15 years as a Tissue Viability nurse in the community.
RGN; DN; BSc (HONS) Independent precriber.
provide service to patients ina variety of settings, Home; clinics; nursing homes. Leg Ulcer service clinic based since 1995. Radical over haul of pressure ulcer provision, Change of assessment & management documentation. Root cause analysis of all Grade 2 above pressure ulcers. Involved in broad range of policys and procedures associated with tissue vaibility. Train all community staff with provision for qualified care homne staff. 2 day tissue viability and 2 day leg ulcer courses, with half day updates (12 a year). Community contract audits x 2 per year and Patient Public Involvelment Audits (PPIs). Attend clinics to support staff and promote EBP. Evaluate and implement evidenced base wound care eg negative Pressure Wound Therapy (NPWT). Introduced Renasys-Go 2 years ago. Saved the trust £1000s compared to previous provider. Wound dressing formulary, to support cost effective wound ca
It’s not possible to give… compassionate care unless you have the right numbers of staff on all the different wards,” Mr Hunt told delegates.
Do you need to quantify that, just so I know in the future at what point I can stop being compassionate, maybe on a sliding scale so I can adjust my compassion with reference to the volume or ratio of patients I'm seeing. If my next patient exceeds my compassion quota I will thus be fully justified to let rip? me thinks a policy is required to ensure continuity, to ensure all staff meet the same quota & a KPI added to my Job spec & measured accordingly. Receipt of CQUIN payments will no doubt be forthcoming if i successfully meet my targets. DUH!!
Compassion is not contingent on the volume of patients, its the right of every patient & responsibility of every nurse is not waivered in times when we're busy.
Comment on: Why are nurses paying for bankers' mistakes?
"gold plated" hardly! Ive been paying since 1974 and added contributions to buy back refunded contribution from 1980, that amounts to over £500 a month. Recent forcast states I'll get £12000 a year. But I've been paying towards this all my working life!! Nurses are penalised for corrupt institutional banking systems, that pay extortionate bonuses on top of salaries. Mmm when's the last time I received a bonus in the NHS for caring, nurturing, improving quality of life, ameliorate symptoms? That'll be never then!!
Comment on: If a wound is infected with anaerobic bacteria, are there specific dressings that should not be used?
Quantifying bacteria ie >10 power 6 tends to be the bench mark to determine infection. This needs to be considered with the host reaction ie do they display signs & symptoms of infection ie Redness (erythema) swelling,heat, induration, pain, purulent discharge, wound dehiscence or wound deterioration, abnormal granualtion tissue, systemic response ie tachycardia, pyrexia, poor appetite lethargy. The latter sypmtoms are probably more diagnostic as its impossible to quantify bacteria by observation. But the host reaction will differ depending upon the host other co-morbidities & general health & medication (immunosuppresives & steroids). This would apply to aerobes as well as anaerobes. With the latter malodour could be a major issue and there are raft of treatments for that symptom eg Charcoal dressings we use Carboflex (particulary good for highly exudative wounds) or Clinisorb. Remember the efficacy of charcoal is greatly diminished once it becomes wet, consequently Carboflex with its combination of hydrofibre, alginate layer will increase the longevity of the dressing in use. As mentioned there is a vast array of anti-microbial dressings on the market, perhaps too confusing at times. Generically these include silvers, iodines, mannuka honey,Polyhexanide Biguanide (PHMB) variations. DACC technology eg Cutimed Sorbact.The clinician needs to appreciate the difference also between colonisation, & the concept of critical colonisation. this suggests the level of bacteria is high enough to elicit a local response ie wound deterioration but is not manifested systemically, this maybe a situation when local wound management needs to consist of some anti-microbial treatment, but again this wound be host specific. Colonisation & contamination is a fact of life with all chronic wounds, these can progress to healing despite this. When useing anti-microbial dressings set a specific end point for evaluation & discontinue if no improvement as with all chronic wounds intransigent healing is usually due to an underlying systemic cause ie Treat the Whole of the patient not the hole in the patient
Whilst I fully endorse most of the comments above and accept holistic approach. When faced with a venous ulcer the pathophysiological consequences are inescapable. Unless you reverse venous hypertension you can engage as much as you like with the social environment but it'll mean diddly to the healing of the ulcer. 40mmHg of pressure is required to reverse venous hypertension (stemmer1969), multi-layer compression has been identified as the gold standard to achieve that. A number of alternative 2 -layer systems have also been shown to be of benefit. Pain is certainly problem but that can be as a result of the venous hypertension and the pressure exerted by an oedematous limb, so compression can also relieve pain in a number patients. to further emphasise the importance of compression the well used cliche assciated with venous leg ulcer patients is "once a leg ulcer patient always a leg ulcer patient". This focuses the care that continues after the ulcer is healed is life long, with the use of compression hosiery. recurrence rates with good after care yes education diet, lifestyle mobility can be reduced to as little as 24% without proper aftercare as high as 74%. The term tight is very subjective, if we are attempting to achieve 40mmHg with our bandaging around a limb with good technique & sufficient padding with protection of vulnerable areas such as the achilles tendon, pre-tibial area malleoli & foot this will reduce the likehood of problems. With some proactive support and planning problems with concordance can be foreseen. How we approach the situation procatively can go along way to supporting the patient coming to terms with bandaging
Even when using "full compression" it is often under applied. The use of laplaces law which helps to determine the ampount of compression required depending on the ankle circumference ie "The sub-bandage pressure is inversely proportional to the circumference of the limb" ie the bigger the leg the greater amount of pressure required to reverse venous hypertension. Most legs will fit in the 18cm -25cm ankle circumference category, but they would still require full compression ie 40mmHg at the ankle graduated to 20mmHg below the knee. This may not be achieved as nurses tend to underbandage rather than over bandage as highlighted in the article. "reduced compression" is often used on the basis of "just in case" its too tight, or I may cause trauma. But if the venous hypertension is not reversed you're unwittingly causing potential problems by inhibiting the natural physiological processes to restablish themselves. We provide mandatory training in leg ulcer management and mandatory updates both of which include sub-bandage pressure checks, whilst I admitt these systems aren't perfect they never the less provide a more objective reference point for nurses to evaluate their technique and adjust accordingly along wiht laplaecs law and the theory & practice of bandaging. I must point out that there is an over emphasis on vascular assessment by Doppler ultrasound. Whilst the procedure elimates any significant ischaemic disease which would preclude the use of compression it still does not indicate the aetiology of the ulcer. Although a mandatory requirement of leg ulcer assessment it will not determine the type of ulcer. A thorough understanding of the A&P of the leg, & signs & symptoms of venous/ arterial disease, and how that is manifested both in the condition of the leg and the presenting ulcer.