carl5480

1)__ Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)? *Yes 2)__ Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work? *Yes; average to large-sized hospital with a level 1 trauma center 3)__ What concerns do you have about the flu vaccine? *None, other than the lack of knowledge some people have regarding the safety and efficacy of it (and how people believe it "gave" them the flu) 4)__ Do you know of anyone who has been released from their job because they did not get the flu vaccine? *No

So you're saying as long as you identify yourself as a scribe or the equivalent it should be fine? Would that not need to be sanctioned by superiors? It is my understanding that dictation and transcription is performed by people who have been trained in that role and who are covered for the practice under their job description.

There is currently a difference of opinion in my office, so I'd like to get a few outside opinions if I could. I work within the wound care department in my hospital. One of my coworkers is currently on light duty a therefore is unable, per our boss, to be in a patient room in a direct care role (it's liability issue for the hospital). In order to try to be helpful, she has made an arrangement with some of our prn nurses that they will see their assigned patients and do the hands-on work while she will document on the patients. To me this is a very dangerous situation. I feel that it is not only unethical to document an assessment on a patient you have not actually assessed, but it is also opening yourself (and the hospital) up for legal repercussions should any litigation occur. To be honest, it feels as if this is medical fraud - documenting that you saw, evaluated, and changed dressings on patients when you, in fact, did not. Am I over-reacting to this? I know it is a somewhat common practice for, say, a physician to state that he examined the patient when in reality he only stood a few feet inside the door so he could say three sentences to the patient before leaving. Still, that does not make it right. When this issue was brought up prior to my co-worker's return, it was my understanding that our boss told her that she should not be documenting assessments. I have not heard of any change since that time. And a final thought: what if my co-worker documented the assessment, and then in the comment box at the bottom stated "the patient was evaluated by Jane Doe, RN." Would that be considered okay since she is acknowledging another nurse was actually evaluating the patient? Or would that be a bad move as it flags the chart for inappropriate or unprofessional behavior? What if the nurse who actually saw the patient typed out a small note that said "I reviewed the documentation by Nancy Nurse, RN, CWOCN and agree," similar to how the documentation of nursing students is signed off? (I'm still not comfortable with that, as at least in that scenario the student nurse physically performed the assessment). Any thoughts on the issue are appreciated. Thanks!

My first personal experience with ACA: Patient X has "Obamacare" insurance. There are two major hospital systems in my area - one does not accept the pt.'s new insurance, the other does but refuses him outpatient wound care because his plan does not reimburse enough to cover their costs of seeing him. How is this helpful? This man has paid for health insurance, and the benefits are exactly the same as if he had no insurance at all. Is this progress? Unfortunately, this is not the only person I've seen this happen to. As a side note: I've worked home health and in several hospitals and have seen first-hand the many headaches Medicare imposes on health-care professionals - denying care, paying less if you don't treat your patient under their exact guidelines regardless of the pt.'s individual needs, etc. A government-run healthcare system that works with the "efficiency" and sense of Medicare is really quite scary...

I probably wouldn't be using iodoform at all after the initial dressing. Iodoform, while it does have antimicrobial properties, has recently been shown to discourage tissue growth. I think you'll find that most surgeons and wound care specialists are trending away from using iodoform at all after the initial I&D or surgery. Many don't use it ever, as there are other options available. Is it on a wound that had a known infection? In which case you probably want to change the dressing at least daily. If there has been no evidence of infection, see above - iodoform is probably not your ideal choice. A plain packing strip would be more appropriate, with or without the addition of an antimicrobial agent like silver (for example). Where is the wound? Acute or chronic? Necrotic wound bed vs. clean vs. granulating? I know you're after an answer to a general question, but all of the above really does make a difference in what dressing you use and how often you change it.

My hospital allows CWOCNs to do bedside debridement, as well as physical (and sometimes occupational) therapists. In Texas, any nurse is technically allowed to debride. However, there are strong warnings that you are probably not legally protected if you haven't been through a formal debridement course (with clinical/lab), so it's pretty much unheard of outside of wound care specialists. Our CWOCNs have a protocol they follow, on which excisional debridement (I think this is the new terminology we're supposed to be using now) is listed. Having said that, we don't get as much reimbursement for bedside debridement as physical therapy does. In fact, there is zero reimbursement for us unless we 1) say "excisional", 2) describe exactly what level of tissue we are debriding, and 3) describe what instruments we use. Even then, no reimbursement unless the physician states in his notes that the wound care nurses are performing excisional debridement. For this reason, we usually order PT to do debridements for us (the physician signing the order is his documentation, I think). The only exceptions are when it isn't feasible for us to track down PT - say in the middle of a wound VAC dressing change, or on the weekend.

I disagree, somewhat. I don't think having a BSN necessarily makes you a better nurse. But part of what makes the WOC nursing so highly sought after (and a higher pay grade, unless you work where I work) is that these nurses are more highly educated than your average bear. It means WOCN certification is obtainable only after completing post-graduate work. This increases the value of WOC nurses as a whole. WOC nurses don't function as the vast majority of other nurses do - they function more as clinicians. They have a higher level of assessment skills (within their specialty) than other nurses. But most importantly, they make decisions that directly impact a patient's entire clinical course. Recognizing that, they need to be more highly prepared than the average nurse, which would require a BSN at the least. Many WOC nurses are actually nurse practitioners as well. If you want to be wound care certified but don't want to get a BSN, there are other certifications out there. But if you want the most intensive program with the most preparation, you'll have to meet the requirements. I'm sure the WOCNCB can give you a better explanation of why a bachelor's degree is required. But for myself, I'd rather be identified with a group of nurses who are MORE educated, as opposed to less, when I'm marketing myself. So no, IMO, nothing "needs to change." You just need to make the decision as to whether or not an actual WOCN certification is worth you personally going back to school and getting a bachelor's degree or not. If not, get a substitute wound certification. But your personal inconvenience is not worth decrying the system that affects so many of us who have decided to make that full commitment. I'm honestly not trying to be antagonistic, but it's important to me that my chosen specialty remain something that only people who are committed and dedicated to will obtain. A WOC nurse isn't someone who just decided last month that they wanted to "try it out and see how they liked it." A WOC nurse is someone who has already worked their buns off, and the specialty as a whole is high-quality because of it.

I've also never heard of the term "resolved with a defect" before. To me, this would be more like a wound that has healed but will always have a noticeable, er, defect. Like it is actually concave compared to the surrounding skin, or the resulting scar from a previous graft site maybe. That sort of thing. But it's definitely NOT resolved if it's still an open wound. Chronic wounds can takes years to heal, but if something has stopped the wound from epithelializing completely there is something going on. Also, I believe it is acceptable practice to get a biopsy of the site for a wound that does not heal despite optimal conditions (many of which kim.jonescw has identified). Not saying this would provide any definitive information you don't already have, but it could.

Sorry, but that's just not true. All wounds, excepting (possibly) only those directly from the OR, have some level of bacterial colonization. For this reason, wound care, and most particularly wound care at the bedside, is rarely a sterile procedure. It is ALWAYS, however, a clean procedure, and as pointed out prior to me, at the very least gloves should be changed between removal of the old dressing and placing of the new one. Most appropriately, new gloves before you begin, new gloves after removing the old dressing, and new gloves after cleansing (before placing the new dressing) is optimal. Having said all of that, there is now evidence to support sterile dressing change procedure on post-op care of a closed incision until complete epithelialization occurs, because you do not want to "trap" bacteria underneath a closed wound. But unless you are going to physically sterilize an open wound, sterile technique is not generally needed.

It seems that my area has a growing number of these cases recently, and the preferred treatment is to remove extremely large amounts of tissue, which results in wounds that are then left open for a period of weeks to months (often with daily or twice daily dressing changes), usually until skin grafting is a viable option. Obviously, due to the nature of the condition and the toxins that are released, being too conservative surgically wound be life- and limb-threatening. I suppose I'm just wondering if anyone has seen any alternative treatments to nec fasc other than leaving the patient with huge open wounds long-term?

This seems like asking for trouble, if you ask me. What if, one day, the patient has a nurse with multiple credentials. Then, the next day, they have a nurse who is "just" an RN and something is less than satisfactory (for instance, the patient must wait longer than they would wish for their pain medication)? Then the patient will be thinking "Well, my nurse doesn't have any extra credentials, she must be a substandard nurse." And then, guess what. Every single nurse from that point on who is "just an RN" will be climbing an uphill battle. Granted, every patient will not think this way, but I believe a significant number of people would. For the record, I have two certifications, but I don't feel like I am a better nurse because I'm certified. Only that I have taken a test that I passed and now get to write extra letters after my name.

