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Practical Issues in Wound, Skin and Ostomy Management
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN
We’ve all experienced how a bad night’s sleep can affect our mood and ability to function the next day. Now imagine you’re a patient who has a pressure ulcer, most likely secondary to a declining disease state, and you’re being awakened and manipulated every 2 hours or in some cases hourly. How is your body supposed to recover without adequate sleep? (more…)
Read MoreBy Jennifer Oakley, BS, RN, WCC, DWC, OMS
I used to think I could do it alone. I took the wound care certification course, passed the certification exam, and took all of my new knowledge—and my new WCC credential—back to the long-term care facility where I worked. I was ready to change the world.
It didn’t take me long to figure out that I couldn’t change the complex world of wound care alone. I needed a team of specialists who could manage my patient’s troubles with nutrition, swallowing, activities of daily living, positioning, body image issues, and many other areas that required expertise I didn’t have. (more…)
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By Lydia A. Meyers RN, MSN, CWCN Missed care, a relatively new concept in the medical community, refers to any part ofrequired patient care that is omitted of delayed. It’s not the same as a mistake or error, but like them, missed care can negatively affect patient outcomes. I want to share the case of a patient admitted into home…
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN As wound care clinicians, we know that an interdisciplinary, holistic approach to prevention and management of a wound is crucial to positive outcomes, no matter where the patient is being seen. Yet too often when a patient transfers from one care setting to another, the only wound information that’s communicated is the…
Antibiotics and conservative surgery yield similar outcomes in patients with diabetic foot osteomyelitis A study in Diabetes Care finds that antibiotics and surgery have similar outcomes related to rate of healing, time of healing, and short-term complications in patients who have neuropathic forefoot ulcers and osteomyelitis, but no ischemia or necrotizing soft-tissue infections. “Antibiotics versus conservative surgery for treating diabetic…
Greet the new year by tapping into some new resources. Free app for patients with Crohn’s Disease GI Buddy is a free tool from the Crohn’s & Colitis Foundation of America that patients can use to stay on top of managing their Crohn’s Disease or ulcerative colitis symptoms. Patients can record what they eat, track their treatment and well-being, and…
By Beth Hoffmire Heideman, MSN, BSN, RN, WCC, DWC, OMS Fifty shades of wound care at home refers to treating the whole patient and the patient’s caregiving supporters—not just the wound. Only by understanding the nuances, or shades, of a patient and his or her environment can clinicians best achieve desired outcomes. Wound healing in home care depends on teamwork.…
Aresolution is a serious decision or determination to do, or not to do, something. Traditionally, most New Year’s resolutions focus on self-improvement: losing weight, giving up a bad habit, exercising more, being a better person. Because most of us spend about half of our waking lives at work, perhaps our work lives should be the subject of some of our resolutions. Here…
By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Description The spiral wrap is a technique used for applying compression bandaging. Procedure Here’s how to apply a spiral wrap to the lower leg. Please note that commercial compression wraps come with specific instructions for…
By Kulbir Dhillon, MSN, FNP, APNP, WCC Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic. Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude…
By Toni Ann Loftus, MBA, RN, MHA Meetings are a powerful communication tool. They bring together people who can look at an issue from their own unique perspective and contribute to a solution acceptable to many disciplines. Generally, meetings are held to: • discuss common issues • brainstorm ideas for solving specific concerns • make collaborative decisions about a shared…
By Jennifer Zinn, MSN, RN, CNS-BC, CNOR, and Vangela Swofford, BSN, RN, ASQ-CSSBB For surgical patients, operative wound classification is crucial in predicting postoperative surgical site infections (SSIs) and associated risks. Information about a patient’s wound typically is collected by circulating registered nurses (RNs) and documented at the end of every surgical procedure.
By Marcia Spear, DNP, ACNP-BC, CWS, CPSN Chronic wound infections are a significant healthcare burden, contributing to increased morbidity and mortality, prolonged hospitalization, limb loss, and higher medical costs. What’s more, they pose a potential sepsis risk for patients. For wound care providers, the goal is to eliminate the infection before these consequences arise. Most chronic wounds are colonized by…
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By Lydia A. Meyers RN, MSN, CWCN
Missed care, a relatively new concept in the medical community, refers to any part ofrequired patient care that is omitted of delayed. It’s not the same as a mistake or error, but like them, missed care can negatively affect patient outcomes.
I want to share the case of a patient admitted into home health care for wound care. The case includes several areas of missed care from many different different sources. (more…)
Read MoreBy Gregory S. Kopp, RN, MN, MHA
A new job can be stimulating, but it can also be stressful. Not only will you have new responsibilities, but you’ll also have a new setting, new leaders, and new colleagues. And the quicker you can figure out who’s who and what’s what—without stepping on anyone’s toes—the better off you’ll be.
But establishing positive relationships while performing your new job well can be tricky. And early missteps can have a lasting effect on your working relationships and your effectiveness. That’s why I recommend using the four tactics below, starting on day one. (more…)
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With so much focus on dressing choices, it’s easy to forget the importance of wound cleansing. Cleaning a wound removes loose debris and planktonic (free-floating) bacteria, provides protection to promote an optimal environment for healing, and facilitates wound assessment by optimizing visualization of the wound. You should clean a wound every time you change a dressing, unless it’s contraindicated.
Here’s a review of how to choose and use a wound cleanser so you can see if your practice is up to date. (more…)
Read MoreIf you’re keeping up on wound care, you know a lot of new things are coming to market with enough decent science behind them to make them reasonable options to consider in your practice. And as true-blooded Americans and citizens of the post-industrialized world, we want what’s newest, fastest, and best in class in everything. It’s just our nature.
But does it truly serve us to be eager to try new therapies even when the current treatment plan is successful? Perhaps. We know we must never close our eyes to new developments in our field that can lead to better outcomes. Knowing when and what to change can lead to better outcomes for the patient, the wound, and our collective pocketbook.
I’ve long maintained we can achieve excellent-quality wound care if we just stick to the basics the vast majority of the time. Why? Systemic, psychosocial, and local factors all affect wound healing—not just the dressing or cream. Our job is to provide the optimum environment possible for wound healing. That requires us to look at and support the whole body toward optimum health, not solely the wound.
The basics begin with identifying the cause of the wound and implementing interventions to reduce, control, or eliminate the cause. Next, we strive to manage local and psychosocial factors by choosing topical products that will maintain moisture balance, keep the wound warm, and protect it. If the wound doesn’t show progress toward healing within 2 weeks (or as expected, given the patient’s overall condition and ability to heal), we need to reevaluate the plan and begin making changes.
The best rule is to make one change at a time. That makes it much easier to determine what’s working and what isn’t. Once all the basics are in place and required changes have been made, if healing is still stalled or nonexistent, consider trying the available new products and specialty products.
Never close your clinical mind to advances in the field. To do that would be a disservice to your patients. But you should change the treatment plan only when a change is needed—not just for the sake of changing it.
Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois
Each month, Apple Bites brings you a tool you can apply in your daily practice.
According to the American Diabetes Association, all patients with diabetes should be screened for loss of protective sensation in their feet (peripheral neuropathy) when they are diagnosed and at least annually thereafter, using simple clinical tests such as the Semmes-Weinstein monofilament exam.
The Semmes-Weinstein 5.07 monofilament nylon wire exerts 10 g of force when bowed into a C shape against the skin for 1 second. Patients who can’t reliably detect application of the 5.07, 10-g monofilament to designated sites on the plantar surface of their feet are considered to have lost protective sensation. (more…)
Do you experience chronic stress? Is your body stiff and inflexible? Does your mind seem dull and sluggish, your spirit exhausted?
Restorative yoga may help “open” your joints, ease your mind, and revive your spirit. It’s based on the concept that we’re overstimulated and don’t get enough rest. Constant stimulation activates the sympathetic nervous system, overtaxing the fight-or-flight response. The body responds by increasing cortisol and glucose production, which (along with additional unhealthy responses) raises the risk of metabolic syndrome.
