Post-op amputation dressing changes *LONG!*

[detroitdano]

I had a new experience today at work. Currently I'm a nurse extern and graduate in 2 months and have been at my job for 22 months. Today was the first time I had to take a fresh surgical dressing off a patient to do an assessment and things got chaotic.

I had a patient who had just come back from the OR after having 4 toes on his foot amputated. His initial assessment he told me his foot didn't hurt, his exposed big toe had capillary refill, he could move it, nothing seemed funky. About an hour later his son comes and finds me and says he is complaining of really severe pain in his foot. This was about 3 or 4 hours after finishing his surgery.

Of course a surgical procedure like that is going to hurt, but I wanted to make sure he had no other complications and had a good pulse in that foot. The surgeons bandaged his foot all the way to about 6" above his ankle so I couldn't check anything. I made a judgment call and took the bandage off figuring the wound would be packed and I could just replace the outer Kerlix. I didn't need to see the wound, just get to his foot to assess it.

I took the bandage off and someone packed his wound with the same Kerlix they used to wrap around his foot. This left me with a handful of Kerlix and I sure as heck wasn't going to unpack the Kerlix from the wound. Part of the wound was exposed. One of the floor interns was outside his room charting so I told him I had to unwrap it and he said the dressing is supposed to be on for 24 hours and surgery is supposed to do the first dressing change. He said it with a very concerned voice like I had just killed my patient. I usually do leave surgical dressings untouched for 24 hours post-op, but I've never had a dressing so overdone that the extremity was unable to be assessed properly.

I cut off the Kerlix that wasn't packed into the wound and the intern put some gauze sponges on top of the packed part of the wound, wet-to-dry, and rewrapped his foot with only one roll of Kerlix instead of three like surgery had done. He left part of his foot open so we could at least see/feel it. There weren't any immediate complications and it was barely bleeding at all throughout the dressing change. His foot had a good pulse and there wasn't any extreme edema to note.

I covered my butt and wrote a note saying I had to unwrap the foot due to the inability to assess it and that the MD redressed it.

The intern and I had a talk and he said he wasn't all that ticked I did it but that it's standard to not change a dressing for 24 hours. I asked a few nurses for feedback on this and got mixed opinions. A few said they'd have left it alone and assumed it was just pain, gave him something IV and kept an eye on him. Others agreed with me and said I was right in unwrapping it to do a good assessment since I was being cognisant of post-op complications like compartment syndrome.

Am I to accept that it's "standard protocol" to leave a foot totally bandaged in Kerlix for 24 hours with no way of assessing any part of it besides a toe? I had a general feeling from some nurses today that it was one of those "it's the way we've always done it" things without any real rationale for why you neglect a thorough inspection for an entire day. There was an order for qDay wet-to-dry changes but it did not distinctly say to leave it untouched for 24 hours so I wasn't going against any orders per se.

Sorry for the long post but I really want to hear some feedback from people who have dealt with such situations in the past. Was I right? Was I wrong? Is there any actual evidence-based rationale for why you'd leave the foot covered up for an entire day without assessing anything besides a toe? I agree that the patient was fine without me going through all that. Yet he could have been in that small percentage of the patient population who has a severe complication and me going beyond just leaving the dressing on (because that's the "usual way of doing things") could have caught something very important.

[iluvivt, BSN, RN]

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]

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]

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]

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

[detroitdano]

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]

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]

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]

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]

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]

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]

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: