Ensure inservice success by covering the basics
Ensure inservice success by covering the basics
Focus on documentation
Medical Innovations, a home health agency in Woodbridge, VA, has developed a simple inservice program that first reviews federal requirements for wound care and then covers documentation and wound assessment. It doesn’t hurt to start with the basics, one wound care specialist says."Nurses need to recognize necrotic tissue as opposed to granulation tissue," says Marilyn Fishel, RN, CETN, MS, wound care preceptor at the Richmond, VA, office of Medical Innovations. Fishel, who often helps nurses with their assessments, notes a few common mistakes nurses make when treating wounds:
• Sometimes nurses use the wrong product to absorb drainage in a wound, often opting for overly absorbent materials when a less-absorbent one would be adequate.
• Nurses sometimes use dressings that are too small. The dressing should always extend about an inch beyond the border of a wound, Fishel says.
• Nurses might leave a wound too dry; the most current research, and the accepted practice, is to provide wounds with a moist healing environment.
How it works
Medical Innovations’ wound care inservice covers the following documentation steps:• Make accurate measurements of wounds at the time of admission, and weekly throughout care. "We use a disposable acetate sheet that nurses can put over a wound and trace the wound, or they can use measurement tape," Fishel says. The sheet provides measurements in centimeters and is disposable. At the top of the wound assessment sheet, the nurse is asked to write down the wound’s length, width, and depth. Also, the assessment asks about the wound’s degree of closure, and whether sutures or staples are present.
• Document, on the plan of treatment, a predicted conclusion to daily or twice-a-day wound care. Nurses use a separate order sheet to write down the specific care procedures for up to three wounds, Fishel says. One copy is left in the home, another copy is put in the patient’s chart, and the third copy is sent to the physician’s office. "Medicare requires us to make a prediction as to how long we’re going to keep doing the wound care," she adds. The order form also has a place for comments where the nurse can write down whether the patient needs special provisions or directions.
• Document the color, odor, consistency, and quality of drainage at each visit. Each of these characteristics should be carefully noted on the assessment sheet according to common criteria. For example, the nurses are asked to describe a wound’s odor using one of the following terms:
— no odor at all;
— a slight odor with odor evident when the dressing is removed and the nurse is in proximity to the patient;
— a moderate odor that is evident at six to 10 feet after the dressing is removed;
— a strong odor that is evident upon entering the room with the dressing intact.
If different nurses are doing twice-a-day wound care, then a complete assessment must be done on each visit as ordered by the plan of treatment. Each assessment also includes a categorization for wound pain, measured in terms of whether it’s mild, moderate, or severe. Moderate pain is defined as uncomfortable, but doesn’t interfere with daily activities; severe pain prevents the patient from engaging in daily activities, including walking. The assessment also asks nurses to classify the wound from Stage 1 through Stage 5.
Vital signs
Nurses are instructed to take patients’ temperatures at each visit and to assess for the presence of infection. "Generally, taking the vital signs is a part of any home visit, whether the nurse is doing wound care or not," Fishel says. "Other signs that indicate an infected wound are drainage or an odd color around the wound," she adds. For example, a yellow or greenish drainage might indicate an infection. Likewise, if there’s redness around the wound and the patient has a fever, then it’s probably badly infected, Fishel explains. "At that point, the patient probably is going to require antibiotics."On the initial visit and weekly thereafter, there must be documentation stating why the patient or caregiver is unable or unwilling to change dressings. Usually, Fishel says, if the patient has a family member who can take care of the dressing changes, then the nurse will go into the home once or twice a week to make sure the wound is healing properly. But with Medicare patients, she adds, "often the spouse is too elderly or has poor vision and can’t do the care." In those cases, the agency will see if there’s another family member who can help.
On day 62 of nursing care, the summary documentation must include measurements and progress noted throughout the care, including any changes in treatment. Medical Innovations gives a "Nursing 62" update summary to the physician to let him or her know what kind of progress the agency has made in the last 62 days, or earlier if necessary.
"Our policy is to change the treatment if the assessment is changing, or if there’s not an improvement in the wound in two weeks then we probably need to make a change in our treatment," she explains.
If branch managers approve the purchase of a Polaroid camera, then two snapshots will be taken at the time of admission and every other week thereafter while daily visits are being made. Fishel reviews the nurses’ wound assessments and snapshots to make sure wound care is progressing as it should.
Medical Innovations also has encouraged nurses to select the right products for wound treatment. "We’ve changed to using some of the newer products on the market that will keep the wound moist," Fishel says.
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