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Broad Street Solutions
James Marx, RN, MS, CIC Editor
P.O. Box 16557
San Diego, CA 92176
(619) 656-7887 Voice/FAX
jmarx@concentric.net
Each skilled nursing facility should take steps to reduce the incidence of avoidable infections of non-surgical wounds. Wound care technique should be defined in the facilityıs policy and procedure manual. Only the supplies needed for the dressing change should be brought to the bedside. They should be placed on a clean surface. Treatment carts should not be use as this surface.
Hands should be washed with plain soap and water prior to putting on gloves. If gloves are changed between performing multiple procedures (dressing change and suctioning) on the same resident, handwashing is not necessary unless gloves are visibly soiled or they have been torn/punctured. Alcohol handwashing substitute may be used if the hands are not visibly soiled.
Non-sterile gloves can be used to perform any non-surgical wound dressing change. Glove changes and handwashing are not necessary when performing multiple dressing changes on the same resident, unless gloves are visibly soiled or the glove is torn/punctured. Multiple dressing changes on the same resident should be done from the most clean (head, hand, foot) to the least clean (perineal or sacral). Non-sterile dressing may be used unless specified by facility policy or physicianıs order.
Soiled dressings, gloves and other items used in the procedure should be disposed an a container which prevents leakage. A biohazard container (red bag) is not routinely necessary.
Review your facilityıs policy and observe staff practice. Use the facilityıs dressing change policy to develop a observation check list. Finally, ask the bedside nurse to review the policy for comparison to actual practice.
Standardized Procedures are not Standing Orders. They are not subject to approval by the broads which regulate nursing and medicine, or those who license health care facilities. Standardized Procedures must be developed according to the following law: Board of Registered Nursing, Title 16, California Code of Regulations (CCR) Section 1474; Medical Board of California, title 16, CCR, Section 1379.
Under Standardized Procedures a registered nurse may perform a medical function beyond the usual scope of RN practice. This must be done in accordance with a written procedure developed by nursing, medicine and administration. The RN must be evaluated and approved as having met the education and experience requirements specified in the procedure. A suggested format can be obtained from the California Broad of Registered Nursing, 916-322-3350.
This opens the possible treating infections without first obtaining a physicianıs order. This can speed treatment to the resident and reduce unnecessary calls to the physician. The following example for Urinary Tract Infection Protocol was provided by the California BRN.
When a female patient complains of dysuria, frequency, urgency or inability of empty bladder completely, the nurse can order a urinalysis (UA) plus culture and sensitivity. The nurse must call the physician first if the resident has a history of kidney problems, is currently pregnant, has diabetes or has had 3 or more urinary tract infections (UTI) in that past 12 months OR any of the following additional symptoms: fever greater than 100 F, flank pain, chills or nausea/vomiting/abdominal pain.
The RN then will perform an abdominal examination and consult the physician if there is CVA tenderness. After the UA results come back the physician is called if there are casts, RBC or protein. Otherwise, if the White Blood Cells are 10 or more the resident is started on the appropriate antibiotic. All this can be done without the physicians order.
The Standardized Procedure should clearly state when the physician is notified. In this case, the physician would be notified during the monthly visit. This avoids frequent and unnecessary calls to the physician. Some drawbacks to using Standardized Procedures they can only be done by a RN, and it requires a fairly sophisticated understanding of protocols. Both which can be accomplished in a Skilled Nursing Facility.
The California Nurses Association offers consultation with their Nurse Practice Specialist, Marti James, RN, JD at 310-664-6369.