Link btwn surgery and district nursing team - any GPs or nurses around to explain

[gingeroots]

Am asking in the spirit of trying to understand and being pragmatic in these overstretched /underfunded times .

Mother in 90's ,leg ulcers ,gouty and infected fingers = lots of dressings .
District nursing team = lots of different people /lots of different levels of expertise .

Mother very stressed by different nurses ,different approaches ,and ( big one for her ) not knowing time of visit .

Me - very stressed by mothers concerns + boxes and boxes of hugely expensive dressings ordered at random by nurses .

Soooo - I visit surgery ,plan to ask if I can bring mother up to surgery for practice nurse 3/7 for dressings ( because I am desperate for continuity and some control over timing of visits ) .
Nurse at surgery ( beside herself over huge over ordering of dressings ) decides she will do home visits to mother .

Surgery nurse now on leave for 2 weeks ,care handed to DTN .
Who have no care plan and ....quite frankly - 2 visits in + sharp deteriotion in one ulcer - I might as well do the dressings myself .

Questions are
should I cancel DNT and do dressings myself ?
should surgery/practice nurse have handed over better ? ( she said no point as DNT would have their own ideas )
long term how can I improve situation ? ( gut feeling is that surgery nurse has over comitted self ,and DNT procedures not adequate ).
and who is" in charge " - DNT or surgery ?

District nurses are often attached to GP surgerys and can get referals from them. Despite your experience DN's are often experts in would care and should be the best peoplt to look after your mother.
I would try and identify the most senior DN and express your concerns. Maybe try and meet up with her at your mothers house to discuss her care.

Ask Gp about 'Tissue viability nurse' - failing that tell GP your concerns

Wounds do go downhill, suddenly and for no obvious reason, it's what makes wound care so interesting, to sad people like me.

Nobody is really in charge, DN do their bit, if they need antibiotics GP does theirs. It's a team effort.

DN get new patients referred daily, some consultants send them to patients every day and even thought the nurse may disagree they cant always say anything and just have to get on with it. It's a high pressure job, they do weekends and christmas. Some patients get abusive or have mental problems and attempt to lock them in the house with them

The question to ask is if any of them, given their expierience, actually expect the wounds to ever heal or is palliatave care and prevention/management of infection.

I personally would not take over care of them. If it goes septic it can get serious quite quickly in the elderly. They dont always show a good inflammotory response so although we can tell an angry pink from a healthy pink we learn on people who are not related to us and we have a much more expierienced clinician guiding us.

District nurses provide nursing care to people in their own homes. Practice nurses provide care in the GP surgery generally. I would hope the practice nurse is insured for caring for people in their own home - you should check that with the practice.

It is normal in a DN team to have several different staff members; what should happen is that a registered nurse shoulf assess your mother and decide an appropriate care plan which would normally be adhered to for a few weeks unless there is a rationale for changing it - e.g allergy or wound deteriorating.

The fact that your mum's wounds are not healing isn't necessarily a reflection on the nurses who have seen her, chronic wounds are notoriously difficult to heal; especially leg ulcers which are often due to a mixture of venous and arterial problems and may never completely heal.

You could request a review by a tissue viabilty nurse.

Hiya, I am a district nurse. I would take your mum to the surgery when you can get appointments and then request DN visits on the other days. Ask for a senior nurse to come in and assess and then others can follow their care plan. If they are not healing ask about a referral to a leg clinic. Your mum should have a set of notes at home to ensure continuity of care.

I can appreciate how you feel about timings of visits by DNs unfortunately we have to prioritise our visits every morning as to who needs urgently seeing, and this can change over the course of a few hours as we get calls come in. We usually visit patients between 10-2 though.

