Davidaugustyn

I flip houses and am starting to hold and rent soon. Other than that, I am trying to delve into freelance nurse writing, but it's been tough.

Hey Overtonis! If there are others like me, there have got to be a lot looking for a way out. I have been flipping houses on the side to get out. I'm looking now into nurse writing to get out of the hourly grind. There will always be a need for direct care nursing, but there has got to be a huge demand for something that will unite people that want out.

I started a wound consultation business from home and saw a few clients before giving it up. The biggest things that slowed me down was that it was a lot of work for the same amount of money as a an hourly job. I learned a lot from building the website, like hidden fees. Wanna open an email account? Costs more than the website itself. Make sure before you commit to one that you know each cost of everything you'll need. If I did it again, I would start more mom and pop. I put a lot of effort in making my business look professional before starting, to give the right image. Ultimately though, it was through word of mouth and referrals that I got business. I don't believe to this day that the website was any help to anyone in my small town. I would make the website when business started coming in. I would have probably not started my business, only because it is hard to break into a higher income bracket as a nurse consultant driving to peoples homes. You can only charge so much for that. So I suggest having a business plan that actually shows profit to be made for you, while affordable rates for the client.

Fistulas are the hardest things to deal with. I shutter when I hear of a new admit coming with a fistula...I wish I could give you better advice...Supplies are drained to quickly with them...

Hello everyone and thank you for having me here. I have enjoyed this forum. First a little background... I have worked in long term care for 10 years, wound care certified for 4. Last year I started working in an LTAC with a wound care team and then was promoted to a wound prevention supervisor. We effectively reduced in nosocomial pressure ulcers from an average of 6 a month to an average of 1 a month over a 9 month period. (5 months high and 4 months low after implementation) I have recently moved on from that the the Director of Nursing position in the SAU adjacent to the hospital. It is an independently run facility but that was sharing the wound care team. As of the new year, we are pulling back wound care strictly to our department. The department does have some issues handling wounds and prevention. My plan is to have floor nurses pick the daily dressing changes back up, where they before never had to do this. We will have a wound nurse that does strictly weeklys, admits, declines, issues, etc. My question is, -Has anyone ever done this and how did they meet the resistance? -Does anyone have any good suggestions? -Turning, as everywhere, is a problem. How have you effectively turned around a non-turning unit? I mostly wanted to start a thread to share a wealth of knowledge. If you have something good, let's here it! Also please let's try to link what we know to best practice and evidenced based effectiveness. Here we go!

That may be true, and I may be speaking from my LTC experience. Of course we would not skip documenting on it; it is there. But if the origin is unknown, there becomes the opportunity to defend allegations of abuse, depending on the wound. That's all I meant. Not that we wouldn't chart, but that we need to find the origin first or at least have a realistic idea of the cause when oversight comes around.

yeah hollister does have alcohol. I mostly use it for a weeping peristoma. If truly is the key for a a good seal. Ask anyone with a long term difficult stoma. It's just how it's used. Like you said, its not glue. the idea is for the o-ring like seal.

I passed my LPN with 85 in 2004

Too bad. You failed.

How many days old is it? Is it appropriate redness in the inflammatory stage? Lots of times it's just a hope that it doesn't dehisce. I wouldn't use topical antibiotic, not best practice. Really I have not seen much help from the outside on an approximated wound.

I have 3 LPN wound care nurses working in the wound care department that I supervised. They were not certified and the company was hesitant to have them certified because of their degrees. The reason they fell into wound care is because the hospital doesn't like to hire LPNs for the floor. Kindred Healthcare based in Louisville KY has facilities all over the country which greatly hires LPNs. I have worked at 4 different Kindred facilities and each has hired LPNs. One facility had an LPN as a Clinical Manager in fact, overseen by the DON. In our wound care dept, we just make sure an LPN does measurements at least every other week. If I were you, I would see how I could position myself to fall into being needed for a wound care position as the certification is expensive.

That's true. Tough situation. I would suggest to him a mattress if he doesn't have one, (something he can't be noncompliant with) and let him be. Those are tough....

Well said mommy.19

I would stick with what I said than. Maybe not silvadene, but a good moisture correct environment and diaper it up.

I'm sorry I was in a mindset when I wrote that. What I should have more clearly stated was that topical antibiotics were useless, and oral antibiotics, unless broad spectrum, have little efficacy due to the way we culture a wound. I do agree with punch biopsy, but only as a means to diagnosing infection. (which I believe can be done with a look and a temp) On that note, Dakins is not best practice either. I have a tendency to speak on the results I see along with the knowledge I've gained. I can see the results with Dakins. (for short periods only) Here is the link to article that sums it up well. http://www.o-wm.com/content/bacterial-swabs-and-chronic-wound-when-how-and-what-do-they-mean I would encourage you to stay minimal with the culturing purulent wounds. It's not a good indicator or the bacterial bioburden. Also purulent drainage is not always an indicator of infection.

No Have them pick it back up.