If that was me, and I'm being honest, I would have written down the order as I'd taken it and I WOULD have written TORB. You tried to do the right thing and he wouldn't let you. So CYA and let him deal with the consequences. The correct answer would be to call him back and get him to verify it verbally (and he's a jerk for not letting you do so in the first place), but this is the real world and who has the time to hold the doctor's hands and MAKE them do the right thing? I suppose some nurses might, but not on our unit, that's for sure.

That is the theory, but in reality it makes little difference except in multi-use vials like insulin. I think it just annoys me because every single day I get asked about this and there are just so many more important things to focus on. But I did warn that it was overly-nit-picky. :)

My pet peeves re: nursing students - 1) I honestly (usually) don't mind if you follow me around so that you can see/learn more. However, if you have a patient assignment, your responsibility is that patient (or patients). It is NOT acceptable to follow me around and not get your basic responsibilities done. For example: if you take a feeder, your job is to help that patient eat, not follow the nurse to another room. 2) Please tell me if I have charted something wrong - I can and will make mistakes. But do NOT tell me that a subjective answer is wrong. If I say that the urine was yellow and you think it was amber, guess what? I'm the one with the license. Keep your opinion to yourself. But if I say that that the patient had an amputated limb and they don't, please feel free to point it out. To extend this point further: know your stuff before correcting your nurse. If you're telling me I'm wrong because I'm flushing a feeding tube with tap water instead of sterile water, you can bet I'm going to be peeved at you. 3) Come prepared to work. If you have one or two patients that day, you are responsible for their care (see #1). You need to be available to help them eat, to the bathroom, take their vitals, and to get their baths done. They are of course free to refuse these things, but if a patient has a student nurse they should not have to go without. 4) In the name of all that is holy, if you can't do basic stuff, ask your fellow students or your instructor for help. I should not have to give a student in their second semester of clinicals a play-by-play on how to give a bedbath. Seriously. 5) Again with the computers. Be aware that if a nurse needs a computer, you must forfeit yours. If your clinical unit is anything like my unit, those nurses will probably be leaving after a 13-14 hour shift. You will get to leave on time no matter what - so don't delay them! More importantly, you could very well be delaying entry of orders, timely vitals/I&O charting, etc. 6) I actually like helping nursing students learn, and I've been told I'm good at it. But even I get irritated when I'm in a hurry and it takes a nursing student 2 minutes to draw up a medication when it takes me 2 seconds. There's not anything the student can do about that though. I was slow once, too. I also get a little annoyed by the repetitive questions - but again that's not the student's fault. If it's a good question it needs to be asked. 7) This is the nitpickiest nitpick you've ever seen, but it grates on my nerves when nursing students make such a big deal about injecting air into vials before withdrawing. I know this is because nursing schools make a big deal out of stressing this, and I cannot for the life of me figure out why. Is it important for multi-use vials? Sure. Is it important for a one-time administration of Protonix or the like? Not at all. I get so tired of addressing this non-issue every single shift. Ok, I feel better now for having said that. :)

That I did say, but that is not what you were referring to in your last post. This is a VERY different statement from "Malfunctions with the computers have...to do with user age". If you didn't misunderstand me, then you know that I never said OR implied the latter statement. And yes, older people are less likely to be adept at computers. This IS a generalization, but it is nonetheless true for the most part. Obviously some older folk have taken to computers like a fish in the water, and it doesn't mean that some younger people aren't dumb as bricks when it comes to electronics. But by and large it is true. Are you really telling me this isn't something you've noticed, honestly? It's not because older people aren't as smart (do I even need to say this?!?). It's a matter of what you're used to. We got our first computer when I was in elementary school, so I'm pretty immersed in computer culture. That is very obviously an advantage over someone who never touched one until they were in their 40s or 50s. If you disagree, that's fine. But all I've noticed is, at work AND outside of work, this seems to be a fairly decent representation. And as I've said, if you truly did not (intentionally) misunderstand me, there was a complete dichotomy of ideas between malfunction and familiarity, which you smushed together so that you could be "offended."