Dressing Changes: Challenges and Scenarios in Visiting Nurse Home Care

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home care nurse with patient

By Margaret Heale RN, MSc, CWOCN

I watched a short PowerPoint DVD on the "bag technique" as part of our regular in-servicing the other day. The presentation started with the most important way to prevent cross infection—wash hands—which is fine. Then came the bag technique. I have no problem with the fundamentals of keeping your bag off the floor, only getting anything out of it after decontaminating your hands, and wiping before you store. I do have a problem with having to place the bag on a Chux or water-resistant wipeable or disposable surface, however.

Having a clean, non-porous surface between me and my patient when doing a dressing is important, but my having my bag go from a chair in one house to a chair in another is not an infection risk any more than my coat is. I appreciate that some homes are borderline in terms of hygiene and so I am apt to check that there are no pet messes or other debris on the chair before placing anything on it, but a whole, environmentally unfriendly, plastic-backed Chux for every visit, no way.

I would rather not waste one for the wound, either. Please let me place a biodegradable bag for rubbish under the wound with an absorbent pad or clean towel, once the wound is cleaned and the skin prepped, tuck the pad into the bag, and push it to one side. The dressing packet being opened or other clean surface can then be placed between the nurse and the wound in case the primary dressing is dropped.

A More Practical Alternative to the Bag Technique for Home Dressing Changes

It is surprising that companies supplying dressings have not come up with a home health box or a disposable clean technique tray. The box could be the height of a ½-gauze loaf or a large bottle of saline, with the lid open on one side to use it, upturned, as a surface for supplies. Another small box inside with five partitions for skin prep wipes, alcohol pads, adhesive remover, and a tube of cream would stop these from getting lost.

The box would be sent with the first set of supplies and come with a pair of sterile dressing scissors or bandage scissors, saline pods or wound cleanser, and some resealable bags for open but unused primary dressings. On the outside of the lid could be a list of supplies needed for each dressing or visit and visit schedule to assist with ordering. It seems such a simple idea, with no real cost, and it would assist so much organizationally.

Home Health Care in Action – "Call the Visiting Nurse"

It is not easy to perform dressing changes in people's homes. A few well-taken photos of some of the places visited by community nurses would really turn people’s heads. Better still, someone should do a TV drama "Call the Visiting Nurse." The first episode may go something like this:

Having already shoveled her driveway to get to her garage, the nurse shovels the ramp to her first patient only to discover the patient's 40-year-old son on the sofa playing a computer game. She leaves in the rain, and for her second trick, has to transcend an uncleared driveway and a very unsafe set of snowy, now icy stairs to a first floor apartment where 10 cats live with their provider (after all, you can't own a cat). This is where the cat vomit is discovered on the chair.

The next home is filled with six children, two dogs, two adults, and a very large flat screen TV, and there has been a burst pipe. The nurse proceeds through dog crates, wet boxes, and mounds of clothes to a patient on the sofa (he has no bed or recliner). The floor is so grubby that she grabs a plastic bag to kneel on while reminding the parent of the dangers of plastic bags to young children.

The nurse's bag balances on a mound of what may be clean laundry. The limb about to be dressed is put on a clean Chux, and a 3-year-old tries to watch intently, despite the nurse's requesting otherwise. The 18-month-old cries at the nurse's feet for most of the procedure, and the nurse's knees hurt from the cold wood floor. To her relief, the keen observer loses interest. Two other children enter the room with a dead mouse in hand, wanting to show it to their dad.

The next driveway is long, steep, and potholed, with the edge hidden by icy slush. She expertly avoids a divot but slides into the ditch. Unable to get grip despite her four-wheel drive, she gets out to see if the carpet pieces in the back of her car might do the trick. The patient's neighbor sees her plight, gets out the tractor, and pulls her back onto the drive.

The farmhouse looks picturesque in the late afternoon light as she bustles in through the door. "Take your shoes off, nurse!" comes a yell from the recliner. As she dutifully complies, three dogs rush up yelping, licking, nudging, and looking for treats. She throws some treats into the other room and closes them out. It is dark, and the closed curtains look molded shut by cobwebs. No need to worry about the floor—she can't see it.

I could go on, but suffice it to say it would make an entertaining drama, just as it makes an interesting and challenging life as a home health nurse practicing wound care.

About the Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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