Thank you everyone .
fluffy I can see why one might become interested ,I'm getting hooked in myself .
I think with my mums leg wounds they won't heal ( she won't comply with pressure dressings or honey ,the latter seemed to really help but she finds it too painful ) because of odema .
But I'm shocked at the sudden breakdown in the long standing leg ulcer which I think is because the nurse who came on Friday didn't use what was used before .
But not her fault because there is no care plan.

iliketea - golly absolutely no blame on nurses ,just trying to get it so that we're all working together .

ninja - I think that's a plan .
And I understand about timings completely - it's just my not very well over anxious mum . She spends ( literally ) all day saying " oh I can't have a cup of tea/go to the loo /eat " because they might be here any minute .
TBH her attitude and my inabilty to reassure her ,drive me crazy .

But I think what you've helped me see ( tho I think I knew it already ) is what is missing and what I must press for is a care plan .

And with the tissue viabilty nurse - we are in a large inner London borough and I am told that there is only one in our borough ,and one in neighbouring borough and they cover for eachothers leave and sickness - so long waiting time .

Aah you see being non compliant doesnt help at all.

Honey can hurt the first few days because it draws all the fluid out and some people really feel it.

Oh yes ,being non compliant doesn't help ....but what can you do ?

She's in her 90's ,congestive heart failure ,stage 3 kidney failure ,shocking tophi gout on her fingers ,post herpatic neuralgia all down one side of her torso ,very limited sight .

She's incredibly stubborn and has a weird defensive/aggresive attitude towards medical people . She doesn't really understand what's going on with her treatment and just gets really angry when told to take more painkillers to help her tolerate dressings .

I can't get her to understand that putting up with a ( bit more ) discomfort in the short term would mean that the wounds would heal more quickly .

She has a very disconnected view about her health - as if it's nothing to do with her and that she has no power to influence it .

But , she's seen by loads of busy ,rushed people who all do different things to her and who have strong accents that she finds hard to follow ...so I think compliance is not encouraged .

And she lives on her own .

Gosh what a bizarre set up.

I'm a practice nursing sister and we are not insured or covered in our employment contract to provide care anywhere other than the GP premises.

Care in a patient's home is provided by the Community Nursing Team.

A downside to care at home is that many community nurses work in large teams with little continuity of care due to the pressure of staffing limitations and pressure of their workload.

A downside of surgery based care can be that small practices may only have one or two practice nurses, so if one is on leave there is no-one who can do the dressings. Also IME wound care skills vary hugely between nurses and surgeries.

Compression bandages can be painful, but then leg ulcers themselves tend to have a distinctive pain. Compression actually helps with oedema, if tolerated. Honey dressings can also cause pain.

You are right in that a care plan is fundamental; I am surprised the community nurses aren't following one.

Yes Sidge ,it's odd isn't it .

I think ,as has been suggested by ninja and others that a combination of surgery care and DNT care is probably the best approach .

Mainly I think to achieve a little continuity .

I'm hoping to see DNT Team Leader on Weds to discuss ,so perhaps we can get things on a planned basis ,even a care plan .

Thanks all for your input ,which has been v helpful and clarified things for me .

Insis

Insist on a care plan. Also when you see the DN ask if they can have your mother down as an early visit, so she is seen first if patient priority allows.

Also have you considere getting a key safe? That may reassure your mum that she can go to the loo / kitchen and not have a problem letting the DN team in, and there will be no rush.

Also, to begin with, it might seem there is no continuity of care, but it really helps in thw long term for all members of the DN team to know your mum and vice versa, give it time and she'll get to know everyone. Also having a care plan will ensure continuity.

Meeting the DN team leader should be helpful, but depending on their set-up you may find that shared care isn't possible. In our area if a patient can physically get to the surgery (even if relying on family for lifts) then the community nurses won't visit. However some areas do encourage shared care, but in these cases a care plan should be core and fundamental to effective management of that patient.

Personally I prefer to keep care of my 'regulars' in house! That way I know they are getting continuity of care and consistent treatment and dressings. It's also easier to co-ordinate any interventions that may be needed such as Dopplers, ordering of dressings, bloods etc.

Thank you sidge and Iliketea.

A lot of the trouble is managing my mum - her anxiety ,her ( understandable ? ) inabilty to see the bigger picture ,with age she has become more and more inward looking .
I keep explaining to her that the nurses list changes daily as people come out of hospital ,crisis arise ,but she doesn't seem to take it in . And gets cross and antagonistic .

