Wound Care

[txdon]

DON's I need your help. I need help developing an effective wound care program at my facility. I currently have a wound care nurse who does all the wound measurements for pressure and non-pressure wounds weekly. She puts them on a special tracking form that includes that family, dr has been notified, careplan updated, etc. The floor nurses are responsible for the daily wound treatments. Once a week the wound nurse comes to the weekly care conference and reports findings. An IDT note is written on the progress of the wound. The progress note usually consist of current measurements and continuing with current treatment.

The nurse I have doing measurements wants to do wounds full-time. She works on the skilled nursing side and thinks she is more than just passing meds. I clearly explained to her that I didn't have a budget of a full time wound nurse. As a result, she is unhappy, complaining she isn't able to effectively do her job. Basically, she feels as though she is being asked to do 2 full time jobs and she says she doesn't feel safe doing the wounds because she isn't able to put the time needed. I will say I have questioned if she is actually even looking at some of the residents on the list, or if she is just putting the same information back on the report on a few of them. Also, I had a resident with a rather extensive wound - it started on her abdomen, and tunneled down to her perineum. This particular wound had three sections. She only documented the abdomen. Also, she is constantly complaining that our wound care program is a mess. She recently mentioned that supplies are left in all the resident rooms, weekly progress notes are not being done, etc.

I have to admit wounds are not my strength. My facility currently has 6 resident's with FAPU's. I am needing some help and resources.

[CapeCodMermaid, RN]

Unless you have lots and lots of wounds, being the wound nurse isn't a full time job. I've been the wound nurse before. When I first started I was also the day supervisor and when I got promoted to ADON, I was still the wound nurse.

Everyone has to buy into the program and understand the importance of good wound documentation.

Don't forget to include on your documentation the level of pain, any preventative measures such as pressure relieving mattress should be addressed. Don't forget to enlist your dietician for nutritional support issues and an OT or PT for positioning and any other modalities they might be able to use to promote healing.

[pixie120]

Unless you have lots and lots of wounds, being the wound nurse isn't a full time job. I've been the wound nurse before. When I first started I was also the day supervisor and when I got promoted to ADON, I was still the wound nurse.

Everyone has to buy into the program and understand the importance of good wound documentation.

Don't forget to include on your documentation the level of pain, any preventative measures such as pressure relieving mattress should be addressed. Don't forget to enlist your dietician for nutritional support issues and an OT or PT for positioning and any other modalities they might be able to use to promote healing.

Agree totally. I would say, and this is from my experience AS a treatment/wound nurse, it's about a one day per week job, so 8 hours. I worked 2 hours per day, M-F came in did all the treatments, housewide, 117 bed facility (not the little things like creams, dry skin, the actual wounds, non-healing, pressure, high risk, diabetic, Arterial and Venous) then did Admissions the rest of the day. I led the skin team, filled out the weekly pressure report for the DNS and corporate and wrote the IDT note for the IDT meetiing, which I attended q thursday as part of the overall nurse manager team (I worked at odd jobs there in addition to full-time admissions, treatments, skin etc..always plenty to do to help the team, infection control etc).

To be honest, it sounds like this "treatment" nurse is trying to get more hours as treatment nurse and less as passing meds, but that doesn't mean you want her on your team if she is "blowing" up the current treatment/skin team/protocals. Most floor nurses don't understand how important measurements, weekly follow-up and eyeball of such wounds IS (no offense here, stating MY opinion) and therefore see a lot of what nurse managers do as "unneccessary or made-up to justify our jobs". THe only way to combat it is, send her to a wound training course, open her eyes and educate and find that one day per week, 8 hours to allow her to concentrate and learn on the wounds. I knew NOTHING of wounds when I graduated (originally LPN), I learned on the job from some great nurses.

It also depends if you want to salvage her. BEFORE I act, I always ask the team "are we trying to salvage" this one? If yes, then do anything/everthing...if no, then....

[itthybitthythpider]

What if you have multiple wound vacs and stage IIIs and IVs. It takes 4 hours just to hit up the big wounds, let alone the little bruises and scrapes and skin tears.

I do wound rounds once a week (I'm a 1 month old ADON) and I'm finding it difficult to get to the little wounds on my one day, yet the nursing staff expects me to do the weekly documentation and to DC all the bruises when they are healed, which seems to involve almost a head to toe assessment every week on every resident. I know the floor nurses can't do that, but I'm having difficulty doing it by myself!