Restorative yoga promotes active relaxation, helping to halt the overstimulation cycle. It promotes balance by alternately stimulating and relaxing the body, which is supported in yoga poses with such props as blankets, pillows, yoga mat, and eye covers. Research suggests restorative yoga may ease hot flashes in postmenopausal women and may promote a calm, positive mood in women with ovarian or breast cancer.
Restorative yoga takes a five-faceted approach to relieve the effects of stress. Over time, you’re likely to notice a new awareness of and appreciation for your body, mind, and spirit.
Simply put, networking is an information exchange, a forum for communicating your needs or agenda and, in return, listening and responding to others’ needs or agendas. Good networking requires emotional reciprocity, which means caring about the needs and agendas of the people you network with. Caring about others’ needs is what nurses do, so networking really shouldn’t be that difficult for a nurse.
1. Using props, restorative yoga supports the body in yoga poses, helping muscles and joints release tension and achieve muscular balance.
2. The restorative poses move the spine in all directions—flexion, extension, rotation, and lateral flexion. This enhances spinal flex-ibility, lubricates vertebrae, and strengthens the deep muscles that stabilize the spine.
3. Inverted poses, in which the feet and legs are elevated, counter the effects of gravity and promote lymph and fluid drainage to the heart.
4. The poses compress and release internal organs, cleansing them while aiding removal of cellular waste and renewing oxygen and nutrients.
5. Finally, the poses balance the body’s male (prana) and female (apana) energies.
To learn the poses, consider taking a restorative yoga class. (See Finding an instructor.) Beforehand, make sure to tell the instructor about any special health concerns you have, so the instructor can modify the poses for you. Expect to bring your own blankets, pillows, eye covers, and yoga mat. The class will last from 60 to 90 minutes.
Restorative yoga typically doesn’t involve active (hatha) yoga poses, although it may include stretching poses to warm muscles and joints before the restorative poses begin. The instructor will help you use your props to make the poses right for you, and will direct you into a pose using them. Expect to stay in the pose for 5 to 10 minutes. The instructor will guide you by helping you focus on your breath and turn your attention inward. If your mind wanders and your body stays active, accept this reaction and don’t judge yourself. Over time, you’ll learn to use your breath to release tension and to focus and calm your mind.
After you hold the pose for the required duration, the instructor will help you into the next one. Generally, the class is near-silent, with minimal talking; the lights are low and music may play.
When the class ends, you may feel more relaxed and in touch with yourself. If you feel restless and jittery instead, accept your reaction. Don’t judge yourself. Try again. Give yourself the opportunity to experience something different.
Restorative yoga is just one method to renew and reconnect with your inner being. Only you can know if it’s right for you. n
Selected references
Cohen B, Kanaya A, Macer J, Shen H, Chang A, Grady D. Feasibility and acceptability of restorative yoga for treatment of hot flushes: a pilot trial. Maturitas. 2007;56(2):198-204.
Danhauer SC, Tooze JA, Farmer DF, Campbell CR, McQuellon RP, Barrett R, Miller BE. Restorative yoga for women with ovarian or breast cancer: findings from a pilot study. J Soc Integr Oncol. 2008;6(2):47-58.
Lisa Marie Bernardo is the managing member of The PIlates Centre, LLC, in Hampton Township, Pennsylvania, and adjunct faculty at Carlow University School of Nursing in Pittsburgh, Pennsylvania.
Sherry stands nervously in the doorway, watching several dozen people chat each other up. The sound of her heartbeat threatens to drown out the conversational din. For the people on the other side of the door, this is a networking event. But for Sherry, it seems like a swap meet of business cards.
If Sherry sounds like you, know that you’re not alone. For many people, networking means an awkward evening spent cradling a wine glass in one hand, thrusting a business card at someone with the other hand, and exchanging small talk.