But she's old ,weary , in pain and mistrustful because she doesn't know what's going on

And of course the system isn't perfect .

The DNs have a key ( team leader has explained in past that this is preferred as it saves nurses time as they don't have to wait for person to get to door ) but they don't always bring it /aren't told there is one .

They do diabetics and something else first thing and come anytime between midday and about 5.30 pm .
And sometimes ( not often ,but even once is enough for my mother to latch on to ) she gets missed off the list and they don't come at all .

It can't be helped but it does make mum anxious and for example means that I can't spontaneously decide to push mum round the block if weather and her health coincide to allow it .

So.... I think I will try and keep her managed at the surgery for all the reasons you give sidge .
But they have only one nurse and she will need to be looked after by DNT sometimes .

Which is where I came in .....care plan is going to be key .

Well the team leader was very nice ,explained that they saw their role as a supporting one and that they were happy with the idea of sharing the care with the practice nurse and me . ( tho I don't actually see myself as qualified in the dressings field ! )

He had some opposing ( well different to practice nurse ) views about type of dressing ,and said he couldn't write guidance about the 2 areas being dressed on the ankle or bottom of the heel in his care plan .
These need a podiatrists to see and advise .

Which I can understand ,but we've been there before . I braved the gales and rain and struggled to take mum in wheelchair to keep podiatrist appt and they were so horrible - senior one stroppily saying " but why are you here ? "

me " DNT say stuff below a certain point needs podiatrist assesment " ,

she " but it doesn't need abraiding ,you should only be here if it needs abraiding ! "

Whatever that is ,so we didn't go back .

And apparently the DNT don't normally use any dressings specifically for fingers ( not even that mini stocking stuff ) .
I just don't understand why everyone is really interested in the leg ulcers - measuring ,photographing ,swabbing ,trying this and that dressing ,but when it comes to the infected fingers .....very little interest .

I mean I suppose I understand that the leg ulcers can get worse and need careful monitoring .
But the fingers are a nightmare ( with my knowledge anyway ) to keep dressings on and to keep the dressings dry . And they keep getting infected .

My partially sighted ,90+ mum doesn't seem able to keep them dry or to put gloves on . And having bandaged fingers makes her even more disabled , even more likely to spill tea on them.

The nurses agree that if the dressings get wet - which they do daily - that they should be changed . But as they also say ,if the wounds are dressed daily they're not given the chance to heal .

fluffy any thoughts ?
or anyone else ?

I would also refer to podiatrist for feet and heels, especially

Sorry pressed send too soon!!

Ask if they can arrange a home visit for the podiatrist - in my area we can do a referral for that.

The fingers, if it is gout, then the wounds will not heal unless gout is treated, so any dressing will just be helping to prevent infection so sharing care with you is probably ok, as it would just be covering them.

The leg ulcers may be the biggest concern because if they are leaking, it can cause protein deficiency, dehydration and infection and is probably the biggest risk to your mothers health, especially with all the other medical issues your mum has. I would be very wary about sharing care of leg ulcers with a relative, only because there is a huge risk of infection and other problems (hence the need for podiatrist input). Also the DN or practice nurse should do a referral to the podiatrist so it's clear why she needs to be seen.

Yes I can see it is a specialised area ,we'll just have to get that organised again .
Hope we catch them in better form - we all have our bad days I guess .

Sorry the podiatrist was stroppy, They meant debriding.

Debriding is the mechanical removal of callus on a wound with a scalpel.

A lot of us do feel we cant do anymore for some wounds than the DN does if no scalpel work is needed. We cant always bring anything new to the treatment.

Unless your mom is completely housebound, and I mean to the point that she cannot go out at all unless you are admitting them to hospital you will find it hard, as a new home visit patient to get a podiatrist visit. You are arranging clinic visits so when the pod phones your gp to check how housebound they will tell us your mom visits a clinic. They wont give you any specific time to visit either, it will be either am or pm.

