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Improving Accuracy in Wound Care Competencies: Thinking Outside the Box


doi: 10.1097/01.NHH.0000324313.30662.da
Tools for Education

Maggie Lott, FNP, CWON, is nursing consultant for HealthCare Educators, Fresno, California.

Donita Stewart, RN, BSHS, is Administrator for BestCare Home Health Agency, Fresno, California.

Address for correspondence: Maggie Lott, FNP, CWON, BestCare Home Health Agency, 770 E. Shaw Avenue, Fresno, CA 93704 (e-mail:

Because home health nurses function independently, supervisors must be confident that each clinician is competent in performing clinical procedures in the home setting. The Centers for Medicare and Medicaid Services (CMS) reported that 60.5% of patients receiving home health services in 2004 had a wound or lesion at admission (Marren & Harrington, 2006). Human patient simulators (mannequins) have been used in nursing education since the 1950s (Peteani, 2004) for practicing procedures, but due to the unrealistic nature of the wound mannequin, our agency searched for a more lifelike model that challenged a nurse's skill and knowledge.

We carved and painted potatoes to simulate wounds and had nurses measure, describe, and dress them. The result was a quick and cost-effective way to observe and assess the staff in a relaxed and nonthreatening environment. We chose a normal saline-moistened gauze packing because the agency's protocol allows nurses to apply this dressing when a wound is discovered after hours and the physician cannot be reached for orders.

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Individualized Wounds

Russet potatoes were chosen as our simulated wounds due to their year-round availability, inexpensive price, and adaptability for carving wounds similar to those seen in patients' homes. In preparation, the potatoes were scrubbed with water to remove any dirt, then carved with a melon baller. Each wound had a minimum depth of 2 cm and contained some degree of undermining. Several had periwound abrasions created with a potato peeler. One had a skin bridge with communication beneath, and another had a tunnel created by coring with a chopstick. Undermining was created by placing the wound bed off center and coring into the potato toward the end.

Once the wounds were made, each potato was dipped into a 4:1 water and vinegar solution to prevent oxidation. If the competency sessions were scheduled later in the day, the potatoes were sealed in a plastic bag and refrigerated for preparation closer to the time. If the potatoes were for immediate use, they were readied for painting.

When the potatoes dried, red, black, and yellow tempera paints were applied with a brush to represent granulation, erythema, eschar, and slough. Light red was used to represent an erythema on the intact potato skin, whereas brighter red was used to simulate granulation. Areas of slough were painted yellow and washed with a light layer of red if granulation buds were emerging. Black eschars were applied on the wounds' edges. When the painting was completed, the potatoes were bagged and refrigerated until used.

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The competency sessions were held in the morning and lasted approximately 1 hour. Stations consisting of the potato, a measuring guide, and a documentation sheet were set up around a conference table along with wound care supplies similar to those found in the nurse's car boxes: place mats, sterile applicators, saline, sterile and nonsterile 4 × 4 gauze, and a cover dressing.

The nurses were instructed to measure and assess the wound, then document their findings just as they would in the home setting. Then, on the basis of the agency's policies and procedures, the nurses were directed to clean and pack the wound with a saline-moistened gauze dressing while the certified wound and ostomy nurse observed for accuracy, technique, and infection control. As the session proceeded, the staff discussed situations they encountered in home settings and used the time to ask questions and clarify misinformation. Any corrections in technique or documentation were incorporated into the ongoing conversation.

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The effectiveness of the potatoes as a teaching tool had been evaluated several years earlier using a written questionnaire, but unlike the wound-competency sessions, the potatoes had not been painted. In the earlier classes, each nurse received a worksheet with a circle colored in to represent the wound bed. The questionnaire showed that hands-on experience improved the nurse's knowledge and skill level.