Networking is one of the most overused, misunderstood, and underestimated terms in the business world (and yes, that includes health care). Actually, networking is just a newish term for an activity that has been around for millennia. Savvy people have always seen the wisdom of seeking out others who can help them get ahead.
Simply put, networking is an information exchange, a forum for communicating your needs or agenda and, in return, listening and responding to others’ needs or agendas. Good networking requires emotional reciprocity, which means caring about the needs and agendas of the people you network with. Caring about others’ needs is what nurses do, so networking really shouldn’t be that difficult for a nurse.
Think of networking as a great opportunity to make yourself known, gather critical information, and meet people who can help you now and in the future. Through networking, you can make contacts that further your agenda—whether it’s to find
a mentor, get information on a program you’re interested in, change jobs, or advance from your current position.
Networking isn’t just who you know, but who knows you. If you listen to other networkers and give them the resources they seek (as by introducing them to key people or sharing valuable information), they’ll become grateful—and indebted—networking colleagues.
At a networking event, the idea isn’t to meet the greatest number of people possible in one evening. It’s to meet the “right” people—those who can help you realize your goal.
When approaching a networking situation, ask yourself, “What do I want this experience to lead to?” You’ll be much more effective if you have a laser-focused goal. The most successful networker isn’t the one who walks away with the most business cards. It’s the one who leaves with the contacts and information he or she had been seeking.
To demonstrate this point, let’s take the case of two wound care specialists, Myrna and Doris—colleagues who’ve carpooled together to a meeting of their professional organization.
Myrna arrives with an agenda and a plan for the evening: She wants to develop a wound care speakers bureau to boost the community profile of staff at her facility. She seeks out several speakers, who give her valuable tips on how to market her expertise. She also shares her vision of a speakers bureau with attendees from other facilities—and is surprised by the support and tips they offer. She leaves the meeting with valuable information that can further her vision. On the way home, she jots down a reminder to send one of the people she met an article he might find helpful. She also makes notes about what she learned tonight, so she can follow up that week. Clearly, Myrna’s networking has been effective.
Doris, on the other hand, goes to the meeting unfocused. She meanders about the room speaking with a lot of attendees, and exchanges a few business cards. But the “Where-do-you-work?” conversations that ensue provide little insight. Although she enjoys the meeting somewhat, she has accomplished little. That’s understandable, as she set out with no goals. She might have been better off spending the night watching television.
To succeed at networking, learn networking etiquette. Rule #1: Turn off your cell phone—or at least put the ringer on vibrate. If you absolutely must take a phone call, discreetly leave the room.
More etiquette advice:
• Wear your name tag on your left lapel so you don’t block your name when shaking hands. If you fill out the name tag yourself, print clearly so your name and title are visible from about 5 feet away. That way, others won’t need to squint at your chest to read your name.
• Keep your handshake firm and friendly. Don’t hang on, and don’t pump! Remember to make eye contact, and smile.
• Keep breath mints handy. Networking usually takes place around drinks and food, and the first thing that greets a new contact shouldn’t be the garlic and onion dip.
• Keep your business cards handy (a business card holder is best), but don’t throw them at everyone you meet. Hand your business card to a contact so it’s right side up and facing that person. When someone hands you a business card, take a moment to look at it; then say thank you and carefully put it away. It’s disrespectful to deface a business card, so don’t write on the back of it.
Okay—you’ve set an agenda, attended the networking event without violating etiquette, and made some good contacts. Now what? This is where many people drop the ball. They fail to follow through on the contacts they make and the information they gain. They simply shove the contacts’ business cards into a Rolodex, where they will sit forgotten.
Instead of letting business cards collect dust, develop a system that helps you follow through with your contacts—whether it’s an electronic tool, a simple calendar notation, or a color-coded filing system. Jot down contact information on each
person you met, along with a summary
of your conversations, when you need to follow up, and so forth. Make the system work for you.