If they have already looked at them and sent you back to DN I can see it happening again, it may well be departmental policy that any wound not producing callus is ref back to DN. If they have a lot of diabetic patients who have wounds producing callus that need opening up weekly these take priority, a leg amputation quite often leads to death within 5 years, if they survive the recovery period, and preventing leg amputations is our main aim. The only thing I can think that we could do is use a doppler to listen to the pulse to monitor how much vessel damage is there, but I always say weighing the pig wont make it any fatter, you should be able to tell by looking at a foot if it's got poor circulation (I mean us not you).

I think we need to look at alternative ways of managing this. You say she gets tea on it yes? The nursing homes I visit use these. You can put a straw in it or drink from the spout. But it is harder to slosh the tea everywhere. I'm not pretending for a second that she will be overjoyed to be presented with it.

Dressing plans do need to change sometimes eg you can apply lyofoam for ages and then all of a sudden the wound edges are white so you switch to an alginate.

Did you ask if they actually expect the wounds to heal?.

iliketea - that's interesting ,and worrying .

I don't know what has happened with my mums legs ,they have suddenly ( as in over last 36 hours ) started leaking ,apart from the existing skintears ( recent ) and long standing ulcer ( that was " sloughy" but not leaking ) she has developed 2 tiny pricks one on each leg and i can see the fluid bubbling out of them . Her slipper was sopping this morning .

The team leader dressed them yesterday but he didn't have the type of dressing he wanted on him at the time so used some gauze ,a pad and a bandage .

Regarding the podiatrist ( and thank you as ever fluffy ) ....we were referred ( by same team leader because of ulcer on ankle ) and I took mum to clinic in January . I wouldn't ask for a home visit as I know what it's like and I can manage with a wheelchair .
I think we will have to return and put up with being caught in cross fire of agencies ,as the team leader won't touch that ulcer unless he has guidance from podiatrist ( so DNT will manage on advice ,which sounds reasonable if the podiatrist doesn't start having a go at us again .)
But it was so horrible that we never went back .

With the tea ,she has a hot water dispenser thingy www.google.co.uk/products/catalog?rlz=1T4ADFA_enGB381GB381&q=hot+water+dispenser&um=1&ie=UTF-8&tbm=shop&cid=2285657819082012520&sa=X&ei=k-aiT92dI8iHhQfanOXgCA&ved=0CKABEPMCMAA#
and I've altered the amount it dispenses so that her cups are less full .

I'm working on the can't get gloves on ( needs this when visits loo ) ,she's currently using the plastic wrapper that her Guardian is delivered in ) but no soloution yet for the rinsing of false teeth .

I've not asked about expectations regarding healing - think negative . Practice nurse talked very delicately /non judgemental way about people who don't put legs up ,tolerate compression bandages etc ,just living with the ulcers .

And are you physic fluffy - the edges of the longstanding leg ulcer have indeed suddenly turned white .

It's very hard ,it makes me think she needs to be in care .
I'm not sure what else I can do and actually feel I'm doing wrong by doing so much .
Hence the willingness of team leader to suddenly include me as part of the dressing team .
Onwards and upwards tho !

Little bit psycic actually, gets less and less as I get older though.

If they are leaking more than before, and the slipper is wet they may well be infected again. I had a patient who had longstanding ulcers once and as he walked down the corridor it looked like he was weeing, the fluid literally poured out of his legs and we had to get he bio hazard cleaning kit out!

When we next saw him he told us it had been the start of infection.

The excess fluid will be making the skin soggy (macerated).

Granulation= healing tissue. Good thing.
Maceration= soggy skin. Bad thing
Slough= a greeny/yellow tissue present on longstanding ulcers. Not really good or bad ime, just a fact of life with ulcers. Gels can be applied to encourage it to lift but it doesnt always suit the wound condition.

A lot of patients have brown vinyl stools given to them by social services that you are meant to use to put your legs up to hip height IME though they are used for the telephone or the radio times.

