Nursing Spotlight: A Day in the Life of a Wound Care Nurse
Working as a wound ostomy continence nurse (WOCN) is like working in an Emergency Department – you never know what’s coming through the door next, says Maureen Ingram, RN, BC, MSN, CWOCN, nurse educator, Delaware County Memorial Hospital.
Maureen Ingram, RN
Ingram is one of four Crozer-Keystone nurses who are certified wound care nurses. Janet Slaven, RN, CWOCN, CIT, fulfills this role at Crozer-Chester Medical Center and Springfield Hospital. Sue DiPaolo, RN, WCC, DAPWCA, covers CKHS Home Care, and Kathy McLaughlin, RN, CWOCN, is on call at Taylor Hospital. All four serve as consultants to nursing and physicians, as educators for staff, patients and families, and as clinical care providers. They are experts on a laundry list of problems that include diabetic ulcers, pressure ulcers, venous stasis ulcers, arterial ulcers, vasculitic ulcers, infected wounds and ostomies, among many others.
Sue DiPaolo, RN
“On any given day, you could have a patient with a deep Stage 4 pressure ulcer or an abdominal fistula, or someone who is having problems with an ostomy,” Ingram says. “You have to be prepared for anything.”
When consulted, the WOCN visits the patient to determine the most appropriate wound care, then discusses the case with the physician and makes recommendations. If uncomplicated wound care is called for, most bedside nurses can proceed on their own using algorithms and reference manuals that the WOCNs have provided along with constant nurse education. If more complex care is needed, such as negative pressure wound therapy, the WOCN educates the staff for that particular patient.
“We also consult with Nutrition, which is extremely important to wound healing,” Ingram says. “We often talk to Case Management and Social Work when we discover issues that need to be addressed at the patient’s home such as inadequate family caregiver support. Wound care requires an interdisciplinary approach.”
Best Products and Practices
One of the biggest challenges for the WOCN is staying abreast of the plethora of new wound care products constantly being introduced. As members of the Delaware Valley Chapter of the Wound, Ostomy and Continence Nurses Society, Slaven and Ingram routinely attend education sessions, access online resources, and network with professional colleagues to make sure they are providing the latest and best quality care to Crozer patients. DiPaolo engages in the same activities as a diplomate member of the American Professional Wound Care Association.
Ingram and Slaven serve as members of Crozer-Keystone’s Medical Value Analysis Committee. In this capacity, they continually research new wound care products and make evidence-based recommendations for the CKHS formulary. Most recently, the two gained approval for Mepilex®Border, a foam dressing that is especially effective for patients with skin tears, a common problem in older patients.
“Mepilex is a Godsend for elderly patients whose skin is so frail,” says Ingram. “The dressing can be left on for seven days, greatly reducing the trauma and pain associated with frequent dressing changes, in addition to saving a lot of nursing time.”
Ingram and Slaven are proud of the products they have recommended for the CKHS wound care formulary. Among them are Aquacel®Ag for wounds with high levels of bacteria, Xenaderm® ointment for Stage II pressure ulcers, and Critic-Aid®, a barrier ointment that has proven highly effective for diaper dermatitis in incontinent patients.
One of the best practices for wound care is prevention. Slaven, Ingram and McLaughlin are part of a system wide committee established in 2008 to develop a skin and wound care bundle to reduce the incidence of pressure ulcers among patients in CKHS hospitals. Implemented last year at DCMH and Crozer, the bundle is helping to increase the use of preventative care measures and reduce the incidence of pressure ulcers. (See “Best Practices: CKHS Skin Care Bundle Receives National Attention.”)
In addition to providing the best dressings and treatments, Slaven emphasizes the importance of providing wound care patients with emotional support. “I believe in a holistic approach,” says Slaven who received certification in integrative and complementary therapies from Drexel University last year. “Patients who have ostomies are often very anxious and upset. I try to be a calm presence, reassuring them that they won’t smell, no one will be able to see it through their clothes and no one will know they have it unless they tell them. I assure them that they are not alone and plug them into resources such as support groups that may be helpful.”
Janet Slaven, RN
Slaven also calms her patients by offering soothing measures such as a back rub before a dressing change. “I want to reduce their stress and bring them to the level of greatest comfort before I begin the dressing change which is often painful,” she says. “Patients really appreciate this. I once had a patient who was back in the hospital a year later. When I walked in his room, he didn’t remember that I was the one who spent an hour on his dressing, but he did remember that I was the one who gave him the back rub!”
Wound Care at Home
Wound care is a really big issue for home care nurses and DiPaolo is the go-to nurse for assistance. “We see a wide range of wounds, from pressure ulcers to stasis ulcers, arterial ulcers, surgical incisions, lymphedema complications, acute wound post-hospitalization, and a lot of chronic wounds from simple to complex,” she says.
“As home care nurses, we must take a holistic approach and look at the patient’s whole environment,” DiPaolo continues. “How good is their nutrition? Are they incontinent? Are labs or support services needed? Do we need to call in home health aides or a social worker? It’s a team effort that involves nurses, physical and occupational therapists, and physicians. Our nurses know that I’m always available to them for wound consult and recommendations to improve the healing process.”
Wound care at home requires a lot of patient teaching about prevention techniques, such as nutrition, hydration, proper positioning and offloading, as well as care. Managing pain is also a big issue. “Many home care patients sit too much all day long because they are in pain,” DiPaolo explains. “This causes pressure ulcers on the sacrum. We teach them how to manage their pain so they can have better mobility.”
Despite patient teaching, stasis ulcers that require compression are another big challenge in home care. “We teach about the importance of compression, but when the stockings get worn out, patients often don’t replace them. As a result, the patient develops edema and that leads to other problems,” says DiPaolo.
“We try to give our patients as much prevention information as possible from day one,” she adds.
Enhancing Nursing Education
At DCMH and Crozer, Ingram and Slaven regularly provide nursing education, both at the bedside and in classroom sessions and skills fairs. Ingram also works with the DCMH Skin Care Committee and Nurse Education Council to disseminate information to the nursing staff. “I always emphasize that nurses have the power to call for a consult from Wound Care, Nutrition and Social Work without a physician order,” says Ingram. “As nurses, we are the ones who have the most direct contact with the patient and family. We are the ones who discover issues that need to be addressed, and nurses need to use that power to help the patient.”
Currently, Slaven is working to put wound care videos on the CKHS Nursing intranet site as a resource for nurses. The videos will provide instructions for more complex procedures such as vacuum assisted closures, fecal management devices, and ostomy care, among others.
DiPaolo conducts nursing education programs and in services on wound care for CKHS Home Care nurses.
WOCN nurses find great reward in their work. “Being able to provide an intervention that will help the patient feel better is gratifying,” says Slaven. “Recently, I had a patient with a very complex abdominal situation that required multiple dressing changes daily. I contacted a company who makes customized wound dressing systems and was able to get one that made her daily care much easier.”
Slaven confesses that complex wound care patients sometimes keep her up nights. “More than once, I have found myself sitting in bed at night talking on the phone to a colleague about possible treatment approaches,” she relates.
“Wound and ostomy care can be difficult for patients and families to face,” DiPaolo says. “It’s rewarding when I can help them cope better. It’s also gratifying to see a wound heal and know that you’ve helped someone to be able to get up, move around and lead a more productive life.”
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