Next, follow through with appropriate communication. Send handwritten thank-you notes to the contacts who gave you valuable information or resources—for instance, those who introduced you to a key player or offered to make a phone call on your behalf. If possible, your note should mention how that information worked out for you. (See Seven steps to effective networking by clicking the PDf icon above.)
In the coming weeks, months, or years, keep these relationships alive and thriving by sending tips or information to each contact. If you see a newspaper article or Internet story about a topic a particular contact was interested in, send it to him or her. This shows you’re thinking about that person, and conveys your generosity and willingness to continue a reciprocal relationship.
Networking opportunities can happen anywhere. Don’t wait for them—create them. Pinpoint your goal, identify the key people who can help make it happen—and then network! It’s as simple as picking up the phone, sending an e-mail, or meeting over lunch. With a little effort, networking can be an enjoyable and valuable career resource.
Selected references
Ames G. Follow-up after the networking meeting and job interview. www.garyames.net/5-followupaftermeet.htm. Accessed August 15, 2012.
Wiklund P. Follow up: key to networking success. Approved Articles Website. www.approvedarticles.com/Article/Follow-up—Key-to-Networking-Success/5022. Accessed August 15, 2012.
Joan C. Borgatti, MEd, RN, is the owner of Borgatti Communications in Wellesley Hills, Mass., which provides writing, editing, and coaching services. You may e-mail her at [email protected].
Read MoreNecrotizing fasciitis (NF) results from an infection that attacks the fascia and subcutaneous tissues. The primary bacterial etiology is group A streptococcus, a facultative anaerobic bacterium. However, other bacteria may contribute. Sometimes called the “flesh-eating” disease because of the potentially devastating effect on the afflicted patient, NF can be monomicrobial or polymicrobial.
The four typical settings for NF are:
Because of the rapid course and ravaging nature of acute NF, clinicians must maintain a high index of suspicion if the patient has suggestive signs and symptoms. In 1990, puppeteer Jim Henson (best known for creating the Muppets) died from NF. At that time, little was known about the progression of group A streptococcal infection.
The disease can quickly cause death, so starting immediate treatment is even more crucial than confirming the diagnosis. Once the disease is suspected, antibiotics must be given immediately and the patient must be prepared for surgery at once. NF spreads rapidly, capable of progressing from a small lesion to death in days to weeks. Thus, delayed diagnosis increases the risk of death. Lack of knowledge about the disease and inability to recognize it promptly are the main reasons many victims die. This article can improve your knowledge base.
NF was discovered in 1871 by Joseph Jones, a Confederate Army surgeon. At that time, it was called hemolytic streptococcal gangrene, nonclostridial gas gangrene, nonclostridial crepitant cellulitis, necrotizing or gangrenous erysipelas, necrotizing cellulitis, bacterial synergistic gangrene, or synergistic necrotizing cellulitis.
NF involves the fascia, muscle compartments, or both. It can affect not only the muscle fascia but the superficial fascia. NF and cellulitis differ in the amount of tissue involved and extent of tissue involvement.
The most common areas of infection are the abdominal wall, perineum, and extremities. When NF affects the perineum and scrotum, it’s called Fournier gangrene, after the French dermatologist and virologist Alfred Jean Fournier.
The most common causes are trauma, surgery, and insect bites. The disease can affect persons of any age. Such comorbidities as diabetes, chronic renal failure, immunosuppressive therapy, hypertension, obesity, and malnutrition increase susceptibility.
NF falls into four classifications based on wound microbiology. Type 1, the most common, involves polymicrobial bacteria. Type 2 results from trauma and is associated with comorbidities. Type 3, rare in this country, stems from gram-negative marine bacteria. Type 4 is a fungal infection occurring mostly in immunocompromised persons. (See Comparing types of necrotizing fasciitis by clicking the PDF icon above.)
The four types of NF progress in a similar way. Bacteria secrete pyrogenic exotoxin A, which stimulates cytokines. These cytokines damage the endothelial lining; fluid then leaks into the extravascular space.
