wounds and arguments

[ItsnurseA]

so my sister who is a first year nurse asks me for advice periodically, this time she asked me it ended in one of our great "who is the right nurse" bickering haha. so we need a little clarification here.

first to start she has a venous wound that just gets treated with calcium algenate and a dry dressing (cling wrap i believe) to hold it in place. there is normally a lot of drainage with this wound but this time she went to change it and she noticed it was going through to the outer wrap. so after she cleans it and places a patch of cal algenate to cover wound she added a piece of non adhesive foam pad over the Cal algenate (not touching wound) to soak up what was going through the cal algenate so that it did not soil the outer wrap.

I told her that she should not have placed that on there because it was just not ordered and she seems to believe that because she followed the order originally and only added it to the outside to catch the excess drainage that it was ok. and she also stated she believes that because it was also a dry dressing used for the same purpose as the cal algenate that it wouldnt pose an issue and just help pick up the slack since the cal algenate was not working completely.

i tried to stress it prob wasnt the best idea based on it not being ordered and she is sticking with she didnt change the order she was just using it to pick up the slack.

help lol

[MunoRN, RN]

I personally don't see any issue with just reinforcing the drainage absorption layer by adding an extra absorbent pad. At least in the practice environments I've been in, that's well within the scope of nursing judgement.

[CT Pixie, BSN, RN]

i work in wound care and we often will add a foam dressing in addition to the calcium algenate. we do it more for padding and protection of the wound.

If its got that much drainage, instead of the foam (which really doesn't soak up drainage well) she could add some 4x4 gauze over the cal algenate or some extra wrapping of the kerlix or whatever top wrap she uses. She should prob give the doc a call and let him/her know of the more drainage than usual.

I'm going to have to side with your sister on this one :)

[jadelpn, LPN, EMT-B]

You can ask for a change in the order. You should call MD if the drainage is getting worse instead of better, as your assessment would indicate that something else may be needed to control this wound, the bleeding, the drainage.

What I would not do is cover the wound more, without the specific OK from the MD. Nurses could just look at the dressing, assess it as clean/dry and intact as they would not realize that the extra padding was there soaking up the fluid/blood and that would be wrong.

If a older wound is suddenly draining everywhere, the MD or wound nurse needs to reassess. Then write a new order (or not).

One shouldn't take it upon themselves to pad something up that needs further assessment. It can be misleading to other nurses who assess the wound site.

[BrandonLPN, LPN]

I sometimes have to veer slightly from the official order as it's written in the MAR if the drainage exceeds what the original order calls for. For example, if the order says to cover with 4x4 and Kerlix, but the 4x4s aren't cutting it, I might add an ABD pad if necessary. I consider that to be a judgement call well within the realm and scope of a licensed nurse.

As jadelpn said, I would be sure to notify the wound care RN and/or the provider so that the increased drainage can be assessed and the treatment order can be changed if necessary.

[Libby1987]

She should of course notify her dr of change in condition with increased drainage and do everything by the book etc but foam on top of alginate is an appropriate and common modality for mgmt of exudate.

[RN6274]

I work with wound care and while yes that wouldn't have been a problem it def needed to be in the order a simple call to the MD to add it would cover your butt

[Libby1987]

Oh geeze I mis read, I thought your sister's wound was her own wound, same answer, different Dr!