The role of the wound care nurse includes assisting the outpatient wound care doctor with debridement. Her duties range from gathering supplies, handing said supplies to the doctor as they are needed, and documentation of the size (Length, width, and depth) as well as taking pictures and uploading them to the patient’s chart. In cases when the doctor is not needed for debridement, the wound care nurse is responsible for assessing the wound, administering prescribed treatment, dressing changes, administering any pain medications per doctor’s orders, and documenting all of the above into the patient’s chart.
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The wound care nurse is also responsible for coordinating and scheduling follow up appointments for future wound care visits for established patients. Another duty of the wound care nurse is to administer IV therapy to patients as per doctor’s orders. There are patients that have had surgeries years prior to the wound becoming infected and it causes them great damage to organs. This damage can have adverse effects on the patient’s nutritional status, fluid and electrolyte balance, and immune system. The wound care nurse will start their IV and administer the prescribed solution to be infused. For instance, a patient that had the majority of her intestines removed due to a non-healing surgical wound from seven years prior and comes in once a week to receive magnesium through IV therapy due to her body’s inability to absorb it alone.
The wound care nurse is also responsible for administering Oxygen therapy via the Hyperbaric chambers to patients in which have slow healing wounds. It is the wound care nurse’s responsibility to thoroughly assess the patient’s past medical history to ensure all of the criteria have been met in which to be a candidate for this certain therapy. Once the specific criteria have been met, the wound care nurse ensures the patient has nothing but 100% cotton clothing on and is in no way a risk for setting a fire through static electricity by attaching a “ground wire” to the patient’s chest. She then places the patient on the stretcher made specifically for the chamber and instructs the patient of what is to come. She educates the patient on the need for “air breaks”, how to perform them, where the location of the speaker is, and makes sure the patient has had adequate bathroom privileges prior to treatment. Air breaks refers to the patient taking a hose attached to a chamber port and breathing room air (21% oxygen) to decrease the risks of oxygen toxicity. If the patient has a history of seizure or pneumothorax, they are required more than one “air break” during treatment and the chamber’s pressure rate is slower to target. It is the wound care nurse’s responsibility to set the pressure and rate of pressure of the chamber to ensure the patient is not brought under pressure too quickly to prevent rupturing the tympanic membrane, pneumothorax, or seizures. Bringing the pressure back up slowly to avoid these complications is her responsibility as well.
dIFFERENT TYPES OF WOUNDS VIEWED
I was not able to identify three types of wounds due to the lack of patients during my shift; however, I was privileged enough to see two types of wounds. I got to experience and assist with changing wound vacuum systems on surgical wounds as well as a neuropathic wound in dire need of debridement.
The surgical wounds were not in the out-patient setting. The facility has an in-patient wound care nurse and she is responsible for the majority of wound care on the floors unless otherwise specified by the physician. The in-patient wound care nurse changes all of the wound care vacuum systems. These systems are primarily used on surgical wounds. These wounds can vary in size regarding length, width, and depth. The two I assisted with were very large. One wound measured 15.7 x 5.5 and the other 13.8 x 7.4 x 5.3. The in-patient wound care nurse assesses the wound bed for abnormal color changes (normal color ranges from light pink to dark red depending on that patient), dehiscence, tunneling, odor, heat, and any inflammation. She cuts a silver sponge just big enough to fit inside of the surgical incision so as not to touch the skin. If the silver is touching the skin, it can irritate the skin and lead to impaired skin integrity and eventually to infection. She covers the silver packed wound with a clear adhesive large enough to cover 6-8 inches in diameter on the silver. She cuts a nickel sized hole in the clear adhesive on top of the silver and attaches a disc that has a hose coming out of the top. This hose leads to the wound vacuum system and will “suck” out any drainage from the wound so it can stay as dry and as wet as it needs to in order for ultimate healing to take place. The in-patient wound care nurse is also responsible for documenting treatment performed, the size of the wound (Length, width, and depth) as well as taking pictures and uploading them to the patient’s chart.
The in-patient wound care nurse also coordinates with the case nurse to get patient’s set up with home health. This assists the patient’s with the ability to be discharged from the hospital and take the wound vacuum system home. The cost for the system is approximately $125/day. Most patients cannot afford to pay out of pocket as the treatment usually lasts for three months.
I also got to observe the debridement of a neuropathic wound. This particular type of neuropathic wound was categorized as a Diabetic ulcer due to the nature of its origin. The patient is a diabetic and had stepped on a nail which went through his shoe and had been putting pressure on the bottom of his foot causing an ulcer. According to his sister, he went a week with this nail in his shoe before someone noticed it. The patient did not feel the nail or the damage it was causing due to inadequate circulation causing nerve damage to his lower extremities. This wound got infected. The infection got into the bone and caused Charcot foot which causes the arch to protrude past the ball and heel of the foot and all pressure form walking goes onto that new growth. The wound from the nail was located on the arch of the patient’s foot and became extremely large, infected and hard to treat due to the patient’s inability to flow his doctor’s orders and stay off of the foot.
The doctor used a scalpel to shave the calloused skin around the outside edges of the wound until he “hit blood”. The doctor said if he gets blood, he gets life and this will help the wound to heal and allow the new, softer tissue to adhere to the wound and close up. For wounds that do not close all the way, a skin graft is performed. Once the skin around the wound started bleeding, the doctor packed the wound tightly, wrapped tape around it to hold pressure to stop the bleeding. Once the bleeding had stopped, the doctor applied silver nitrate to the specific areas that were bleeding. This chemical cauterized the area and stopped the bleeding altogether so the nurse could clean and bandage the wound. The patient was set another appointment.
NURSING INTERVENTIONS REGARDING THE DIFFERENT TYPES OF WOUNDS
Some nursing interventions regarding the types of wounds I observed include assessing the wound daily, as well as the patient’s nutritional status and any risk factors for infection. Another important intervention is patient teaching regarding foot care with respect in what not to do as well as what patients can do on their own to reduce occurrences. Some of these include wearing shoes, checking patient’s feet daily, and taking special precaution when trimming toe nails. A nursing intervention for reducing wounds all together is doing a full head to toe body assessment of their patient daily to determine any risk factors for wounds that may aren’t pre-existing but can become a problem quickly.
ONE ASPECT OF PATIENT TEACHING
One aspect of patient teaching that I identified was during an initial wound consultation. The in-patient nurse taught the patient how to splint her stomach with a pillow if she had to cough to help reduce any pain or discomfort at the wound site.
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Another aspect of patient teaching was the in-patient wound care nurse teaching a diabetic patient with several amputated toes about foot care, never going anywhere barefoot, and checking his feet daily with a mirror to help catch potential problems to avoid missing possible complications causing wounds and eventually more amputations.
WHAT WERE MY STRENGTHS & WEAKNESSES
My weakness in this experience was my inability to be patient and go at a slower rate than what I like. Wound care on an out-patient basis, is not something I believe I will be interested in once I graduate. I liked going around to the patient’s on the floor and being able to take care of many rather than sitting around talking about softball, Christmas, and whatever until there was something to do. I’m not a person that can sit still for long; especially if I feel I am in the way. I am highly likely go and find something to do.
My strength in this experience was mainly my ability to handle seeing grotesque wounds and not being bothered by it. Blood, broken bones, open wounds, or anything of that nature has never really bothered me. I am almost sure that one day I will cross something that will have an ill effect on me. However, until then (and more than likely after then), I want to be in the middle of it all learning whatever I can about everything I can.
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