M proteins in streptococci and β-hemolytic streptococci exacerbate the immune reaction by inhibiting phagocytosis of polymorphonuclear leukocytes and normal neutrophil chemotaxis. As the immune reaction increases, blood vessels dilate, allowing toxins to leak through vessel walls, which in turn decreases blood flow. As the cascade continues, hypoxic conditions cause facultative aerobic organisms to grow and become anaerobic. These bacteria exacerbate destruction of surrounding cells and lead to release of carbon dioxide, water, hydrogen, nitrogen, hydrogen sulfide, and methane. As the infection continues to progress, toxins spread throughout the bloodstream and the patient becomes septic.
Obtain the patient’s medical history and description of the wound. Determine when the changes first appeared and whether the affected area seemed to get worse recently.
In all NF types, patients commonly present with a small, painful area (possibly with entry marks) but no other signs or symptoms. The wound may appear as a bulla, cellulitis, or dermatitis, representing an infection developing in underlying tissues. The skin may have a wooden-hard feel as the infection progresses to the subcutaneous space and causes necrosis. The wound becomes discolored and necrotic; drainage is rare until surgical debridement begins. The patient quickly develops fever, chills, nausea, and vomiting. As NF progresses, bullae become dark purple with darkened edges; the patient grows disoriented and lethargic, and organ failure and respiratory failure
ensue. Without treatment, the patient dies.
Diagnostic tests usually include magnetic resonance imaging, complete blood count with differential, comprehensive metabolic panel, and cultures. (See Diagnostic findings in necrotizing fasciitis by clicking the PDF icon above.)
Immediate surgical debridement and broad-spectrum antibiotics are needed to stop the immune response to infection. Clindamycin, gentamicin, penicillin, or metronidazole may be given alone or in combination until culture results are available. Supportive care includes total parenteral nutrition for nutritional support, I.V. fluids, and oxygen. Limb amputation should be done only as a last resort.
Surgical debridement involves penetrating deep into the fascia and removing all necrotic tissue. After the first debridement, release of “dishwater fluid” may occur.
Administering hyperbaric oxygen therapy (HBOT) after the first debridement increases tissue oxygenation, thus reducing tissue destruction by anaerobic bacteria. During HBOT (usually given as a 90-minute treatment), the patient breathes 100% oxygen in an environment of increasing atmospheric pressure.
HBOT should be given in conjunction with surgical debridement (usually after each debridement) and should continue until necrotic tissue ceases and cell destruction stops. HBOT also promotes collagen synthesis and neoangiogenesis (new blood vessel growth), which boosts blood supply and oxygen to tissues.
Adverse effects of HBOT include ear pain, oxygen toxicity, and seizures. Ear pain can be minimized by swallowing or yawning. If the patient continues to have ear pain, ear tubes may be inserted by an otolaryngologist. During HBOT, air breaks (intervals of breathing room air) are important in controlling oxygen toxicity (the main cause of seizures).
Throughout the HBOT treatment period, wound dressings must be simple. Well-moistened gauze dressings and an abdominal pad provide good support. Once necrotic destruction occurs, dressings depend on wound size and the need to fill cavities. The patient may require a diverting colostomy, depending on wound
location and the amount of uncontrolled diarrhea. Blood glucose levels must be monitored before and after HBOT, as this treatment affects blood glucose.
During initial treatment, patients need supportive care and monitoring. Once they’re out of danger, begin teaching them how to prevent NF recurrences. Advise them to control blood glucose levels, keeping the glycated hemoglobin (HbA1c) level to 7% or less. Caution patients to keep needles capped until use and not to reuse needles. Instruct them to clean the skin thoroughly before blood glucose testing or insulin injection, and to use alcohol pads to clean the area afterward.
Before discharge, help arrange the patient’s aftercare, including home health care for wound management and teaching, social services to promote adjustment to lifestyle changes and financial concerns, and physical therapy to help rebuild strength and promote the return to optimal physical health. One helpful patient resource is the National Necrotizing Fasciitis Foundation. The Centers for Disease Control and Prevention section on necrotizing fasciitis includes “Common sense and great wound care are the best ways to prevent a bacterial skin infection.”
