New grad question re wound care order

[skyvortex01]

Although home care is not the ideal first job for a new grad, it was the only one i was offered so I was wondering if some of you seasoned home care nurses could answer some of my questions.

Today, for example, the visiting dr saw a pt that has a 0.5in x 0.5in x 0.25 in wound on his lateral malleolus. His (first) primary care dr said that it was a venous stasis ulcer and to just put bacitracin and leave OTA. THen the visiting dr took over and said that it's cellulitis and ordered Keflex po, a wound care nurse, and a wound care specialist. I asked him if he wanted me to put anything on the wound and he just said to have a wound care nurse see the pt and treat. Am I missing something? Does the wound care nurse make decisions on her own as to what should be put on the wound, dressing-wise? Also, don't primary care dr's treat wounds like this also? I'm just wondering if he was just trying to pass off the responsibility to someone else, when he could have taken care of it himself. I feel a little bit guilty since I'm the one that referred the pt to this dr after the family asked me if I could find them a visiting dr.

Anyway, it's times like this that I honestly wish I was in a hospital setting with a nurse by me, where I can just ask her questions. I did notify the dir of nursing and told her of the situation. She said that as a home care nurse, I am also a "wound care nurse" and that I can see the pt. But I asked her if she can go out to see the pt, to placate the dr that a wound care nurse was there to see the pt. (She has more experience than me with wound care but she's not a certified wound care nurse). Apparently she just used nursing judgement and placed a hydogel dressing on it.

Thanks for your thoughts, comments.

PS-Do a lot of private home care agencies have certified wound care nurses? I'm assuming that majority of the home care agencies affiliated with hospitals have them..

[luvmy2angels]

I work for a decent size home health agency and we are affiliated with one of the local hospitals. We have about 40 nurses (RNs and LPNs) that are our "field staff" (the nurses that are going out and doing the visits). Out of that we have only one certified wound nurse. We are all on the same team and are all consindered wound nurses since the majority of our work involves taking care of wounds. If we have a wound that is not healing or we just aren't sure what we should be doing we call the wound nurse and have her go out, she can make suggestions and call them into the Dr, but we still need to obtain that Dr's order for the treatment. I have taken care of many status ulcers and have never seen an order to use bacitracin. Good luck, sounds like a confusing situation.

[NRSKarenRN, BSN, RN]

one of nursing's best kept secrets is while attending physicians in a hospital setting will ignore nurses advice, primary care physicians often request homecare rn's to "eval and recommend treatment" for wounds as we deal with them daily in our practice. "you know more than i do" is frequent comment from pcp's who call my intake department with wound care requests.

our free-staning nonprofit homecare agency has standing protocols based on diagnosis and wound characteristics/staging that we recommend all the time to physicians after eval visit --docs will sign verbal orders discussed with them. we send cetn for complex wounds, those not healing after 4-6 weeks and upon pcp request. admit rn will make initial recommendation, the cetn chimes in with their expertise with visit within 1-2wks of soc. occasionally, cetn may recommend followup at one of our area wound care centers for further diagnostic testing/physician review.

last year our agency purchased camera's so all complex wounds, stage 3-4 and those non-healing can be photographed, digitally linked to chart and cetn's review online ---aids in knowing which patients are priority to be seen when you have a 4,000 patient census.

see the resources under our wound, ostomy, and continence forum to learn more about wound care. as a new rn, i would request to spend a day with your cetn to gain skills and confidence in caring for patients.

[skyvortex01]

Thank you for your comments. NRSKarenRN, I did checked out the wound, ostomy, continence forum and found it very helpful. Love your posts:) Also, I would love to shadow a CETN nurse but our agency is fairly small and we don't have one on staff. But it did give me the idea of asking a local hospital if they will let me shadow one of their CETN nurses for a day. Any other suggestions on how to expand my knowledge/skill base are welcome.