I would actually love a good system so I can keep it to once a week. I don't want to do wound rounds full time (our building only has about 80 beds), but something needs to change so the bruises and such aren't falling through the cracks on weekly documentation and DCing of treatments. Any ideas? Should I spend a couple hours each day and get 1/4 of the residents thoroughly, or should I try and keep it all the same day, or should I give more responsibility back to the floor nurses? I really want to do the best for our residents, efficiently and safely.

Thanks!

[CapeCodMermaid, RN]

We have 3 residents on wound vacs, each with several stage 3 or 4s. The wound nurse, also the

ADON gets it done in one day. As for the nurses not having time to do a weekly head to toe assessment, we do ours on shower day. It's practically the 11th commandment. Thou halt do your weekly skin check (or else).

[itthybitthythpider]

We have 3 residents on wound vacs, each with several stage 3 or 4s. The wound nurse, also the

ADON gets it done in one day. As for the nurses not having time to do a weekly head to toe assessment, we do ours on shower day. It's practically the 11th commandment. Thou halt do your weekly skin check (or else).

Ok, so I just need to be faster . We have the CNAs fill out skin sheets on shower days, but I'm talking about DCing old bruises. Is that done by the wound nurse, too, in your building? To me, it almost seems to take another full head to toe assessment! So I'm trying to get ideas for how to streamline the process. Thanks again!

[CapeCodMermaid, RN]

Who ever writes a treatment order to monitor a bruise should have an end date....really there's not much change after the first 72 hours and if there is, they can write an order to continue for another 72 hours. The wound nurse does not do or monitor every treatment....only the pressure areas and vascular wounds. Perhaps the floor nurses need to be doing more in your building.

[debRN0417]

The only full time wound nurses I have ever seen are in very large facilities (only one nurse). I have seen full time "treatment nurses" who do all the treatments in some smaller facilities. Most wound nurses I have had experience with are consulted when there is a new wound and do wound rounds weekly, doing all the mesurements, documentation on the progress of the wounds, and changing treatments if needed (consulting with MD). The remainder of the time, the unit nurses are doing the treatments however they are ordered.

[itthybitthythpider]

Ooh thanks guys. So you don't monitor until they are gone, just for 72 hours to make sure they don't get worse?

[txdon]

Thanks for all the wonderful advice. At my facility the "wound nurse" is responsible for doing weekly documentation on all pressure and non-pressure wounds. She follows the resident weekly until healed. She is responsible for doing a weekly assessment of the area in question but not a head to toe. The head to toe assessment is the responsiblity of the floor nurse who is assigned that resident. The wound nurse has designated one half and one full time day to document and assess wounds. Her full time day consists of pressure wounds, usually about 15 residents. Her half day consists of non-pressure wounds such as skin tears, bruises, etc. Ususally they go much faster because it is basically monitoring or documenting area resolved.

[NotFlo]

Wow I'm in a 120 bed facility and we have a full-time, certified, 32 hr wound nurse and she's a godsend. Don't know what we'd do without her.

Our facility is big on wounds though, we work with two area surgeons that do flap repairs and grafts and take most of the their patients, they come in and do rounds at the facility weekly, and we advertise heavily to get wound patients.

She does the weekly pressure/non-pressure wound documentation and measurements, and is usually consulted for initial treatment orders. Once weekly she, the medical director, an APRN wound specialist and a physical therapist specializing in wounds does rounds "the wound team".

We floor nurses do our own treatments and dressing changes the rest of the week.

It's pretty typical for us to have multiple vacs, whirlpool txs, stage 3 and 4 pressure areas, skin grafts, etc. on each of the two rehab floors.

[Bblessing2u]

Hello,

I am a one year RN, have recently gone to a WCEI wound and skin care weekend class and am working on getting my preceptor hours in to be certified. I was just offered the position of wound care nurse at the LTC that I work for as a shift nurse. I am scared to accept as I don't feel like I really know anything yet! I am sure they will train me, but I am forever asking other nurses how to do something or to explain things to me. I wonder too if I will be getting some resentment from some of the LPNs that are great in the wound area at work. Any advice is appreciated!