Patient Skin Care: Protecting the Body’s Largest Organ

Podcast Transcript

Carol Pehotsky (00:04):

No matter what our specialty or setting is as nurses, skin health, skin assessment, skin protection is so important and foundational to what we do. It's why we talk about it in nursing education, whether our experience pre-licensure was recent or a long time ago. I'm so glad to be joined today by Dr. Mary Montague-McCown to talk more about how we can all as nurses protect our patients' skin.

(00:32):

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing. From patient care to advancing your career, to navigating tough on the job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

(00:53):

Welcome back everyone. As the group of us that get t- together and talk about, uh, topics for discussion for this podcast, you know, we have a rotation of sorts. We, we love bringing in people who have, uh, interesting life stories. We love bringing in folks to talk about how we can best take care of ourselves or interprofessional relationships, but we also like to sprinkle in clinical experts who really can help us think about, no matter where we are in our nursing career, w- what are some things we can learn, what are some basics we need to get back to. And, and we try to think about topics that could affect all of us as nurses, no matter what population we're serving.

(01:30):

So, what better topic than skin (laughs) and skincare? And so, I'm so delighted to, to be joined today by longtime colleague and friend, Dr. Mary Montague-McCown. Gosh, we've known each other for a long time.

Dr. Mary Montague-MCown (01:31):

A long time.

Carol Pehotsky (01:42):

I've learned a lot from you. (laughs) And I'm so glad that our audience will get to learn more as well. So, Mary is our program manager for our Wound, Ostomy and Continence nursing program here at Cleveland Clinic. Mary, welcome. Thank you for coming on the show.

Dr. Mary Montague-MCown (01:54):

I appreciate the invitation, Carol. Thank you.

Carol Pehotsky (01:56):

Excellent. So not everybody has gotten to s-, benefit from your expertise like I have, so can you kick us off a little bit about just a little bit about your journey, what got you so passionate about skin and WOC nursing that you could share with our audience to get us started?

Dr. Mary Montague-MCown (02:09):

So, I'm going to preface my answer by saying way back when, and I'm not going to say-

Carol Pehotsky (02:15):

(laughs) That's right.

Dr. Mary Montague-MCown (02:16):

... how way back when we're talking about. This specialty began with ostomy care.

Carol Pehotsky (02:16):

Mm. Mm-hmm.

Dr. Mary Montague-MCown (02:21):

So, in those days, we were referred to as enterostomal therapists-

Carol Pehotsky (02:28):

Oh, yeah. Mm-hmm.

Dr. Mary Montague-MCown (02:28):

... or ET nurses.

Carol Pehotsky (02:30):

Yes. (laughs) Yes.

Dr. Mary Montague-MCown (02:32):

And ET, you know, the photo of ET-

Carol Pehotsky (02:33):

I'm, I'm guilty of doing that, yes.

Dr. Mary Montague-MCown (02:34):

Yeah.

Carol Pehotsky (02:34):

(laughs)

Dr. Mary Montague-MCown (02:35):

So, I began my career on a med surg unit at Lakewood Hospital.

Carol Pehotsky (02:39):

Mm-hmm.

Dr. Mary Montague-MCown (02:40):

And I was fascinated every time the ET nurse came onto the floor-

Carol Pehotsky (02:46):

Mm.

Dr. Mary Montague-MCown (02:46):

... and saw a patient.

Carol Pehotsky (02:47):

Okay.

Dr. Mary Montague-MCown (02:48):

So, I just made it my business to go into the room when she was on-

Carol Pehotsky (02:48):

Oh, that's fantastic.

Dr. Mary Montague-MCown (02:52):

... the floor-

Carol Pehotsky (02:52):

Yeah.

Dr. Mary Montague-MCown (02:53):

... to see what she was doing.

Carol Pehotsky (02:54):

Mm-hmm.

Dr. Mary Montague-MCown (02:55):

And I loved what she was doing.

Carol Pehotsky (02:57):

Wow.

Dr. Mary Montague-MCown (02:58):

So, when she went on vacation-

Carol Pehotsky (03:00):

Okay.

Dr. Mary Montague-MCown (03:00):

... the first time, she said, "Would you cover for me?"

Carol Pehotsky (03:02):

Ah, oh, wow.

Dr. Mary Montague-MCown (03:02):

I said-

Carol Pehotsky (03:03):

What a great experience.

Dr. Mary Montague-MCown (03:04):

I said, "Joy..."

Carol Pehotsky (03:05):

Yeah.

Dr. Mary Montague-MCown (03:05):

And her name was Joy Bredenbeck, and she is still with us, and I saw her a couple months ago.

Carol Pehotsky (03:11):

Yeah. (laughs)

Dr. Mary Montague-MCown (03:11):

Still involved in society.