Did the dn see the wet slipper? is there a strong smell to the exudate? Hopefully they will be re-dressing the wound before Tuesday? these things ALWAYS happen on a BH weekend. It's uncanny.

fluffy thank you so much for replying .
This must be so boring for everyone but I'm scared and stressed now .

I have never seen mums legs leaking before .
On weds morning ( the day after the long exhausting hospital visit )I called on mum .
She was sitting in the chair really wet from knee down .
She was distressed -TBH I thought she must have had a TIA and wet herself .

But it was coming from her legs .
Team leader called a few hours later by which time ( I'd wrapped in clean towel ) not so bad .
I didn't show him the slipper or socks .
I did say as he was finishing last dressing " isn't mums legs dripping ? "
but he thought it was something else . ( moisture from gauze he'd cleaned it with ,me being mistaken ? )

I called to check Thurs morning and that's when I saw these pinpricks /nicks with fluid bubbling up from them .
I'd collected the nurses prescription by then and used the padded bandage to ( not tightly and from foot to below knee -all probably wrong but what can i do ,thought best as a nurse coming today ) wrap round them . And then some slinky bandage over that ,not tight .
I also changed the secondary dressings on the wounds ,left primary ones in place .

Update - Team leader has just returned my worried call . He says I've done right thing . Nurse ( shes a HCA actually and I really like her ) coming today .
He says he's not worried that there's any infection and that it's just "pitting odema " which would only be cured by having legs raised .

I do encourage her to put legs up on a highish stool that I pad up ,might almost be hip hight ,hard to tell as when she has feet up like that her torso seems to slump down in chair .

Maybe I should get a reclining type chair ?

Thank you again for replying . Will understand if you want to bow out of this long thread - just posting it helps me order my thoughts and calms me down a bit .

Oedema will cause leaky legs ginger.

Excess fluid in the limbs normally stays inside the skin, causing swelling and tightness of the skin. If you think, her skin is damaged, broken, split, fragile so the fluid has an exit point. A bit like an old hosepipe that has been left outside in the sun and wind and is a bit thin, a bit cracked - as you turn the water on it will seep or spurt out of the worn, cracked areas of hosepipe.

Elevation is ESSENTIAL as it helps cheat gravity a little bit and encourages some of the fluid back up to the groin and torso where it can be drained away by the lymph system and heart/kidneys. It also puts less pressure on the skin. Would she lie on a bed or sofa with her legs up on pillows? You can put towels on them then. Ideall her legs should be as high or higher than her hips but for some elderly people this is uncomfortable for their backs, breathing etc and also they can't get up for the loo easily!

In quite a few elderly people healing the ulcers can be very very hard, especially if they don't tolerate compression or elevation. There are usually lots of other underlying problems too like heart failure, poor kidney function, mild anaemia, peripheral vascular disease, venous insufficiency and suchlike. Sometimes we have to be realistic that we may not heal longstanding leg ulcers and focus on keeping the legs clear of infection, dry and comfortable.

Hope things improve for her.

Thank you Sidge - being able to post and get replies means so much to me .

She has all those things you list ....and can be very stubborn and kind of secretive . ( guess her strength of will has got her this far ,so mustn't knock it ! ).

I think she only has her legs elevated when I'm there ...

I feel calmer about her legs ,the HCA was fantastic and dressed all the various bits with great care . And actually the fluid loss has slowed down .

But she left the fingers to me .... I guess I shouldn't have offered to do them .
If I'd known how pussy they were ( and smelly cheesy ) I'd have wanted someone else to see them .
Mum knows she should keep them dry so she dries them out on the heating pad she has on her lap .

I just don't understand why the fingers are a lesser concern and why the nurse would be happy to let me dress them - tho I can see that there is a lot of experience in dressing legs and none in fingers .
But having a bandaged finger on each hand impacts so greatly on her day to day activities .
All the professionals ( GP and hospital ) seem a bit stumped by the gout ,I think it's going to being a long road to get it under control and meanwhile there seems to be little interest in managing it's effect on mums fingers .