Discussion #1 – Review of Scenario A
Yes, I believe the RPN is still competent to provide care, but I think more support may be required to see if a new approach may be needed to optimize care and healing based on any other underlying complications.
According to the CNO 3 factor framework, as conditions deteriorate or become more complex there is increasing need for consultation from a more experienced or knowledgeable nurse or other health care professional. I would look at all risk factors and take a team-based approach to determine if other factors may be impeding healing, or if other specialists may need to be consulted. Based on his co-morbidities of CHF and Diabetes, I don’t believe we can assume that either condition have made him unpredictable in outcome unless there is assessment of acute need. Again, I would take this to a team-based approach and involve others for consultation and recommendations. Wound healing is a complex process, impacted by multiple physical properties further complicated by diabetes. Without knowing if his diabetes is well managed or if his CHF is well managed it is hard to predict if the wound outcome may be on a stable path or not. Perhaps there is an underlying infection at play. If the RPN has the knowledge, the skill and the competence I believe she should remain part of the care team.
Yes. A knowledgeable RPN can advocate for their client and report to the physician of the current status of the client’s wound. Based on their assessment findings they can determine the current treatment plan they are implementing is not therapeutic to the patient and also if the client’s CSM for example has deteriorated. A RPN can take these findings and SBAR to the doctor and then can carry out the new treatment plan for the client. The nurse must possess the knowledge (ie: proper assessments, the therapeutic effect of the wound care treatment), skill (ie: perform wound care competently) and judgement (ie: patient advocacy etc). Having an understanding the client’s disease process will help guide their assessments and understand why the wound may not be healing. I have experienced many patient’s wounds worsen under their current treatment plan and due to their disease process worsening.
I agree with my peer Jacquline, the RPN is able to care for a venous ulcer dressing. The RPN performing the dressing must self-reflect if she/he has the knowledge, skill, and judgment to carry out this care. Equally important, we have to look at the client, the individual holistically not his just medical history of diabetes and congestive heart failure. Is the client’s diabetes controlled? what are their blood sugar readings? Are they taking their insulin/ hypoglycemic medications as prescribed? what is the client’s diet? does the client need a medication review? What are the client’s most recent vitals? Is the wound infected? most recent blood work? There are so many unknowns that need to be ruled out before making an assumption the client’s care needs are beyond the RPN. Above all, all the nurses should consult with the interprofessional team for further investigation.
I believe it is appropriate for the RPN to continue to provide wound care for the patient provided the nurse has the necessary experience, knowledge and skills to do the task. In this scenario the patient ulcer got worse after 2 months of wound care so in this case the RPN should reassess the condition of the wound and collaborate with his doctor to determine a better treatment plan. It is necessary to consider any changes in the health condition of the patient that might be contributing to the worsening condition of the wound.
I like the thoughts you shared on this discussion post. The general sentiment seemed that this patients care would still be within the scope of practice of an RPN provided they consulted with the appropriate care provider and had the necessary knowledge, skill and judgement. The important things to consider is that although you may be able to provide care, there is a high probability that the wound will now require a different treatment, which would require an order. Whether it is a Nurse Practitioner who specialized in wound-care or a doctor, the wound would need to be re-assessed and a new treatment plan developed.
As some have also mentioned, you will want to work with the healthcare team to identify the cause of the wound deteriorating. Is this natural given the patients condition or has something changes that has caused this wound to worsen.
Thank you all for your contributions to the discussion!
I was a little surprised to read your comment that if the treatment plan changed a new order would be required.
Where I work in primary care at a family health team, when we send wound clients to Home and Community Care Support Services for wound care we typically just indicate “wound care per best practice guidelines”. I have not worked on the other side to see all that happens on the receiver’s end. Nor did I realize that if the outlined treatment plan were to change a new order would need to be obtained. I assumed there would be medical directives in place for assessment and treatment.
Definitley something to think about.
It would definitely depend on the individual situation however my thought was that if there was significant deterioration and the wound needed a different type of dressing or certain type of product, that this would require a new order.
Hope this clarifies my thoughts a little.
I believe the RPN is still absolutely able to provide care for this client. She can adjust her treatment after consultation with another nurse, particularly a wound care specialist. She can also reach out to the client’s doctor making sure to point out that she has been treating this for 2 months. Venous ulcers can be especially difficult to treat and heal. The key is to acknowledge that the treatment isn’t working and seek consultation.