My Scope of Practice: The Wound Care Jigsaw Puzzle
To the outside world, wound care can seem like glorified dressing application, but people within the field understand all too well the complex care puzzle. Treating a wound, coordinating care with other clinicians, and gaining the patient’s trust can make achieving results seem almost impossible to piece together. Nancy Weckel, BSN, RN, CWCN, reassures her patients that they can figure out the wound care jigsaw puzzle through an individualized treatment plan.
“Patients with diabetes often need a hand to hold when they first arrive to clinic because they associate a wound with amputation,” Nancy explains. “They come to us frightened and often thinking amputation. When they're in this state of mind, that is not the time to scold them for not checking their feet or controlling their blood glucose better. It is my belief and practice that it is the time to offer hope and options for treatment.”
Nancy started her nursing career after graduating from the 4-year Bachelor of Science in Nursing program at Wagner College (New York, NY). Her career led her west to the University of California-San Francisco Medical Center, where she gravitated towards vascular patients. “That was back in the day when patients stayed weeks to months inhouse, and we got to know our patients well,” Nancy says. “It was also when a majority of patients had terrible, painful wounds that ended in amputation.” Eventually she transitioned to a dynamic wound care clinic, finding her calling among patients with wounds and their families.
In her current position as a Case Manager for O’Connor Hospital in San Jose, California, Nancy works side-by-side with a physician on an assigned caseload of patients. Typically, patients are seen weekly for wound evaluation to determine if the wound is progressing or regressing.
“The most challenging aspect of my job is having to limit time per patient,” Nancy says. “Isn’t that everyone’s challenge? Patients with chronic, nonhealing wounds are extremely complex with multiple comorbidities. It takes time to coordinate their care and work within a multidisciplinary team approach. You have to be a master multitasker and good communicator.”
As treatment modalities and testing improve, Nancy relies on a variety of diagnostics to get a sense of how the wound is healing. “There are numerous diagnostic tests to consider: blood work, tissue cultures, biopsies, and perfusion studies for extremities as well as radiology studies,” she says. If a wound treatment protocol is deemed to be inappropriate, Nancy and the physician tweak the treatment to best accommodate the current wound characteristics. “In many situations, patients benefit from cellular tissue products,” she says. “There is a plethora to choose from and learn about. There are also adjunctive therapies, such as hyperbaric oxygen therapy, mist therapy, and negative pressure wound therapy.”
Connecting the whole patient (not just the hole on the patient) with a comprehensive treatment plan is the focus of Nancy’s practice. In addition to discussing options with the treating physician, she orders products from the manufacturer to ship to the clinic and works with the insurance provider for authorization and reimbursement. Patients who present with several comorbidities require Nancy to collaborate with her multidisciplinaryteam members that include an infectious disease specialist, endocrinologist, primary care physician, rheumatologist, and nutritionist as well as vascular, podiatric, orthopedic, and plastic surgeons.
Most importantly, the provider-patient relationship is at the core of her practice. “Once the patient-provider relationship has started and wound care is under way, the patient is more responsive to diabetes teaching and the ‘scolding’ can begin,” Nancy jokes. “It sounds corny, but I feel so blessed to have the opportunity to work with patients who have challenging wounds and challenging lives and to see these often life- or limb-threatening wounds heal and see the patient return to a higher quality of life. These patients are very courageous individuals, and I like to think they instill a bit of their courage and strength in me during our time together. I don't forget them once they’re healed!”
Over her career, Nancy has learned a great deal; she cites courage, compassion, and her signature expression, “stay in your lane” (meaning to focus on the present situation at hand), as her main lessons. For future wound care professionals, she recommends always listening to the patient from your heart — the patient is the key to healing puzzling chronic wounds.
Fitting the pieces of the wound care jigsaw puzzle together is the glue of Nancy’s scope of practice.