Wound Care Nursing: Interview with Jessica Pappas, RN, CHRN
Using hyperbaric oxygen therapy to promote healing
Jessica Pappas, RN, CHRN, Casa Colina Hospital and Centers for Healthcare, Pomona
Where do you work and what is your position?
I work in the Outpatient Wound Care and Hyperbaric Medicine Department at Casa Colina as both lead nurse and hyperbaric nurse. I also serve as supervisor for the medical assistants who see patients in the wound clinic.
In our facility, we have both inpatient and outpatient wound care teams. In the department where I work, we have a nurse practitioner who is WOCN (wound care, ostomy and continence) certified and works alongside the physician, who is trained in infectious diseases. The majority of the staff are trained medical assistants, certified nursing assistants and licensed vocational nurses.
We only treat patients based on the 14 indications and guidelines approved by the Undersea and Hyperbaric Medical Society (UHMS). Some hyperbaric centers also use hyperbaric therapy for conditions such as cerebral palsy, autism/Asperger syndrome or stroke. Whether hyperbaric oxygen therapy (HBOT) is appropriate for those conditions is still being studied.
Can you share the arc of your nursing career?
I knew I wanted to be a nurse all through high school. I earned my bachelor’s degree in December 2009. As a new nursing grad, I accepted an ER position in San Bernardino in 2010 and quickly discovered that the emergency room was not going to be my nursing specialty of choice.
While I was looking for a longer-term career opportunity, I found Casa Colina (which was a freestanding acute rehabilitation facility at the time) and applied for an inpatient nursing position. While I was waiting for that position to open up, they offered me a position in the outpatient wound care clinic. I accepted it and I’ve been here ever since.
Even during my short time in the ER, I had found that I naturally gravitated towards wounds, so I was perfectly positioned to fall in love with wound care. Although wounds in the ER were generally acute abscesses or out-of-control infections (like MRSA), it gave me the exposure I needed to move into chronic wound care.
What intrigues you about working with wound care patients?
Patients generally come to us because they’ve had a wound for a great deal of time that is resistant to conservative treatment. Patients are afraid to have a large, vulnerable opening in their body and we have the experience and resources to fix it for them.
I find a lot of satisfaction in helping patients to heal and return to normal life without a wound. Being able to provide them with everything they need to heal is so satisfying. Chronic wounds don’t heal overnight. If patients are willing to commit to the process, we develop relationships with them, in some cases over very long periods of time. We have a significant success rate.
What can you share with us about hyperbaric oxygen therapy?
Many nurses really don’t know what HBOT is. I truthfully had never heard of it before starting this job.
Hyperbaric chambers look very futuristic. Ours are made of clear acrylic, have an internal diameter of 32 inches and are about 8.5 feet long. They deliver 100 percent oxygen in a pressurized chamber at two times atmospheric pressure, which is like diving 33 feet in saltwater.
The pressure allows the oxygen to enter the patient’s bloodstream and gain direct access to the plasma. The goal is to provide hyperoxygenation, which leads to angiogenesis and, ultimately, wound healing.
Before a patient enters the chamber for a hyperbaric oxygen treatment, we measure their blood sugar and vital signs. The patient is then placed completely inside the chamber and the door is secured. Once the interior pressure exceeds the normal pressure outside the tank, the lock mechanism engages, forming an airtight seal.
Many patients have claustrophobia and we have to coach them through the experience. If they compress and decompress at an average rate, the process takes approximately one hour and 45 minutes. Hyperbaric treatment is generally prescribed for 90 minutes per day, Monday through Friday, for up to 40 treatments.
We have two chambers that are side by side. I sit in between the two so that I can monitor and respond to any needs the patients receiving treatment may have. Since the chambers are made out of clear acrylic, the patients can see me and other staff at all times.
When patients are inside the chambers, they have a communication button that they can press in order to alert me. I can then pick up a phone, talk with them and address their concerns. There’s a television above each chamber; patients can watch TV, bring in their own DVDs or listen to music.
What about patient follow-up?
Patients receiving hyperbaric oxygen therapy need to understand from the beginning that their wounds generally won’t heal completely by the end of the prescribed period. Even though the overall goal is angiogenesis, most patients won't have normal perfusion by the time treatment is over. That can be frustrating for patients with unrealistic expectations. With improved perfusion, most wounds will heal over time. A handful may go on to amputations, but we do our best to prevent that.
HBOT isn’t a cure in and of itself. Patients also have to participate in wound care, show up for hyperbaric treatment as prescribed, control their glucose and eat healthy proteins that promote healing. Wound care using hyperbaric treatment is a multifaceted approach with the patient at the center of the process.
Can you tell us how the wound care you do differs from burn care? Are there similarities?
We primarily care for chronic wounds in our department. In some cases, that does include burn patients who may be healing from significant burns or skin graft procedures. However, the majority of our patients have diabetic ulcers, venous ulcers, neuropathic ulcers, pressure ulcers or arterial ulcers. That being said, we treat each wound based primarily on the etiology of the wound and generally follow moist wound care practices.
How have advances in technology impacted wound care?
Wound care is constantly changing. There are always new skin substitutes and modalities being developed. Many of the skin care products that we use contain collagen, silver or sometimes both. Silver helps to kill bacteria on the surface and collagen promotes healing through tissue granulation.
Tissue-derived wound products are now being used to help treat chronic ulcers. For example, some are derived from human placenta or pig intestines/ urinary bladders, or contain hyaluronic acid. Researchers are using various methods to derive human growth factors that will promote healing in very difficult wounds.
We have recently seen impressive wound healing with tissue-derived dressings. When pale, unhealthy granulation tissue grows in a wound bed, you won’t be able to get the wound to really heal. The tissue products promote granulation, sometimes producing red, healthy granulating tissue within a few days of initiating treatment.
For patients with ulcers related to diabetes or idiopathic neuropathy, we use total contact casts. These are special walking casts made of fiberglass. They look just like a normal cast, but the patient’s weight is distributed to the cast, not onto the bottom of the foot where the wound is located. We have seen significant wound healing with our patients using a total contact cast, which allows optimal offloading for an ambulatory patient.
What do you recomment to nurses interested in exploring wound care and hyperbarics as a career path?
Before applying for CHRN [certified hyperbaric registered nurse] certification from the National Board of Diving and Hyperbaric Medical Technology (www.nbdhmt.org/chrn.asp), nurses need to attend a 40-hour course and complete 240 hours of actual on-the-job experience.
For wound care, I would suggest finding a facility, applying to a wound clinic and getting as much experience as possible. You can read all you want about wound care, but to know what you’re really doing, you need to get your hands dirty, so to speak.
The next thing on my list is to earn my WOCN certification. I love what I do and I might consider pursuing an APRN degree, but right now, I’m focused on raising two little children. Meanwhile, I’d like to attend wound care and ostomy nursing association conferences and continue to learn as much as I can.
If I do decide to become an advanced practice nurse, I would like to stay in wound care and hyperbarics as my professional focus of choice. I see myself being in this field for a long time.
This article is from workingnurse.com.