CWOCN

Sometimes wounds do okay and heal in spite of what we do to them. Using the principles of wound management, removing or controlling the cause of the wound or it's failure to heal is key. If an infection has causes the wound to dehisce, then I suspect the person may be doing okay because of antibiotic therapy. Why could you not put a wound VAC on this wound? That would be standard and would probably speed up the discharge from the hospital. Who will be doing BID dressings at home? Is this practical for this patient? A longer acting absorbent dressing that will wick off drainage, provide a moist environment, and protect the wound is what you want to see in a dressing. The AHCPR (AHRQ) guidelines state on page 53 that wet to dry is not a continuously moist dressing, and that is what a wound really needs to heal. Perhaps a wound gel if the bed is clean will let the wet to dry gauze last a bit longer. Every 4-6 hours for a wet to dry dressing is really ideal if you must do a wet to dry. Let's not forget the original intent of the wet to dry...Debridement. If the wound is clean and granular, then wet to dry is really not the best clinical practice.

I'd check page 52 of the AHCPR (now AHRQ) guidelines for the treatment of pressure ulcers. The evidence-based research is in there. This really isn't new information, though. Dr. Winter did his research in the early 60's to show that W-D isn't the best for wound healing. Medicare recognizes that it delays healing, and if we have a pateint who comes in for hyperbarics, or even a VAC, we have to make sure that the wound care they had the last thirty days was "appropriate", and w-d isn't considered the best clinical standard. There is also a good article on the difference of opinion between practitioners who order wet to dry, and the nurses who do the care---they don't agree on what the definition of a w-d is!!! Please remember also that in any nursing book, the ONLY indication a wet to dry is listed as used for is one that requires debridement. If you have a clean granular wound, that is not an appropriate choice. Think of getting a book on wound care that indicates what each dressing is for and how to use it. It is like a drug book for dressings. Remember that the clinician who performs the wound care is responsible for the wound care done...with or without a doctor's order.

Dressing choices should be based on drainage--the amount and character. How well is the dressing supporting the wound? How much drainage is left on the dressing you just took off? You want a moist healing environment, you want the wound to be clean. Wounds want to be clean, moist, protected. Know the different dressing categories, what they are for and go from there. I agree that there should be some protocol for the wound care that is being done. It should not be left to anyone's whim. Try Cathy Thomas Hess book Wound Care. It gives an overview of the product categories, trade names, what they do, etc. That should be a good start.

Any accreditted program is going to take lots of time and energy...and those health requirement/form things...but it is really worth the effort. Have you tried http://www.igateway.com/clients/weai/homestudy.htm Wicks? Might be more do-able for you....I did mine by going away from home for two whole months in Texas...Would have probably considered this had I known, but there were no available preceptors for me here at home, so I was stuck anyway. Lots of great experience with different conditions, wounds, devices, styles with a program at a major medical center. I saw things I'll probably never see again, but will be able to say I did if I do...Make sense? Good Luck. Michelle

I don't know exactly how she did it, but a co-worker started working for an agency who actually got 16 visits in a day...She was paid per visit...probably didn't have to cover much geography. The way I see it, we all like to sit and chat and "be there" for our lonely clients. I have been advised to get down to business, make it very clear what the goals for the visit are, stick to a time limit, and simply indicate that the instruction will be continued at the next visit, and Bye-Bye... Without lowering your standards, I do believe there are some things that can be eliminated in the visit. Don't set yourself or the visiting nurse up for failure by writing things into the treatment plan that aren't necessary at every visit. DO vital signs need to be done at EVERY visit? If we are worried about BP, take that. If a wound, take the temp. Meet the goals, tell the patient where you will pick up at the next visit, stick with the plan, make it simple. Of course there are always things that are new that will be a real time-suck for you, but these things have helped me manage my time a little better. Can't help you on the OASIS time frame--that's always a given for me...

Are you certain this was a venous wound and not an arterial wound? We usually don't see venous wounds down past the ankles. If her arterial circulation is compromised, I'd be very careful with the w-d thing. I would choose an antimicrobial barrier ointment to be applied and keep the bed moist. If you are debriding a wound with necrotic (yellow or black) tissue, w-d can work, though it is very non-selective (takes off the good and the bad), and can be dangerous if there is a vessel close by. Look at the goals for a 90 plus year old woman. There is a chance that if her circulation is crummy, she may NEVER heal. That may be, but your job is to keep her out of infection...hope this helps. Michelle, RN CWOCN

Need to know if condom caths are considered under medicare bundle as a routine supply, or if they are incontinent supplies...and patient should purchase...I know I should know this...any help would be appreciated...Thanks:rolleyes: