My Scope of Practice: One-Step Care Yields Big Results

    Angela Box Peterson, RN, WCC, began her career in acute care nursing, working on med-surg, ICU, ER, and ambulance units. She moved into management, coordinating the staffing and care for a vent-dependent pediatric patient and serving as a Public Health Nurse, a Supervisor, and a Quality Assurance Coordinator in home health and an Assistant Director of Nursing for a nursing home, among other assignments. But she didn’t realize how happy she could be until she became immersed in wound care. Her pursuits and passion enabled her to find an effective approach to skin care in patients with fecal incontinence. “I love (caring for) wounds,” Angela says, “and prevention is a critical part of care.”

    Angela graduated from Mississippi University for Women in 1988. Almost 13 years of various home health, hospital, and unit management responsibilities left her burnt out and yearning to get back to hands-on patient care. A position as Special Programs Coordinator came available for wound/ostomy care at Shelby Baptist Medical Center, Alabaster, Alabama, an acute care facility outside of Birmingham. “At the time I was hired, working in wound care didn’t require certification,” Angela says. “My experience in home health had involved a great deal of wound care but when I realized that surgeons depend on a wound care specialist to lead the way in post op care, I took classes. In 2005, I became a certified wound care coordinator.” Angela is also PICC-line certified.

    On most days, Angela deals with complicated post op wounds, no matter how “nasty or smelly.” Her current biggest challenge is fistulas. “We often are faced with caring for enterocutaneous abdominal fistulas in the hospital,” she says. “The patients and family get so frustrated.” Bariatric patients, an increasing population (“We had five in 1 month”), present unique skin/wound issues. “In morbidly obese patients (650 lb +), the skin loses integrity and opens into a hole or abscess beneath the wound. Compromised blood flow and nutrition make healing difficult. I have one patient with an abdominal wound that won’t close after 9 years of care.”

    Angela’s ostomy patients are seen mostly after surgery but Angela stresses that pre-surgery teaching makes all the difference. She is gratefully anticipating the formation of an ostomy clinic at her facility’s sister hospital. Meanwhile, she recommends that patients and caregivers visit ostomy product manufacturer websites for information. “ConvaTec’s website is great,” she says.

    Wound/ostomy care should incorporate attention to emotional concerns. One of the special programs Angela coordinates is pain management. She also helps staff deal with “sick person’s syndrome,” a side effect of chronic conditions such as hard-to-heal wounds. Long-term patient mentality often involves dependence on caregivers who treat their charges like children. Angela is striving to get Psychiatry on board, especially for NPO patients. “We need to get patients onto food so we can administer antidepressants,” Angela says. “We also want Rehab to get patients re-engaged in real-life activities like animal care or needlepoint. We would like to see everyone up and moving about.”

    Not long ago, Angela faced an unusual challenge with fecal incontinence. The hospital’s growing population (the hospital has added a number of beds since 2000 when Angela started working there) was strapping the staff and the number of patients with fecal incontinence, likewise, was increasing. Angela needed to find an efficient solution to help nurses prevent and treat skin breakdown and improve patient skin and comfort. The hospital’s two-step incontinence protocol (patients were regularly cleansed and then ointment was applied to the perineum) was unnecessarily time-consuming. Angela instituted use of Comfort Shield® Perineal Care Washcloths (Sage Products, Inc., Cary, Ill.) — disposable, pre-moistened cloths that clean, moisturize, deodorize, and treat the skin with protective dimethicone in one step. After implementing the new product, nursing units saw a steady reduction in skin breakdown. Because patients and staff were pleased with this outcome, the washcloths also became part of systematic care of patients with urinary incontinence. After this change, Angela noted a decline in sacral coccyx pressure ulcer incidence. In 13 months, the hospital experienced a great reduction in Stage I and Stage II pressure ulcers; Angela estimates that has saved the facility $160,000 in 1 year. To reassure administration regarding costs, Angela conducts period prevalence and incidence studies to justify use of the product.

    Over the next 5 years, Angela anticipates moving into more of a wound/ostomy care consultant role as her Special Programs Coordinator responsibilities are re-aligned. Her successful endeavor, switching to a new product, underscored her commitment to seeking better approaches to patient care. As Angela says, “Even small improvements can make a difference in my scope of practice.”