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 ?

I find with some professionals if they can't fix it they just don't pay it any attention.

If they can't fix it what can they do? It's a bit depressing really when you can't fix something.

Mmmm . lots of things that can't be fixed - heart conditions ,diabetes ,asthma ..
But they're managed rather than ignored .

Sorry I meant if you cant give it a tablet or get the patient to do something then they just turn back to the computer screen.

Like me with my chest, doesnt conform to any illness so ignore ignore ignore.

sorry coming in late here but the issue of yr mum worrying about when the nurses will turn up..we address this by calling those pts on the day to give them a time we are coming.
There are quite a few pts on our caseload we do this for, providing yr mum can answer/hear the phone.

As lengthy experience as both a DN and a PN, I would definitely leave the dressings to the DNT. I am generalising, but many PN have very limited experience of up to date woundcare (as doing dressings doesn't generate income for the GP's!) whereas a hell of a lot of DN time is woundcare based.

Having said that many DN health care assistants are now sent out to do quite complex dressings due to staffing constraints, and I would be concerned that not all would have sufficient underpinning knowledge and awareness of deterioration and when to report. There is much more to it than just following a careplan.

I echo what others have said and ask to meet with the team leader to mutually agree a plan of action going forward. Expecting a set visiting time however is unrealistic. DN workload varies massively, and 10 minute routine visit can suddenly take you 45 if there are problems!

Be warned though, I have known leg ulcers of 15 years or more that still aren't healed. Good luck.

....oh, and is your mother prescribed dieuretics (water tablets) for her leg oedema? If so,is she taking them?? If not, does she need the GP to review?

Thank you guys .

What can I say ? I think we have an imperfect system , the practice nurse is good and some of the members of the DNT are good .
Some ,actually ,aren't .
No doubt training and experience comes in to it .
With both there seems a lack of interest in the fingers .

With the practice nurse there is continuity which is helpful and easier for my mother .Plus easier to arrange blood tests and get antibiotics .

The DNT really aren't able to say when they're coming ,I accept and understand that . My very anxious mother struggles with it .

CPtart - yes takes diueritcs ,quite a high dose I think - 80mg in am and 40 mg at lunch .
She does take them .

I have a feeling that the sudden onset of the weeping might some how be related to the 5 hour hospital visit the day before ....maybe her legs were knocked with all the transfers involved in getting her there . We didn't use hospital transport as that would have involved an even longer day - need to be ready 2 hours before appointment time and not unusual to get home about 8pm .

Maybe her kidneys are getting even worse .

I don't know - I feel very cross and sad .
The hospital visit was for a review - general one of all her issues .
The clinic was running late ,we were last in to see doctor and frankly it was dreadful seeing him .
He conducted the whole conversation at speed of light ,fired questions at me that I couldn't answer ( kept asking when heart failure/gout etc first diagnosed ) ,never took eyes off computer ,categorically said mother on wrong dose of aspirin ) . Barely spoke to mother .

Mother has so far received 3 letters since visit with dates for xrays to chest and neck ( which we were told about ) and a full bladder scan ( never mentioned and I don't know why requested - and I have no idea how my mother will cope with it .)

I had asked for rheumotolgy ( sorry too tired to spell ) referral for gout and was told they might or might not ,couldn't tell me what the referral would depend on .

Clinic said they'd phone with follow up appt for this week .They haven't and havent returned my call as promised .

So mothers care - like so many elderly very complex and like swimming through porridge .
And how do elderly cope if no relatives to assist ?

And if her legs are weeping ,I can see that wrapping them in padded bandages ( as per Team Leader ) will keep her bed/clothes etc dry .

But ,but .....won't it also mean that she's sitting with legs wrapped in wet material ?

And won't that be bad for the skin and the wounds to be wet all the time ?
Maceration and all that ?

My head hurts with it all - surely she needs some closer monitoring ?

Re the dressings it depends on what's used, ginger.

Many modern dressings are hugely absorbent and keep the fluid and exudate away from the skin so the wetness won't be bad for the skin. Pads such as Mesorb, Kerramax and the like are very absorbent and if changed as needed will not leave fluid against the skin.

I'm sorry the hospital visit was so unhelpful

Thank you Sidge - the calm voice of reason !