The life-threatening nature of NF, scarring caused by the disease, and in some cases the need for limb amputation can alter the patient’s attitude and viewpoint, so be sure to take a holistic approach when dealing with the patient and family. Today, NF has a much better survival rate than 2 decades ago when Jim Henson died. In my practice, I’ve seen four NF cases. Thanks to early identification, good wound care, and HBOT, these patients suffered only minimal damage.
Selected references
Boyer A, Vargas F, Coste F, et al. Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med. 2009;35(5):847-853. doi:10.1007/s00134-008-1373-4.
Cain S. Necrotizing fasciitis: recognition and care. Practice Nurs. 2010;21(6):297-302.
Centers for Disease Control and Prevention. Notes from the field: fatal fungal soft-tissue infections after a tornado—Joplin, Missouri, 2011. MMWR. 2011;60(29):992.
Chamber AC, Leaper DJ. Role of oxygen in wound healing: a review of evidence. J Wound Care. 2011; 20(4):160-164.
Christophoros K, Achilleas K, Vasilia D, et al. Postraumatic zygomycotic necrotizing abdominal wall fasciitis with intraabdominal invasion in a non immunosuppressed patient. Internet J Surg. 2007;11(1). doi:10.5580/17a8.
Ecker K-W, Baars A, Topfer J, Frank J. Necrotizing fasciitis of the perineum and the abdominal wall-surgical approach. Europ J Trauma Emerg Surg. 2008;
34(3):219-228. doi:10.1007/s00068-008-8072-2.
Hunter J, Quarterman C, Waseem M, Wills A. Diagnosis and management of necrotizing fasciitis. Br J Hosp Med. 2011;72(7):391-395.
Magel DC. The nurse’s role in managing necrotizing fasciitis. AORN J. 2008;88(6):977-982.
Phanzu MD, Bafende AE, Imposo BB, Meyers WM, Portaels F. Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer). Am J Trop Med Hyg. 2012;82(3):478-481.
Ruth-Sahd LA, Gonzales M. Multiple dimensions of caring for a patient with acute necrotizing fasciitis. Dimens Crit Care Nurs. 2006;25(1):15-21.
Stevens DL, Bisno AL, Chambers HF, et al; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.
Su YC, Chen HW, Hong YC, Chen CT, et al. Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg. 2008;78(11):968-972.
Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg. 2007;2:19.
Lydia Meyers is a medical reviewer for National Government Services in Castleton, Indiana, and a clinical liaison at CTI Nutrition in Indianapolis. She has 11 years of wound care experience in nursing homes, wound clinics, and home health.
Read MoreJim, a 52-year-old patient with colon cancer, received a new ostomy. He needed a custom fit for his appliance, which took 10 days. During this time, trying to obtain a good seal and treat the peristomal area wasn’t easy. Despite my best efforts, Jim’s skin was denuded from contact with stool. Although he was in great discomfort, he wanted to wait until my next visit to tell me about the problem. Fortunately, his wife was worried and contacted me directly.
Jim lives in a neighborhood with a low crime rate, so I’m able to see him within
a few hours of his wife’s call, even though it’s late at night. As it turns out, I make
extra visits to help him manage his stoma until the customized appliance is ready. As with any home care situation, I’m ready to do my best for my patient.
Many home-care patients like Jim benefit from the interventions of a wound care clinician (WCC). More than one-third of all home-care admissions are wound related, and home wound care has become one of the fastest growing needs and skills in home-care services. So if you’re a WCC, you may want to consider home care as a practice option.
Delivering wound care in the home differs dramatically from delivering it in the hospital. Given the complexity of wound care and the multiple factors that affect healing, home wound care is a challenge. Some patients have chronic conditions, such as diabetes or wounds or open sores that don’t heal easily. In other cases, the patient or caregiver is unable to change dressings. That’s where the WCC comes in.
