My Scope of Practice: The Face of Dedication

You're not obligated to win. You're obligated to keep trying to do the best you can every day

     - Marian Wright Edelman

     A graduate of the Texas Woman’s University (Denton, Tex) nursing program, Julie Ortiz, CWOCN, joined the staff of the University of Texas MD Anderson Cancer Center (MDACC, Houston, Tex) in 1996 as a medical surgical nurse; she became a research nurse in 1997. In the latter capacity, Julie worked with several surgeons in the center’s Department of Surgical Oncology. By 2002, ready for a career change, Julie left her research nursing position to attend the MD Anderson Wound, Ostomy, and Continence Nurse (WOCN) education program. When she completed the WOCN program in May 2002, she immediately began working as a WOCN at MD Anderson.

     Julie currently works with a team of nine WOCNs; their workloads are divided according to patient cancer type. Julie serves the outpatient clinics of the Gastrointestinal Center, The Ben Love/El Paso Corporation Melanoma and Skin Center, and the Robin Bush Child and Adolescent Center — all conveniently located at MDACC’s main campus. In addition, she is responsible for pediatric inpatient care at the Children’s Cancer Hospital. Julie is paged regularly by physicians and their teams throughout the different centers seeking wound care and tumor recommendations, skin assessments, preoperative teaching, stoma site marking for ostomy surgery, postoperative ostomy teaching, and evaluation. Her responsibilities have enhanced her understanding of the importance of nutrition regarding wound care and she continually relies on the expertise of each center’s dieticians.

     Routine assignments involve working with clinic nurses to prioritize the patients’ needs and diverse schedules. “I rely on the care team to assess the true area of concern so I can determine how to best use my time,” Julie explains. “This results in daily staff education regarding skin breakdown identification, tube site assessment, and correct identification of patient issues. My coworkers take over for me one day a week (we work four, 10-hour days) or when I am on vacation.”

     Julie says there is never dull day in wound care; she finds it fascinating. “In my 12 years as a RN, I have seen great changes,” she says.” Wound care dressings keep evolving — from dry to wet to negative pressure to hydrogels and absorptives such as calcium alginates to silver-impregnated products to the latest — honey. My education has taught me the process of wound healing and how these products can either support or disrupt healing progress.”

     The wounds Julie sees in cancer patients include surgical wounds, disrupted surgical incisions, tumors and damage from tumors, fistulas, radiation skin changes and sequelae, pressure ulcers, wounds from shear/friction, chemical and mechanical damage from tubes and drains, perianal skin damage, and infections. She notes that non-cancer wounds of neuropathic or diabetic ulcers and peripheral vascular disease are prevalent as well. A significant number of cancer patients also suffer with different types of wounds. Because the majority of Julie’s patients fall into this category, she knows how the disease and the treatment affect each patient. Yet despite their multiple challenges, Julie’s patients are thriving and surviving regardless of diagnosis. “Cancer treatment usually includes multiple modalities,” she says. “Chemotherapy used concurrently with radiation precedes surgery and surgery is quickly followed by more chemotherapy. This process makes wound healing important — cancer treatment should not be interrupted. A delay in wound closure may [result in] the optimal window of postoperative treatment being missed. Because cancer also causes pain, it is important to use products that minimize the patient’s pain as much as possible. Plus, cancer treatment affects patients’ skin. Simple cuts and skin tears that heal quickly in most healthy people can become larger wounds in our compromised population. Teaching our patients to protect and prevent these problems is important.”

     One challenge in particular is odor control. Daily washing with deodorant or antiseptic soap may work for one patient while another patient may require Dakin’s solution; charcoal-impregnated products may suffice for one group of patients but silver-impregnated products may work better for others.

     Honey is by far one of the biggest advancements among wound care products— specifically, Derma Science’s Medihoney (Princeton, NJ). The Manuka honey holds great promise for the MD Anderson wound population and has yielded notable healing results. “Our team did a literature review for odor control,” Julie explains. “Honey was found to be most effective product. Odor was controlled quickly in the few patients on whom it was tried. Honey also is a good debrider. With the loss of papain enzymatic debriding agents, my group is reviewing other debriding products. Honey and honey-impregnated dressings are promising.”

     Julie also has had experience with continence, pediatric, and pressure ulcer care. Incontinence and the resulting skin breakdown, especially among immunocompromised populations, can result in large wounds. To protect patients’ skin, MD Anderson recommends moist cleansing and the liberal use of skin barrier creams, a strategy common in Julie’s pediatric population. She adds, “When skin is opening and weeping, the use of ostomy powder and skin barrier film known as ‘crusting’ can provide the needed protection to allow the skin to heal.”

     Although colleagues handle pressure ulcer care, Julie teaches the patients’ families how to prevent and treat these wounds. The facility is a Magnet Hospital that participates in the National Database for Nursing Quality Indicators (NDNQI), gathering quarterly pressure ulcer prevalence information.

     Being a dedicated WOCN has its share of challenges — for Julie, helping people cope with the emotional devastation of their wounds or ostomies is the biggest. She makes sure her patients know that products are available to help them resume as normal a life as possible and that the patients’ friends and family are provided ongoing reassurance that their loved one is receiving proper care and support.

     Julie credits much of her success to her mentors. Colleagues Rosalie Johnson and Cynthia Timms inspired her to become a WOCN. Coni Ellis and Janet Davis encourage her to teach and present her work to the ever-evolving wound care community. Looking ahead, Julie would like to attend a national conference and present a poster or abstract, perhaps at a future Symposium on Advanced Wound Care. She also is interested in exploring the role of nutrition in wound healing and prevention. “Wound care gets people on their feet faster,” Julie says. “At MDACC, faster wound healing outcomes mean fewer delays in getting to the next phase of treatment.” Efficient and timely treatment are essential in obtaining optimal healing— the ultimate goal at the end of the day in Julie’s scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.