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.
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:
I wouldn't go that far. Asking the RN to give pain meds, then assessing the patient's response while also monitoring the status of the extremity would have taught you a lot as well, without potentially causing an infection to a fresh surgical would by disturbing the dressing.
I understand your intentions were good, and that your rationale was to be able to visualize the foot in order to assess it and palpate a pulse. There are a lot of catch 22s in nursing and often you have to think through and figure out which course of action is least likely to result in harm to the patient.
Virgo_RN, BSN, RN
3,543 Posts
I wouldn't go that far. Asking the RN to give pain meds, then assessing the patient's response while also monitoring the status of the extremity would have taught you a lot as well, without potentially causing an infection to a fresh surgical would by disturbing the dressing.
I understand your intentions were good, and that your rationale was to be able to visualize the foot in order to assess it and palpate a pulse. There are a lot of catch 22s in nursing and often you have to think through and figure out which course of action is least likely to result in harm to the patient.