Wound Care in LTC

[xxAngelxx]

I am just finishing up my second week at my very first job as an LPN. I've noticed that many of the nurses I work with do not make any time for wound/skin care. I know we are all busy. But a small wound, untreated, will just get bigger and worse.

Two quick examples....

1. A very obese lady has two small open areas deep in here, um, butt crack (for lack of a better word). Its probably due to her incontinence, I've been told. But nothing is being done. I suggested an Extra Protective Cream, and was told that would definately help SO much. But no one puts it on! Even the CNAs won't do it during her brief changes.

2. A older gentleman with a urostomy has major skin excoriation around the stoma. Why? The wafer is cut completely open (to wear it attaches to the urine bag) instead of being cut to be fitted around the stoma. So that skin is always exposed to urine. I asked the treatment nurse and she told me I was right, that the wafer does need to be cut to fit the stoma, and that even though there is excoriation, the skin cannot be exposed still.

The couple nurses I spoke with said they don't do wound care. I've seen how awful this stuff can get and I'd hate to see infections occuring because of something preventable. As a brand new nurse, is there anything I can say or do?

[Midwest4me]

You or the treatment nurse needs to obtain some orders, either by phone or grab the doc on his next rounds and have him look at the skin problems to see if he wants to order something. In the interim, it seems to me that there should be some non-rx skin cream/barrier that you have in-house to use on that lady's cleft in her buttocks. Also, re-emphasize repositioning every 2 hours.

[Thornbird]

Definitely report skin condition to the doctor and get orders. Once the orders are on the treatment sheet, the nurses will have to "find time" . Some facilities will allow you to put something on the treatment sheet as a "nursing measure" if it doesn't require an order. That way it is documented at least. Examples: Observe and document skin condition @ urostomy site q shift. Apply protective cream to glutel fold after each incontinent episode. Also add protective skin measures to the CNA care plans when needed.

Once things like this are in writing, people can be disciplined (written up) if it doesn't get done (which does still happen).

If you, as a brand new nurse, can't do this, most facilities have someone responsible for Wound Care. Sometimes it's a separate position. Other times, the Infection Control Nurse or the MDS Coordinator does this. If all else fails, go to the DON. Skin care can make or break a facility. Also, stand your ground with the CNA's - you are their boss!

[hst01]

ive noticed where i work that sometimes nothing for sking sores will be ordered unless we the nurses inform the doctor that something should be ordered.. if the dr doesnt see a need that we just apply strict turning for those patients that you described in your first example to prevent further breakdown,,,

[CoffeeRTC, BSN, RN]

#2...the colostomy issue is just sloppy nursing care. The waver needs cut closer to the stoma. If there is a gap, I will appy a bit if zinc oxide to protect that area from stool.

#1....The regs on skin care have changed. Each resident needs a routine comprehensive assessment on the skin. The nurses should be aware of those skin issues. It is basic nursinga care to clean and protect the skin. If there is an open area (and this one sounds like a Stage II area) there should be a treatment. Find out what your protocol calls for and call the doc. Get an order and get this lady treated.

[southernbeegirl, BSN, RN]

I agree with all of the above. I would also add that while she is in bed, she shouldnt have a brief on...just a pad under her to prevent worsening breakdown.

[achot chavi]

While I agree with all that is written here- it is my experience that unfortunately you will probably not be effective in making a change unless you enlist the support of your DON. I would make an appointment with her or him and express your concerns. If the indifference comes from management then my advice is to find a better facility.

What you described is - to my way of thinking- unacceptable.

Regarding involving the doctors- I would make all communication in writing so that he cant say that he was uninformed... do you have a communications book between Nurse and Doctor? If not suggest it- its great- the doctor can't claim he wasnt told about a problem and this way nothing gets forgotten or lost in the shuffle.

BTW- we have more professional words than "butt crack"(sic) such as the sacrum, the coccyx, the skin folds of the buttocks, between the buttocks, although your choice made me smile ( thats worth something!)

I'm glad that you care- keep it up!!