I find it hard to trust the professionals dealing with my mother ( mistakes in past ,diagnosising fractured hip as muscle strain with no xray ,withdrawing diueritics because of potassium levels with no monitoring etc,etc ) and my brain wasn't regestring that such materials might exist and that obviously they'd be chosen .

I know every one is busy ,but it wouldn't have taken long for Team Leader to have explained this ( tho worry ,worry ,not sure he really took in new weeping scenario ) .

I shall persevere with clinic and try and get a better result .

I expect they do like lots of tests to help them review the situation but in my book they should all be explained to the patient ( why they want them ,whats involved ) and there should be some recognition of the huge physical toll attending for them takes on my mother ( not to mention me ) and some negotiation possible about whether all of them are really essential .

( tell me I'm right Sidge and encourage me .... )

I suspect the three appointments for tests we've had aren't the end of it .

Thanks for reading if you've got this far !

You are so right! Of course patients and their involved relatives/carers should be kept fully informed at every step of the way. However I think many HCPs forget this (I'm sure I have been guilty of it too) and focus on the "what needs doing, why and when" and forget the "telling the patients why are we doing this" part.

Sometimes you have to be rather annoying assertive and tell HCPs that you want to know what's going on and why and what the alternatives and desirable outcomes are. Make them stop and explain! They often forget that the world and his wife aren't medics and don't know what is going on and why.

Well ... seems common care plan not possible because the DNT and the practice nurse " have different employers " .

I suppose that's because the GP surgery is a business ( or something ...I knew I should have been following all the stuff in the press recently ) .

we do shared care with the practice nurses
they have a few pts who can't make it to the practice as much as is needed and we visit on those days
we follow their lead and write the plan for home visits so it's there for each visiting nurse

seems ridiculous that they can't communicate and agree on the dressing plan

It all seems a bit odd to me .

Nurse who called on Weds informed me that they weren't doing the fingers .
Me " why's that ? "
Nurse " well practice nurse is doing them "
Me " no ,she's on leave "

Today she was saying that she understood that I had said I would do them .
I try and explain that I'm happy to do them provided someone else ( a HCP ) looks at them regularly and confirms that what I'm doing is ok .

I make it sound as though we're arguing ,we're not .
Everyone is really nice ,but I feel that there's a subplot I'm missing .

Regarding the care plan there was lots of talk of it being a legal document and taking responsbility ... but if sharing the care is not possible I wish they'd just say so .
The DNT Team Leader says it's fine ,no problem and then seems to backpeddle .

does seem odd to me

so are the fingers being dressed twice a week or more often?

can someone not write a care plan for the fingers and agree to do them regularly so they can be assessed?

Are her fingers still infected?

Fingers - three times ,yes still have pus .

Team Leader said would do care plan for legs ( can't do ankle because needs podiatrist input ) and said he would note that daughter doing fingers .
When I queried this ( me " why are fingers different from legs ? " ) he said that he assumed that I'd been shown by a proffesional what to do .
But as I told him - I haven't ! .( tho I've learnt a lot while doing them )

When I asked why AG primary dressings used on " sloughy " leg wounds but N A and gauze used on pussy fingers he reminded me that he'd asked whether mother on antibiotics . But as she finished the last course 3 weeks ago I'm not sure of relevance .

I said ( politely and non confrontational I swear ) that maybe chronic finger problems possibly unusual ( nurses say they are not used to doing fingers and none of them have ever seen the finger dressing - like mini tubifast with "sugar tong" applicator that I've bought ) and maybe advice could be sought .
But he just says " I've seen them and NA and gauze are fine . "

But someone upthread did explain leg wounds are more serious ,so perhaps I'm worrying too much .

if the wound bed on her fingers is green and sloughy , they won't heal until that is dealt with
they need something like flaminal forte a gel that deals with infection and slough or purilon gel
once the wound bed is showing pink healthy tissue then NA and gauze is sufficient
but the healing will be delayed until the slough is dealt with

Thanks ggirl - more like red inflamed over whole finger ,down to midway btwn first and second joint and pus in one central spot ,like a boil ( it's where the tophi have broken thru skin and infection got in ) ..

Practice nurse is back mid week so will be taking mother up to surgery ,if it gets worse meanwhile I'll take her to walk in near us .

The DNT saw fingers on weds - at my insistence - they don't think cause for concern .

ah right ..ignore my ramblings then ...sounds painful!

oh no ,not ramblings - your post vry hlpful . Several leg wounds going on .