Legally Speaking: Wound care and perioperative nurses

Wound care nurses provide care to individuals with ulcers of the lower extremities due to poor circulation or diabetes and individuals with wounds sustained during a traumatic event. Another group of nurses who provide expert wound care on a regular basis are perioperative nurses. The Association of periOperative Registered Nurseshas developed a Surgical Wound Classification Decision Tree to help establish classifications for the surgical wounds perioperative nurses see on a daily basis. The decision tree is based on a scheme developed by the CDC. The decision tree, which can be found at the AORN website, contains clinical observations which can then be used to determine the likelihood of a surgical site infection. The classification can then guide appropriate surveillance and preventive measures that need to be taken by nursing personnel. As an example, if the surgical wound occurred due to a nopenetrating blunt trauma, the surgical procedure free from entry into the respiratory, alimentary or genitourinary tract, and the surgical wound is closed or drained with closed drainage, the classification of the wound, determined by the circulating nurse, is a Class I-Clean wound, according to the AORN website.

Documentation is essential

Documenting the assessment and the classification of the surgical wound by the circulating nurse in the perioperative setting is essential for good nursing care, not only in the perioperative phase, but also when the patient leaves that setting and goes to a patient care unit. The wound care must be appropriate to the wound's classification. Such care could include dressing changes, careful assessment of the patient's overall condition (e.g., vital signs, color, level of pain), assessment for possible dehiscence, proper medication administration, including antibiotics, and the observation and assessment of any postoperative wound drain.

Wound care case details

In one reported case (2009, Kerns v. HCA Rehab), a patient was transferred from the hospital to a rehabilitation facility after surgery for a hip replacement. The patient's discharge instructions from the hospital, which were ordered after the surgery and based on the perioperative nurse's initial post - surgical care and the surgeon's orders - required that the surgical wound be observed daily during the daily dressing changes. A week after the patient's arrival at the facility, the nurse changing the dressing reportedly dropped the dressing to be placed on the patient's wound. Instead of getting a clean dressing, she placed the dropped dressing on the patient's surgical hip wound. Eight days later, the patient was re-admitted to the hospital due to an E. coli infection in the wound. The wound was irrigated and debrided at the hospital and the hip prosthesis had to be removed and reinserted several months later. The patient filed a lawsuit alleging negligence of the nurse for failing to meet her standard of care by using a dressing that was not sterile. The rehabilitation facility was also found negligent for failing to educate its nurses in proper wound care and infection control procedures. In addition, the facility was found to be negligent in failing to assign a competent nurse to the patient. An award of $437,239 was given the patient, according to an article in the Legal Eagle Eye Newsletter published in 2010. Although no perioperative nurse in the above case had a role in the rehabilitation nurse's negligent conduct, this case points out the importance of the circulating nurse's documented initial assessment of a surgical patient's wound, its classification, and the nursing plan of care required to be done by subsequent nurses who care for the patient. Adequate and complete documentation by the perioperative nurse not only helps ensure non-negligent care for the patient, but it also avoids the perioperative nurse's involvement in a later suit filed by an injured patient due to negligent care of the surgical wound. Although an implausible excuse for what occurred, the nurse involved in this case could try and allege that the nursing care plan from the hospital and the perioperative nursing notes did not guide her in discarding the dressing she dropped on the floor and using a new, sterile dressing in its place.