Wounds present challenges for nurses in any setting, but in the home, clinicians also may deal with vermin, no running water, patients who cannot pay for supplies and unhealthy lifestyle choices by the patient or their caregivers. Yet nurses in the field rely on a passion to overcome all obstacles to help their patients.
I love what I do, said Jocelyn Francois, MSN, RN, WOCN, a wound care ostomy continence nurse at MJHS Home Care in Brooklyn. The reward is to see the patients wound heal.
As a wound care nurse, Francois consults with other MJHS home care nurses to identify a wounds etiology, recommend the appropriate treatment and secure a plan of care from the physician. She may evaluate a wound via telehealth but, ideally, will make a joint visit to help the staff nurse learn.
Marian Owens, BSN, RN, CWOCN, a wound care specialist at North Shore-LIJ Home Care in Great Neck, N.Y., is called in for wounds that are not healing, on patients with daily dressing changes, before the patient is recertified for a longer episode of care, and often when the managed care company requests a certified nurses assessment.
In home care, you work as a team, Owens said. Because of the length of service, you develop relationships with the patients.
Working in the home gives you a different perspective, added Dina Stasolla, RN, a nurse at Visiting Nurse Association of Hudson Valley in Tarrytown, N.Y.
I love it, because you walk in to [find] a huge abdominal wound you could put your fist in and six to eight weeks later, its closed, Stassola said. You have a rapport with the physician who ordered [the care]. You work with the same people all of the time.
Nurses may make suggestions to the physician, but some surgeons often have a preferred plan of care, said Stephanie Lutz, BSN, RN, a staff nurse in the Queens region at VNSNY.
While in the home, nurses work alone and must be flexible and organized, said Fran Cox, BS, RN, CWON, a wound care nurse at Winthrop-University Hospital Home Health Agency in Mineola, N.Y.
Home wound care basicsJocelyn Francois, RN
Home care nurses treat a wide variety of wounds everything from pressure ulcers to surgical and traumatic wounds to stasis ulcers. Nurses typically use a clean versus sterile technique. Nurses carry their own soap, alcohol-based sanitizer, paper towels and gloves. They create a clean field and will place their bag on a plastic trash bag or paper towels on a firm, dry surface. They double bag soiled dressings and dispose properly.
Home care nurses must order supplies from a vendor for delivery. Some patients may not be able to afford the supplies, or the parcel service will not deliver to unsafe areas. That forces the nurses to come up with a different solution, maybe an alternate treatment plan or having supplies delivered to the office.
In the home, nurses rarely use saline wet-to-dry dressings. Medicare and other insurers no longer advise using this type of dressing. Nurses use advanced wound-care products, such as alginates and gels, and negative-pressure therapy, all of which require less frequent visits.
Moist wound healing is the big thing, Lutz said.
Owens described a case with necrotizing fasciitis extending across the patients abdomen and into the perineal area. It required two nurses working together for two to three hours to apply the negative-pressure therapy, but the wound closed. It was a great outcome, Owens said.
Most patients with wounds at Winthrop home care are seen two to three times per week. Nurses teach caregivers how to provide care when appropriate.
Nurses build bonds
Good relationships with patients are invaluable, Francois said. You need to engage the patient and family from the beginning to participate in their own care, she said. Make sure you have a good rapport. You are on the patients territory. and they must approve the plan of care.
The home care nurse must assess co-morbidities and help patients learn to manage all of their conditions. Nutrition is key to healing, and nurses will educate and may suggest modifications to the diet.
Nurses figure out ways to work within cultural preferences. A male might make decisions for the female in the home or refuse to let a female change his dressing, and the nurse must adjust, Owens said.
Home care nurses never know what to expect.
Home environments may be less than ideal, with no running water or bugs scampering around. Bedbugs are a common problem. Stasolla recalled a patient with maggots all over his feet. The physician requested the patient remove the dressing and clean his foot with soap and water in the tub before the nurse arrived.
Depending on the agency, nurses may handle bugs and unsafe clutter differently, usually bringing in a social worker to solve home issues. At MJHS, agency staff will arrange for the patient to be cared for in another setting, a family members home or nursing home, while an exterminator deals with bugs. If VNA determines the patient is in an unsafe environment, it may come up with an alternative plan for the person.
Every day is an adventure, Cox said. When you open the door, you have to adapt.
Debra Anscombe Wood, RN, is a freelance writer.