We have 3 WCC nurses at my facility including myself that have taken a "certification" for sharp debridement. (though not acknowledged by the state except as being educated) We cannot technically do sharp debridement. I believe only because PT here does it and can charge for it. If you were going to do this right, you should get PT involved so you can bill. Sorry to say thats how it is. I will still cross-hatch and provide minimal sharps when I think it's necessary. If you still want to have them do it, I would suggest a weekly debridement day and only remove minimally.

OK. I never advise to culture a wound, and that is best practice. A wound is full of bacteria. There's nothing that can be done about that. Unfortunately there my be MRSA or somethings else in the wound that won't be killed with just any ABTX. Doesn't matter though because oral ABTX are practically useless to a wound. Fortunately, you don't need to kill wound bacteria internally as you would pneumonia. (Unless it's getting severe and spreading) Dakin's solution. I'm not one to put bleach in an body cavity, but I have seen some very successful results from a low concentrated dakins (1/16) in reducing signs of infection. I always use dakins for a week or two on excessive green drainage. Silver if not yet severe. I've never really been one for honey. Though I love natural benefits, I find honey better for internal healing where dakins can't go. I use a diluted honey for pink eye in our house. Works every time.

What kind of bed? If there is moisture involvement you may want to implement a low air loss mattress. I have seen these patients before, with skin that just literally just shears off. but it's rare. Have you had these before? For you to have 2 at once you might want to consider that you have a bad process at your facility. Just a thought. Otherwise, the mattress. What type of draw sheet are you using? Are you using one? I get the impression your staff is not very willing to make a change for these residents. Will they adjust to changes in the plan of care or will they need monitoring for providing it? If they're a sling lift, they may need to be bed bound for awhile. idk, depends on the severity. Overall, make sure you are not negligent. If the patient needs the right product or device, make sure it's provided. Make the patient a L+R turn only. No back time except if eating. At that, only 45 degrees. Boost only when on their side, not back. Less layers. No hydrocolloids or dressings at all is usually the case. Thin layer of thin zinc based cream usually the best with my experience. Even better, if continent or get a foley, leave the chux off and use just a draw sheet. msg me if any questions. More info would be helpful

I am a proponent for the natural cure. On the note, we converted all of our santyls to honey at one point. It was a mistake and we switched back. Honey does not debride like promised. I have used colloidal silver a couple times and saw good results. but as is always said, healing is from the inside out. Who know what really worked and what the body provided... The colloidal silver worked well as a peristomal skin rash/denusion wash.

More detail. Does she has an ostomy? Or stooling out of the wound? Not sure. If I understand, you're trying to heal up the entire rectal area (rectal CA?) The one patient I had, we use a silvadene slurry (I know we don't use silvadene any more) We just never got a seal. half and half saline and silvadene soaked kerlix with ABDs over the top and a netting underwear and foley cath. She had an ostomy though...

I have seen and know what you're talking about. They often don't go away and often deteriorate further. I wouldn't aspirate only because it's not ever a recommended treatment. On the other hand, talking common sense, I would if it was dad at home because they only ever end up rupturing anyway and being treated then.... In the clinical setting, we do what you're doing.

I have a step process I use when I have peri-stomal denuded skin. I had a horror film patient. Every time I heard a page to the room. I knew I would be dealing with this horrible leaking ostomy. I've had much practice with probably 50 different supplies on this patient, and can tell you what works. They cost, but get them: Medline marathon liquid skin protectant. It's a cyanoacrylate based purple prep that works magic on denuded skin. Once the skin does better, switch back to whatever you're using. When you have a bad patient, you have to buy what it takes to provide adequate care. I'm in a facility that uses only hollister too, but it doesn't cut it all the time. After experience with many bad stomas: 1. I don't crust. I find that whenever I have a reason to crust (except for rash and nystatin powder) I use the marathon prep instead and it works superior to crusting while holding a better seal. 2. LESS layers! Don't use hydrocolloids, they just aren't best. Maybe a duoderm brand or another brand works better than what I've used, but the extra layers just make things worse, especially for a patient that applies it. If anything, use eakins discs 3. You don't use paste? You have to learn how to use paste! Paste is the best thing since sliced bread....when used right. Make sure you cut your appliance right and place your bead around the appliance opening. The crucial key is: YOU HAVE TO LET IT SIT OTA FOR 10 MINUTES. This may be time consuming, but worth it in the end. It works like a O-ring and can seal a denuded area. The slightly dryer paste doesn't get all sticky on the skin either. 4. Experiment on paste until you get it right, and it will be your friend.

I agree. More information. If no slough, VAC it! Not over packing right? just throwing that out there....don't stuff, fluff.

Everyone is right. Stick to drying only. What you're going to want to watch more is where the necrosis stops. Sometimes it continues to grow up the toes and to the foot, seemingly to the point of adequate perfusion. If you identify that with this patient's risk factor and appearance that this area may just continue up the foot and into the lateral medial leg, it may be leading to amputation. All I'm getting at, I've seen toes dry up and fall off, leaving a perfectly nice foot left over (with proper drying) If you see the areas as stable, be hesitant when the surgeon offers up amputation.