Like other patients across the continuum of care, home-care wound patients require accurate and thorough wound assessment, as well as documentation that provides information about wound status and aids development of a plan that supports healing.
Of course, the plan of care must address the whole patient, not just the “hole” in the patient. The WCC must take into account comorbidities, individual wound-care requirements, assistance the patient may need due to physical or mental deficits, and nutritional support. Additional factors that affect wound-care strategies include wound characteristics, family support, and insurance guidelines and reimbursement.
The WCC’s role in home care includes providing clinical expertise, working with other healthcare team members, and providing education.
If you’re a WCC and considering home care as a career option, know that practicing in the home can be a real eye opener. For starters, consider geography. Shortly after I started as a wound care nurse/consultant in home care, I was visiting patients all over New Jersey, some days driving 200 miles. As I quickly discovered, once you enter the home, don’t assume you’ll simply change a dressing and then be on your way. Instead, you may find you are, in essence, the family case manager who’s expected to “fix everything.” This role requires equal doses of planning and creativity.
What’s more, expect to do some improvising. In acute-care settings, all the supplies you may need to prevent infection—gowns, gloves, masks—usually are within arm’s reach. But in home care, these supplies may be absent, meaning you’ll need to set up the cleanest environment you can under the circumstances. That might mean using disposable drapes and dressings. Be sure to carry large amounts of hand sanitizer.
Dressing selection is perhaps the biggest challenge in home wound care because
it involves not just wound-specific issues but financial and practical considerations. The ideal dressing in the home is one that needs to be changed only every other day, at most. Evidence shows it’s not practical to try to change dressings two or three times daily at home unless the family is providing care.
Because the home environment may lack all the resources you need, remembering everything you need to do before you leave the patient’s home may be challenging. To help keep things on track, develop a checklist of reminders that covers these points:
Typical home wound-care hours are 8:30 a.m. to 4:30 p.m. But realistically, expect variations. For instance, as you’re about to leave, the patient might say, “My wife isn’t feeling well. Could you take her blood pressure?” This means you’ll stay a little longer.
When planning home visits, be aware of safety concerns. If visiting after hours could put you in danger, it’s safer to instruct the patient to call an ambulance and go to the local ED.
Reimbursement is an important factor in wound care in the home. To be eligible for home care through Medicare, patients must be homebound—meaning they don’t routinely travel to run errands or visit or they’re not able to obtain or receive needed medical services. (With private insurance and workers’ compensation, eligibility requirements may be less restrictive.)
Know that a Medicare patient receives home care as an “episode.” Episodes are 60-day periods; within each 60-day episode, a $592 cap is allotted should a patient require supplies for wound or ostomy care needs. Except for negative-pressure wound therapy, a home care agency can’t bill Medicare for products used; instead, the home-care agency is responsible for the cost of all topical wound-care products and dressings. Agencies may keep patients on service even if they exceed the allowed amount, although patients reaching maximum benefits commonly are discharged from service. Home-care agencies have no choice but to discharge Medicare patients they find aren’t truly homebound.
Also, be aware that Medicare views home health service as an interim service. When a patient is no longer making progress, Medicare expects that the family will provide the patient’s care or the patient will enter a skilled care facility. So it’s important to work hard to obtain good outcomes—not just for the patient but to maintain Medicare reimbursement. Like many private insurance companies, Medicare reimbursement is based on pay for performance; if an agency doesn’t deliver optimal outcomes, it receives lower reimbursement, increasing its financial burden.
WCCs use their knowledge and clinical expertise to improve patient outcomes and teach patients, families, and other healthcare team members. They also give the agency recommendations for care and supplies that are evidence based and reflect current best practices in wound care. Accomplishing these goals in a timely fashion under various constraints can be challenging. But if you choose to work in the home, try to keep a smile on your face and joy in your voice for each patient and family. If you like challenges and want a job where you can apply your creativity and function independently, becoming a home-care WCC might be the right choice for you.
Connie Johnson provides wound care in the home and in acute-care settings.
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