If you have ever provided care to a patient with a wound ? whether post-surgical, a wound due to diabetic neuropathy or a burn ? you know all too well how vital your assessments and interventions are either to heal the wound or, at a minimum, keep it from progressing further.
Wound care skills are vital to the well-being of your patient. So, too, is certification, either as a certified wound care nurse through the Wound, Ostomy and Continence Nursing Certification Board or as a wound treatment associate through WOCNCB?s educational programs for nonspecialty nurses who work in wound care.
Regardless of your certification or educational preparation to care for a patient?s wound, it is essential to practice in accordance with your standards of practice for that particular patient.
Consider patients who acquire pressure ulcers while in a healthcare facility. According to the Wound, Ostomy and Continence Nurses Society, ?avoidable? pressure ulcers are those that developed when a facility did not do such actions as evaluate the resident?s clinical condition and pressure ulcer risk factors and/or monitor and evaluate the impact of any interventions instituted to heal the ulcer. In contrast, an ?unavoidable? pressure ulcer is one that developed despite the facility?s evaluation of the resident?s clinical condition and pressure risk factors and instituted interventions with resident needs, goals and recognized standards of practice.
Needless to say, among other WOCN recommendations concerning pressure ulcers, more needs to be done to establish ?effective processes to ensure ... consistent application of evidence-based prevention interventions? by all staff in all settings. So, too, is the need for accurate documentation of preventive measures, and, when applicable, the clinical reasons why preventive measures are not appropriate or feasible so that if a pressure ulcer is ?unavoidable,? the clinical basis is evident.
The importance of evidence-based interventions and accurate documentation of preventive measures is underscored in a recent court decision in which a home healthcare RN was assigned the care of a patient who returned home with an ?almost healed? Stage 2 decubitus ulcer.
Approval was not given by the patient?s insurance company to visit daily so a reduced plan of visits was approved by the patient?s physician. During the first two visits, the patient?s pressure sore, located at the tailbone, was measured, the measurements were documented, and the RN?s assessment that the ulcer was ?100% pink with no odor? and would be completely healed in three weeks, was noted in the patient?s record. The RN left a voice mail with the physician concerning her findings.
On the next visit, which was two days after her visits above, the RN noted that the ulcer looked ?90%? pink and had a fetid odor.? The nurse documented these findings in the record and left another voice mail for the physician.
Three days later (no one answered the door on a visit two days after the last visit), the RN found the ulcer as she had seen it on her earlier visit and also observed that the patient?s lower right extremity was swollen. The RN suspected that the care that was to be done by the family was not being done, but she did not notify the doctor.
Three days later, the ulcer had ?serious changes,? including an increase in the serous drainage from the wound, a ?fetid? odor and the wound was significantly larger. Again the RN left a voice message for the doctor.
When the RN visited the patient again three days later, the pressure sore was even more necrotic. At this point, the RN told the family the patient had to go to the doctor?s office. He was admitted to the hospital with a Stage 4 ulcer that reached his tailbone. The patient?s ulcer never healed and it required a ?flap? procedure to attempt to close the wound.
The patient?s family filed a lawsuit and a large verdict was entered in favor of the patient. The court held that the RN?s negligence contributed to the patient?s worsened condition. This case illustrates clear directives for nurses caring for a patient with a pressure ulcer, especially when it appears that the wound deterioration could have been avoided.
Underscored by the principle that you have a duty to prevent an unreasonable and foreseeable risk of harm to the patient, the directives include:
Maintaining the standard of care for pressure ulcer patients;
Initiating appropriate clinical interventions when the patient?s condition and pressure ulcer deteriorate;
Contacting the physician personally (not by a phone message) and documenting contacts in the patient?s record;
In the home setting, assessing family responsibilities in the care of the patient and intervening as needed;
Using your professional judgment to alter care within your scope of practice (e.g., more frequent visits, discussion with the family about their responsibilities of care of the patient, suggest seeing the physician sooner); and knowing when to get help when you cannot handle a patient care situation by yourself.
Sources
WOCN (2009). Position Statement: Avoidable versus Unavoidable Pressure Ulcers. Available at www.wocn.org (Click Library/Resources on the left hand side of the home page, then Library on the drop down menu).
Olsten Health Services, Inc. v. Cody, 979 So. 2d 1221 (FL District Ct of Appeals) 2008. Available at http://caselaw.findlaw.com/fl-district-court-of-appeal/1160380.html (pages 1-8). Accessed November 17, 2014.
Nancy J. Brent (2012), ?But I left Voice Messages and Notes??, (1)2 Wound Care Advisor. Available at http://www.woundcareadvisor.com (Click on the Archives tab, then on the Journal cover for Volume 1, No. 2 (July/August 2012).
