New dermal nurse doesn't seem to know what she is doing!

letina · Aug 1, 2005

The treatment is tid and consists of removing the old packing and putting in new guaze. They are not flushing it or debriding it. The dressing over it is causing reddened skin from the adhesive.

tid seems excessive. Not surprising the skin is reddened from the trauma of removing adhesive tid. What is the wound being packed with?

If your colleague is open to suggestions, ask if she has considered using a hydrogel eg. Intrasite (to help debride) and an activated charcoal dressing eg. Carbonet, which would help reduce the malodour. This could then be changed just once daily.

ChangeAgent · Aug 2, 2005

"..... She is constantly locking all the treatment supplies in a locker that none of us has a key to. Some of our current wound patients are not healing as good as they did before she started.
By the way, the family of the patient above took care of her at home and said that "It has only been like that for a week." :angryfire

You raised some really points. Many facilities do not want to pay for someone certified. By the way there are some nurses out there practicing wound care without any training. More alarming - there are NP's doing the same. I dont believe in week long crash courses - or similiar programs without a practicum. I attended a graduate level course (one semester of wound and one semester of ostomy and continence). While I realize this is not an option for everyone - it is the standard.

Its interesting because I have seen the "dangerous" results of erroneous staging. When you Stage a wound - you are basically telling me (BTW an expert witness and LNC) that the wound is not infected - and also telling me that it is not a wound from a cutaneous manifestation of chronic disease. I have seen doctors mess that one up. Staging also gives clinicians a false sense of security - if I had a dollar for everytime I heard "its only a stage I or II" without takign into account the chronicity of the wound (Osteo) or colonization or infection. I feel that there is a component of diagnosis involved and therefore in the hospital within the role of an APN.

Legally I see your responsibility as no different than a doctor practicing incompetent medicine. If the doctor prescribes the wrong treatment you are obligated legally and ethically to intervene.

Remember patients families do not "see" the same thing we do when we examined the patient. In my practice I have doctors and staff nurses all the time not recognize the severity of a wound that gradually evolves. One successful approach is to make sure your facility documents a complete "naked" exam on any admissions. Some elder are incontinent and dont tell anyone and lie on admission assessments. This could be disastrous from a PR perspectice when in assisted living you are asking the family to bring in Depends two days after admission. I have witnessed some adult children do care - they stand in the door way of a bathroom, arm outstretched, with a wash cloth, and handing it to mom.

I recognize sometimes a wound that is likely stage IV but has not opened up yet. This is the reason if I see purple or dark discoloration I document "...likely Stage IV - presentation heralds a much more serious lesion."

dinkymouse · Aug 3, 2005

Change Agent-you have given me some good pointers, especially on admissions. I am going to recommend the products letina mentioned. It is funny how sometimes you instinctively know something. I admitted a resident once and notice many tiny sores on her hip. I seemed to know that it was much worse inside than out and yep, it was a stage 4 with the tendons and bone infection. We had started good care on them before they opened but I felt so sorry for her. Some nurses said that it was not painful for her to have the treatments, but to me it seemed like her moaning, pulling away and increased blood pressure meant she felt it. What do you give your pts. before tx's. :nurse:

ChangeAgent · Aug 3, 2005

Change Agent-you have given me some good pointers, especially on admissions. I am going to recommend the products letina mentioned. It is funny how sometimes you instinctively know something. I admitted a resident once and notice many tiny sores on her hip. I seemed to know that it was much worse inside than out and yep, it was a stage 4 with the tendons and bone infection. We had started good care on them before they opened but I felt so sorry for her. Some nurses said that it was not painful for her to have the treatments, but to me it seemed like her moaning, pulling away and increased blood pressure meant she felt it. What do you give your pts. before tx's.

Orals are fine if you can coordinate - or IV in hospital setting. It is very difficult - I understnd where the RNs come from in the hospital...With coordinating pain meds to wound care. Sometimes you are doing a linen change - perineal clean up and it is works out well to do wound care then.

In that situation you described - it does sound like pain. You are a good advocate.

dinkymouse · Aug 5, 2005

I watch the skin nurse do this treatment today. I am wondering if she should have cleaned it with something before putting the bandages back on. She soaked 4x4's in a liquid that begins with a d and plopped them back on without any type of cleaning. There is about a 6"x4" area of blackened skin over the buttocks at the top. Towards the bottom is open fleshy skin that is right at her rectum and around under her labia. When she changed the dressing the patient had just had a bm which was loose and I would be worried about ecoli or such. I asked her to pick a specific time she wanted to do the tx so we could medicate her before. She has an order for darvocet 1 hour before the tx but it's never given because we don't know when she is coming down. I helped her turn this patient today and I had to tell her we weren't going to turn her back on to the bed pad that had bm smears on it. She just tossed this lady around like she was a sack of potatoes. :angryfire I let her know that this patient wasn't comatose and had pain. I guess I am not the only staff who thinks she doesn't know what she is doing. I really want to thank you all for letting me rant. She keeps using paper tape which is causing more skin irritation and would have left some 2x2 attatched to her skin if I hadn't pulled it off. 2 of the wounds are looking well with granulation occuring.

UnderpaidNurse · May 5, 2006

As a soon to be LPN graduate, and most likely going to end up in a LTC facility, is there somewhere I can look to become educated in wound staging and management? While I wouldn't be considered a wound nurse, it would benefit me greatly when doing weekly/monthly skin assessments and give me a basis for some of that good old "critical thinking" they stress, in helping my patients. I live in NC (sorry, that might help in pointing me in the right direction).

Thank you