what would you have done

I am a new nurse I work part-time float PRN any shift. When getting report I was told that all charting and treatments were done. When we were going over the residents I was told that rsdt. x was fine. About 1 hour before my shift was up the aide asked me to come look at rsdt x's bottom that there was an open area that was bleeding. I found a pressure ulcer about the size of my palm on the coccyx area with minimal bleeding. I asked the aide if she took any bandages off of it and she said there was none on it. I checked the tx book and the only tx for it said " apply silvercell". It didnt say to clean it with anything or to apply a dry dressing. It was only to be changed on one shift which was the next shift in 1 hour. I wasnt sure what to think so I tried asking another nurse but the nurse was to busy to help. I decided to hold off doing anything since the order did not seem complete and i knew the nurse taking over for me wrote the order so that nurse would know why it was written that way and it was due to be done on that shift. i explained all this to the aide. What I forgot to do which I will be the first to admit I should have was ask about it in shift report. The next day when getting report from the off going nurse I asked about the tx and was told they new nothing about it but it didnt sound right to them either so i made a note to ask the nurse when i gave report bc it was again the same nurse who wrote the order. when giving report that evening i was not given the chance to ask. The oncoming nurse asked the aide if rsdt x had a bandage on that it was ridiculous that the rsdt had been left without 1 the night bf. Now we all new the comment was directed at me. I explained myself and was told that the order didnt come from the WCC and that is why it wasnt detailed that it was just common sense to clean with NS and apply a dry bandage. Now if I had wrote the order I would have wrote all the details bc to me that is common sense but i didnt write it and that is not how it was written. I didnt know if there could have been a reason that they werent putting a dressing on it like location. But again I was told that it was absolutely ridiculous of me. So i was wondering what some of you would have done.
I would have put a bandage on it. It needed protection. Packing/etc I wouldn't do without an order, but covering it with a dressing would have been appropriate. You don't have order sets at your facility for wound dressings? Might be something to suggest. She should have wrote the full order though, and also additionally given you this info in report. You can also always call the MD and clarify the order.

I can see where you would have been faulted for follow up that was not timely, however, I do agree with you. A valid order needs to be in place, unless, there is some kind of a standing order in the facility that covers what the other nurses seem to think you should have done.

Why did you not find this area on the patient at the beginning of the shift during your primary assessment?Whenever a wound is found, it needs to be assessed, cleaned, and dressed. Proper documentation needs to be filed.If no orders are available on how to do it, we follow protocol and then call PCP to get a clarification (if incomplete order), new order, and/or consult w/wound care. If you find a situation such as this you are responsible for addressing the issue either by taking care of it yourself or by passing it on in report if your shift has ended. However, this kind of wound should have been assessed at the beginning of your shift. jmho.

Quote from maelstrom143Why did you not find this area on the patient at the beginning of the shift during your primary assessment?Whenever a wound is found, it needs to be assessed, cleaned, and dressed. Proper documentation needs to be filed.If no orders are available on how to do it, we follow protocol and then call PCP to get a clarification (if incomplete order), new order, and/or consult w/wound care. If you find a situation such as this you are responsible for addressing the issue either by taking care of it yourself or by passing it on in report if your shift has ended. However, this kind of wound should have been assessed at the beginning of your shift. jmho.

I agree with above - should have been found during initial assessment. Then you would have had your entire shift to clarify the order.Regardless, I would have ensured pt safety, i.e. applied a dry dressing, at least, then spoke with the oncoming nurse. I would have wrote a note to make sure to speak with her so I would not have forgotten and it would have been handled.Like you, though, I would spell every detail out about a wound and dressing change so anyone finding a pt this way would know how to ensure the proper care. Have you checked? There may be a basic protocol for wound care - just not dressings.

You don't say what type of facility this is in (not that it matters much). If it is LTC..you prob aren't doing a head to toe so what the CNAs tell you is what you get for changes in skin condition. If the order wasn't complete, do what you need to do to clarify it or complete it. Leaving the resident without a dressing on isn't right. All facilities I've been in have a p and P for different types of dressings. If you couldn't find it, ask. For the most part, cleanse with NSS apply dressing and cover.

Does your facility have policies on skin issues like this? Good to know! Also, it is within the nurse's scope of practice to apply a dressing of some sort. Your facility may have a standing order for immediate care, including products to apply. I recommend you go to www.medlineuniversity.com and take their pressure ulcer prevention course and other skin related courses. Prevention is within your scope of practice.

To those who are saying that you should have been found it on your inital head to toe, when you have 40 pt you don’t do had to toes, it would take your whole shift, it’s not acute care. I’m surprised you did nothing though when it was found. When I worked long term care, we had had standing orders for all wounds. I would have done an done an assessment, taken measurements, irrigated, applied aquacel and put on a mepiplex boarder. If it was more involved I would have called my charge to get a second opinion. I would not have left it open, that is just begging to get infected. Maybe where you work you don’t have the autonomy to choose your dressings, if not I would have gotten an order assap, and still taken measurements, irrigated, applied aquacel and put on a mepiplex boarder, so it would not be left open.

I wouldn't worry about the type of drsg or cream or ointment so much. The important thing is pressure relieve. Make the pt. a side to side turn (if those surfaces are available), place a pressure relieve mattress if you have access to one. Measure the wound and document in detail and initiate wound care sheet if applicable. Notify DON or supervisor and dietary and let them or the regular floor nurse get the DR.s orders straightened out.

The hospital I work at has a wound care sheet for dressings that we as nurses can use without a doctor order and what dressings are used for different wound types, it's fabulous, I love it and it cuts out those non specific orders or incomplete orders because it's all right there and we can change it as needed, the sheet goes into the chart and updated as needed. Always, always pass it on in report, nothing is worse than not getting an accurate/up to date report, which you should have received as well.

I really don't see your problem here and you are getting worked up over nothing.A nurse can clean & cover a wound. You don't need a wound care nurse to assess every patient. You should have the skills to assess the wound, clean as appropriate and cover with a padded dressing, or with clear opsite so you can see if the wound is healing or not. And document everything - start a wound chart if necessary.What are you actually getting annoyed about - that no orders were written re this wound, or that nobody had noticed it except you?I don't understand what you are confused about. And I couldn't understand all the abbreviations you used - could you type them out in full once, then use the abbreviation later maybe. Thanks

To the OP, I would have cleaned the wound with NSS, put on the ordered cream/ointment and then covered it by putting a clean dry dressing on it (most likely a gauze). I'd get that patient off their bottom and make sure that T&P was being done. And then charted the info about the wound (size, area, treatment done etc).In my facility unless specifically stated, all wounds are covered with something..be it a clean gauze or op site, or whatever best suits the area/wound. All our docs will state specifically leave open to air or do not cover if they don't want it covered. I can't recall any recent ones that were left to air.