Our wound-competency sessions were evaluated by verbal feedback from the nurses. Each nurse was asked a series of questions relating to the effectiveness of the simulated wounds and the conduciveness of the sessions to demonstrating skills and learning new information. The general consensus was that the potatoes were challenging as wound models and representative of what the nurses dealt with in the homes. This also opened up the sessions for discussion on the proper use of products and infection control.

For the less experienced nurses, the session was practical, giving them information that would improve their patient care. The administrative staff also was pleased because the nurses were able to see patients the remainder of the day, and the cost of the project was $25 including the paints and dressing supplies.

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Follow-Up Improvements

As wound models, the potatoes continue to need refining. Because the paint washes off, the potatoes cannot be cleaned before measuring, which is not acceptable in the home when the wound is being measured. Several approaches have tried to remedy this problem including baking the potato before painting, using acrylic paints, and spraying the paints with a sealant when they dry. Coloring of the wound bed still remains a problem.

Despite this drawback, the agency will use potatoes in next year's competency sessions. Because our nurses have demonstrated that they know how to pack a wound with saline-moistened gauze, we will take them to the next level. They will be provided with a short scenario about the patient including the wound location, the type and amount of drainage, underlying medical and social conditions, and the pertinent lab results. Also, various types of wound care products will be available, and the nurses will choose what they think is appropriate. In addition, we have developed a wound care competency evaluation form to help us determine whether the sessions help the nurses and demonstrate their skill (Figure 1).

Using the potatoes has given us a unique opportunity to evaluate and educate our nurses in a cost-effective manner. We are pleased with the skill level that the nurses demonstrate and feel comfortable with their independence in the field.

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Scenario 1

Figure. No caption a...

The patient is an 83-year-old man with prostate cancer, advanced dementia, hypertension, and arthritis. The man is receiving Lupron injections, Aricept, Namenda, Dyazide, and Motrin. He is bedbound, incontinent of bowel and bladder, and cared for by his daughter. He has been eating poorly for 10 days and is becoming more confused and lethargic. The redness on his sacrum turned black and odorous 1 week ago and now is open, with a large amount of yellow/black drainage. His more recent serum albumin level is 2.2.

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Scenario 2

Figure. No caption a...

The patient is a 68-year-old woman with rheumatoid arthritis, hypertension, gastroesophageal reflux disease (GERD) and insomnia. The grandson living with her has an infected tattoo that he acquired while in jail. The grandson is her caregiver. She says a spider bit her on the left leg shortly after her grandson arrived, but she did not see it. The bite swelled up, then turned red and became very tender. Since the site has opened, it has produced large amounts of beige drainage. She is on prednisone 5 mg daily, Tenormin, and Pepcid.

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Scenario 3

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The patient is a 75-year-old man who fell and fractured his right hip. A pressure ulcer developed on his right heel while he was recovering from surgery. The heel has a small amount of yellowish/serous drainage. He has diabetes with arterial disease and hypertension. His hemoglobin A1c is 8.5. His right foot has no palpable pulses but feels warm, with capillary refill of the nail beds at less than 3 seconds. His toenails are thick and crumbly. He is taking Avandia, Amaryl, and Glucophage for diabetes mellitus; Lasix, KCL, and lisinopril for hypertension; and Plavix for arterial disease. He does not follow his diet. His wife is his caregiver, and she has mild dementia.

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Scenario 4

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The patient is a 79-year-old woman with an arterial ulcer on the top of her foot. The foot has nonpalpable pulses, but the vascular surgeon says that she has only moderate arterial disease. The wound base is dry with slough and exposed tendon. There is no drainage and no edema. The patient has smoked 2 packs of cigarettes a day for 70 years and refuses to take medications. She lives with her 60-year-old son who has diabetes and is willing to learn the dressing changes.

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Marren, J. M., & Harrington, C. (2006). Improving wound care outcomes. American Journal of Nursing, 106, 37.
Peteani, L. (2004). Enhancing clinical practice and education with high-fidelity patient simulators. Nurse Educator, 29, 25–30.
© 2008 Lippincott Williams & Wilkins, Inc.