for 24 hours and if it did I would have called the surgeon and got an order to remove it or ask him or her to come in and take it down b/c your patient had a complaint that you needed to investigate.

lpnflorida · Mar 12, 2009

I believe you did what you felt what in the best interest of your patient. Would I have done the same? Most likely no, I would have called the doctor first letting him know what my concerns were. Then followed what ever further orders he gave me.

We have a doctor who routinely orders no dressings are to be changed by anyone , but him. This goes on for weeks. He comes daily does his own dressing changes. We always try and make sure to be in the room when he does it, so that we can see what the site looks like. He is a specialist who's patients pretty much were poor candidates to start with. No one touches those dressings. Amazingly his outcomes are fantastic. He has less infection rates than most surgeons. We document what we see, what the patients says, then the infamous "surgical site unobserved per doctors orders" if we were not in the room at the time he changes the dressing. Or we document it was changed by the document and to refer to progress notes for further description.

Blee O'Myacin, BSN, RN · Mar 12, 2009

That soon after surgery, I would have checked cap refill, given pain meds as ordered and paged surgery to come and assess the patient. What did the primary nurse think about this situation, out of curiosity? I realize that you were acting with your patient's best interest at heart, but there is a reason why surgery does the first dressing change. The surgeon or surgical resident could have determined whether or not the patient's condition warranted risking infection disturbing a sterile dressing so soon after the surgery, and either had you do the change or came up to assess the patient due to a potential complication.

Take Care,

Blee

CoffeeRTC, BSN, RN · Mar 12, 2009

Haven't done acute care in yrs, but I go along with Blee's post.

detroitdano · Mar 12, 2009

I believe you did what you felt what in the best interest of your patient. Would I have done the same? Most likely no, I would have called the doctor first letting him know what my concerns were. Then followed what ever further orders he gave me.

I absolutely agree that calling the doctor first would have been a better choice in the end, but I did not anticipate exposing the wound site, that was a complication of the poor way it was dressed. You don't need a doctor's permission to assess a foot so had it been wrapped properly I'd never have exposed the wound and the doc wouldn't have to get involved at all. If I knew I would have had to expose it I would have called the doctor and said it would involve exposing the wound and what he would like me to do, 100% for certain.

That soon after surgery I would have checked cap refill, given pain meds as ordered and paged surgery to come and assess the patient. What did the primary nurse think about this situation, out of curiosity? I realize that you were acting with your patient's best interest at heart, but there is a reason why surgery does the first dressing change. The surgeon or surgical resident could have determined whether or not the patient's condition warranted risking infection disturbing a sterile dressing so soon after the surgery, and either had you do the change or came up to assess the patient due to a potential complication.[/quote']
My primary nurse agreed with my action and said I was right in looking at it. I didn't consult her first before unwrapping the foot, as like I've said before, I did not intend on exposing the wound. I know I need permission to get that involved in something. I immediately alerted her to it after having the wound rewrapped since I didn't want to leave it open to room air for any longer than necessary.
Surgery was not going to do the first dressing, or at least it was not specified anywhere for it to be left alone for surgery to do the first change. There were standing orders from surgery for the nursing staff to do wet-to-dry dressing changes the next day. Surgery actually came by later on in the shift after this incident and looked at his toe and dressing and said he looked good and never mentioned anything about my note at all to us.
It does make sense when you say the surgeon can decide if it's worth the risk to disturb a sterile dressing but this would not have been an issue had the surgeon wrapped it properly like every other toe amputation patient I've had for the past 2 years. I don't find myself fully at fault for the complications that took place in assessing his foot thanks to the poor dressing.
I spoke with my clinical nurse specialist on my unit today and she said if it comes up as an issue in the future she will defend my decision and believes I made the right call going about it as I did, and that I went in not knowing the wound would be exposed to air as a complication. That made me feel better as she is a Master's-prepared nurse with decades of experience who is on our unit to give advice and guide our care. I felt my blood pressure drop after talking with her. :chuckle
She also agreed that it's an extremely double sided situation. Had I opened the dressing and he had severe compartmental syndrome everyone would have been praising me for good patient care and helping the surgeons to catch an early complication, but instead he was fine and I got lectured for it.

Virgo_RN, BSN, RN · Mar 12, 2009

If the great toe had good cap refill and was pink, warm, and dry, the patient could wiggle it and had no numbness/tingling, and the dressing didn't appear to be overly tight, I'd have given the pain meds, elevated the extremity, and left the dressing alone.

detroitdano · Mar 12, 2009

If the great toe had good cap refill and was pink, warm, and dry, the patient could wiggle it and had no numbness/tingling, and the dressing didn't appear to be overly tight, I'd have given the pain meds and left the dressing alone.

It was cooler than on my previous assessment and he said he couldn't feel it as much as before. If he had said "Dude, my foot hurts" without any change in condition and without the facial grimacing I'd probably have just asked my RN to give him some pain meds after a quick once over but things changed and I made my move.

Virgo_RN, BSN, RN · Mar 12, 2009

One of the s/s of compartment syndrome is that the pain does not go away with pain meds, so giving a fast acting pain med and evaluating the response would have been one of my initial nursing interventions.

detroitdano · Mar 12, 2009

One of the s/s of compartment syndrome is that the pain does not go away with pain meds, so giving a fast acting pain med and evaluating the response would have been one of my initial nursing interventions.

Very good point indeed, definitely a fact I'll never forget.

Virgo_RN, BSN, RN · Mar 12, 2009

I think you meant well, and that should count for something. But I can also see how disturbing a dressing that soon after surgery would be frowned upon due to the risk of infection.

detroitdano · Mar 12, 2009

I think you meant well, and that should count for something. But I can also see how disturbing a dressing that soon after surgery would be frowned upon. Live and learn, right?

Of course. If I had just asked my RN to give pain meds I'd never have encountered this situation in its full extent and learned from it. :wink2:

Post-op amputation dressing changes *LONG!*

Post-op amputation dressing changes LONG!