[Sharon]

Discussion #1 – Review of Scenario A

[Nely]

Although the patients Pressure Injury is getting worse, there are multiple factors to consider including:
– patient environment and care support at home
– patient ability to connect with MD for ongoing assessment and care
– did the RPN escalate this worsening of the wound to seek additional guidance or care plan? Orders?
– is there something more going on with the patient? perhaps some blood work?

No reason why the RPN needs to disrupt this relationship.

[Katie]

I agree with how you added in the client responsibility piece, this is key in the home and community sector, while the nurse is responsible for ongoing assessment and appropriate escalation a huge part of what happens in the home is reflected by the education we provide to clts and families.

[Jeanette]

Discussion #1
Scenario A
In making the decision as to who should care for this pt a RN or RPN due to an increase in the size of a venous ulcer many factors should be considered.
-Access pt’s co-morbidities remain unchanged
-Has blood sugar levels and diet remain the same
-Has pt’s blood pressure has changed
-Life style changes – partner away or if living alone has something happened that could changed in his life style.
-Was he ill
I would Say there is no reason that the RPN could not still care for pt.
RPN should consult with other nursing team re wound and collecting other pt information re condition as well as consult with a would care specialist
RPN could also reach out to Pt’s MD for further direction if they have been seen in office and having regular check in’s
RPN could arrange for more help around pt’s home if living alone
Due to all the factors above I would say no, there is no reason to have this pt seen by a RN and the RPN can keep providing care for the pt at this time.

[Johanna]

I would say, yes, the RPN is capable of continuing to to provide wound care to the patient, “but…”
When an unexpected change/deterioration occurs in the patient’s wound, it is time to assess what has changed. Have there been any changes in the patient’s support at home, their home environment, or their diet? Is he continuing to take his medication as ordered? Have their been any changes in his life in terms of stressors or major life events? Perhaps the wound now needs daily dressing changes, or twice daily dressing changes, rather than only three times per week.
The next step would be to notify the patient’s practitioner of the worsening wound and any findings in the RPN’s assessment. The practitioner should schedule regular visits and order lab work and testing to determine any new underlying issues that may be contributing to the worsening wound.
The next step would be to refer the patient to the Regional Wound Care Nurse Program to assess whether a change in the resident’s dressing would be helpful.
It might also be helpful if the patient could be referred to a Registered Dietician to assess for ways to increase protein intake in his diet, to facilitate better wound healing, and also to help regulate his blood glucose levels.
In conclusion, it may be helpful to the patient if the RPN collaborates with an RN to ensure that no factors or interventions are missed, but the RPN may continue to provide care for the patient.

[Maame]

I agree with you the RPN can continue working with the client but also colloborate wite the RN.

[Katie]

Yes, the RPN can continue to provide care, but the expectation would be that escalation for additional support would be required. Currently in the home care center when a wound declines, stalls x 2wks and/or does not achieve 30% healing within 30 days will require escalation. This process is followed regardless of nursing designation.
These parameters are noted by q visit wound care assessment with weekly measurements, monthly images and with decline. HCCSS would be required to be notified with request for authorization the Wound Resource Nurse to become involved for further, reassessment of wound care frequency and supplies to be reassessed.
MRP would also need to be notified.
Ongoing Cardiopulmonary and Diabetes Assessment would be completed related to clts co-morbidities and escalation to MRP as required. Additional supports such as Diabetic Education Center may be requested.
This clt falls within the home care RPN scope of practice as all nurses received Wound Care Fundamentals Training and Validation on a regular basis to ensure the knowledge, skill and judgment required for provision of care is maintained.
This falls with the 3 factor framework as the environment is stable and consultation has been initiated to ensure escalation process has been followed related to the less predictable outcome that can occur when deterioration noted.

[Maame]

I believe the RPN can still provide wound care client , but there needs to be extensive assessment. The client has congestive heart failure and diabetes. Is he taking his medications? insulin? what has blood sugar levels been like? what does his diet consist ? All factors need to be taken into consideration. Lastly, him being in a home care setting the RPN will benefit from meeting with the interdiscipilinary team on the next steps for the client. Also the RPN colloborating with the RN will be beneficial because the RPN can have additional guidance while trying to resolve the issue.

[Norma]

You have all come to what would be the correct solution here. In the community, RPNs are often highly skilled and knowledgeable about wounds and many have taken additional education in this area of practice. You all considered the other factors in your decision-making and in this case, the RPN does continue with providing care for the patient in consultation with other healthcare providers as needed.

To streamline care pathways, improve access to minor and routine care in the community, and increase patient choice in where to obtain health care services, the Ministry of Health has directed the Council of the College of Nurses of Ontario to make the necessary regulatory amendments to authorize RPNs to independently initiate Irrigating, probing, debriding and packing of a wound below the dermis or below a mucous membrane. This was part of the expansion of the scope that came into effect in July 2023.

[Author]

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