3PRN

Twenty years ago, small, rural hospital and new to ICU. Pt. admitted for pain control with epidural drip. All through the night shift I was in the room titrating up and down depending on his level of pain. At one point, there was hardly any medication going at all because he had such good pain relief. The MD came in at 0730 and discharged the pt. because his pain level was zero. The pt. also gave kudos to the nurse (me) who was by his side all night managing his pain so expertly. I went into the room to discontinue the epidural. I followed the tubing from the pump to his back and saw to my horror that the tubing was not in his back and had never been in his back, as there was a large puddle of IV medication on the floor behind the head of the bed where the tubing was swaying in the air.

Thanks for the update. I'm preparing for my 5 year CWOCN testing in a few months and the continence exam is the most difficult in my opinion.

Check out the web page of the Wound, Ostomy, Continence Nurse Society (WOCN.org). You'll find lots of information on the various programs including WEBWOC, the online program. To sit for the exam(s), you will need a BSN and have completed a program. I will never regret my WOC education. My peers thought I was crazy taking off to Texas to learn about wounds and ostomies. It's the best thing I ever did as a nurse and I can honestly say I love my job! BTW, most hospitals will require certification or that you are in the process of completing a program. Let us know what you decide.

It was irritated where the bandage was but how was the wound? I'm guessing it was all healed. You just got a lesson in autolytic debridement! I think you'd make a fine wound care nurse.

When I was told that I must say (to EVERY patient) "I'm going to close the curtain now to ensure your privacy"....I nearly gagged! Of course I'm closing the curtain to ensure their privacy, but I REFUSE to announce it! If you haven't, please refer to the book 1984 and read up on Newspeak.

"can you control evacuation of the bowel with a colostomy." This was the original question. Since we're talking about evacuation through a stoma and not through the rectum, muscle and sphincter control are not the issue. The issue is timing of bowel movements which can be controlled by daily irrigation. Ostomates can reduce their bowel movements to once a day if that's what they train their bowel to do.

There is a way to control the timing of colostomy output, and thousands of ostomates do this daily. It is called irrigation. After the abdomen has had plenty of time to heal, irrigation teaching can begin. The stoma must come from no farther up the bowel than the descending colon. Unfortunately, this technique is unknown to patients unless someone tells them about it, and this person is you! You can google "colostomy irrigation", and you can contact your major vendors...Hollister, Convatec, Coloplast, and others and they would be very happy to discuss the particulars and the equipment needed to perform the task. My patients that irrigate wear only a small patch over their stomas, no wafer, no pouch. It's a very freeing thing for ostomates and should be taught when applicable.

Odors tell us a lot about our patients, especially the bad ones. You will learn to diagnose a pseudomonas infection without a culture, GI bleed without an CT scan, C.Diff without a stool sample, impending death in a pt. that doesn't look too bad. I depend on odors every day. They're part of my nurse's 6th sense. One thing I never do is breathe through my mouth! I figure if odors are caused by bacterial waste they're already going up my nose. I sure as heck don't want them in my mouth. For wretching odors, I wear a mask and save the patient humiliation by telling them I have allergies and I might sneeze, which is usually true.

Oh the shoulda, woulda, couldas...I've got a million of them. My goal was to graduate from nursing school at 40. Check. BSN by 45. Check. MSN by 50...OOPS! Too expensive. Anyway, feeling behind at the beginning of my career, I made a decision to transfer units every 4 years or so. I've worked med-surg, ICU, trauma/neuro, ED, OR, and oncology. Each specialty involved new training and study. I loved all of it! I now call outpatient wound and ostomy care my home and plan on never leaving until they drag my old carcass out of the building!

I loved working in the hospital. But when I started spending more time writing about the teaching I'd done than the actual teaching and more time writing about my interventions than the actual interventions, I moved to outpatient care. Now I spend my entire day "fixing" people. I see them from week to week and really get to know what makes them tick. I do an evaluation/assessment paper on their first visit, a treatment note after each visit, an occasional progress note to the MD, and a discharge note when they don't have to see me anymore. Shazzamm!

If you go with the pre-fab, you should still use extra protection under the tubing now that it's going to be under the compression. Either foam or the cotton layer of your Profore.

I have done this but under hospital supervision, not as outpatient. However, I would consider an outpatient if the person was directly involved with their own care. After the dressing is in place, put a small piece of foam under the tubing near the suction disc. This will prevent the tubing from causing a pressure ulcer under the compression. As you are wrapping the leg, wrap under the tubing so that when you are finished, the tubing is on the outside of the wrap. If still unsure, follow psychnursewannabe's advice and call your vendor rep. They would be happy to assist you.

For her comfort and to decrease time spent on dressing changes you can't go wrong with the wound vac. Drainage won't be an issue as it goes into a throw-away canister. Typically dressing changes are Monday, Weds., Friday, but in this case you can go the full 72 hours between changes. The only problem I see is reimbursement. Typically the insurance company wants to see improvement in measurements.

I took the EMT course while I was on my 4-year waiting list. I did it just for the knowledge gained and it was a great experience.

One time on night shift I was called to a code and left a bag of popcorn in the microwave. At 300 joules I smelled smoke and nearly ****** myself! Then I remembered the popcorn. The fire alarms went off, the fire department crashed through the unit doors...and it just went downhill from there. The patient died. And, at the end of the shift I just stood before management and silently wept. I was not fired but sternly warned. I was also shunned for quite some time due to the new "no microwave popcorn" ruling.

VAC VAC VAC! This area can absolutely be vac'd and with excellent results. The one thing that worries me though is your statement, "As much as I can." this tells me that the area continues to be traumatized by friction, shear, and pressure. Tell your nurse to bring in the VAC rep when you have your first dressing. The rep will offer suggestions on how to best dress the wound to maximize the benefits of the machine. It doesn't cost anything for the rep to come out. It's my experience that home patients do extremely well with this treatment. GO FOR IT!

While treating an outpatient for a pressure ulcer 3 days/week, I removed the dressing one day to find the coccyx was missing in action. I had her go home and look under the couch cushions, her car seat, etc. She did have osteomyelitis in the bone and I figured one day it would crumble. But her dressing was intact! That was 3 years ago and it's still a mystery.

What would we do without foam dressings? I've found that Optifoam, Allevyn, and Safetac (Molnlycke) are great for a lot of wounds but sometimes spread the drainage around the periwound causing problems. I find myself going to the Poly-Mem more frequently because it takes the drainage and holds it in the outer portion away from the wound. Another superb foam is the Molnlycke "transfer" foam. It's thin and pliable and also takes the drainage away from the wound. The vendor reps are always happy to bring you samples. (I am not a rep).

Free range maggots in a necrotic wound...especially if I don't know about them before removing the dressing. I feel a little disturbed just thinking about it.

The foam must be removed before more granulation tissue develops so time is not on your side. The most accurate and least painful way to do this is with a pair of forceps. With wet to dry's you will also be removing the healthy tissue which your patient has worked very hard to grow. Pick it out, fiber by fiber. With the next dressing, place a contact layer (Mepitel, Triact, adaptic, etc.) beneath the foam. Your patient will thank you for it!