Carol Pehotsky (03:14):

Wow.

Dr. Mary Montague-MCown (03:14):

I said, "Joy, I have no training. I can't cover for you."

Carol Pehotsky (03:17):

Mm.

Dr. Mary Montague-MCown (03:17):

She said, "Mary, you were with me. You helped me teach this patient."

Carol Pehotsky (03:21):

Oh, gosh. Yeah.

Dr. Mary Montague-MCown (03:22):

"You can cover for me."

Carol Pehotsky (03:23):

Yeah.

Dr. Mary Montague-MCown (03:24):

So, I covered for her. It was only one patient while she was gone.

Carol Pehotsky (03:26):

All right.

Dr. Mary Montague-MCown (03:27):

And I loved it.

Carol Pehotsky (03:28):

Mm-hmm.

Dr. Mary Montague-MCown (03:28):

I just loved it. So, when Joy retired, the director of nursing said, "Would you be willing to go to school?"

Carol Pehotsky (03:29):

Wow.

Dr. Mary Montague-MCown (03:36):

And I said, "Well, you don't have to ask me twice."

Carol Pehotsky (03:38):

(laughs) Yeah. What a wonderful opportunity.

Dr. Mary Montague-MCown (03:40):

Right.

Carol Pehotsky (03:40):

That's amazing. Yeah.

Dr. Mary Montague-MCown (03:42):

So, I came down here-

Carol Pehotsky (03:42):

Mm-hmm.

Dr. Mary Montague-MCown (03:43):

... main campus, went to school, and that began my wound, ostomy, continence journey. It's been since 1996.

Carol Pehotsky (03:52):

Oh, wow. All right.

Dr. Mary Montague-MCown (03:53):

And I-

Carol Pehotsky (03:54):

It has been a journey.

Dr. Mary Montague-MCown (03:54):

Yeah.

Carol Pehotsky (03:55):

(laughs)

Dr. Mary Montague-MCown (03:55):

So, I'm not going to do that high math, but (laughs) but I've loved every single minute and I've enjoyed the learning. So currently we are called wound, ostomy, continence nurses.

Carol Pehotsky (04:06):

Mm-hmm.

Dr. Mary Montague-MCown (04:06):

We are not ET nurses, because-

Carol Pehotsky (04:08):

Right. (laughs)

Dr. Mary Montague-MCown (04:09):

... because the practice has now-

Carol Pehotsky (04:11):

Mm-hmm.

Dr. Mary Montague-MCown (04:11):

... enveloped wound care and continence care.

Carol Pehotsky (04:14):

Sure. Absolutely. And we're so lucky to have that as a specialty and to have resources at our disposal to tap into some of those higher-level specialty care.

Dr. Mary Montague-MCown (04:14):

Right.

Carol Pehotsky (04:22):

And certainly, wounds start with good skin care, how we prevent wounds starts with good skin care, right? So, I'm hoping to spend a little time talking about that, and then I'd love to dive into more of your wound, ostomy, continence experience.

Dr. Mary Montague-MCown (04:34):

S- sure.

Carol Pehotsky (04:35):

Hopefully, we have listeners all the way from I, I'm curious about nursing school to I'm fully into my career. And so those of you who haven't started your nursing school journey, you will spend a lot of time talking about skin and basic skin assessment. From your expert vantage point, we all get that basics, what are some things as nurses we need to be really paying close attention to? I've gone from school to its real life, or I've been looking at skin for however many years, but what are some things maybe we sometimes miss or special things we should be paying attention to?

Dr. Mary Montague-MCown (05:05):

Well, I think the first thing is we can generally incorporate a good skin, and I'm not talking about a detailed skin assessment-

Carol Pehotsky (05:14):

Sure.

Dr. Mary Montague-MCown (05:14):

... but looking at the skin with our other daily activity.

Carol Pehotsky (05:18):

Mm. Mm-hmm.

Dr. Mary Montague-MCown (05:19):

So, as we're listening to our patients' lungs-

Carol Pehotsky (05:21):

Sure.

Dr. Mary Montague-MCown (05:22):

... we can be aware of what the skin is-

Carol Pehotsky (05:22):

(laughs) Yes.

Dr. Mary Montague-MCown (05:24):

... looking like on the-

Carol Pehotsky (05:25):

Yep. Yeah.

Dr. Mary Montague-MCown (05:25):

... you know-

Carol Pehotsky (05:25):

Mm-hmm.

Dr. Mary Montague-MCown (05:26):

... the posterior because we know those are generally the areas where we see skin breakdown.

Carol Pehotsky (05:32):

Sure.

Dr. Mary Montague-MCown (05:32):

So, incorporating just looking at the skin-

Carol Pehotsky (05:35):

Mm-hmm.

Dr. Mary Montague-MCown (05:36):

... into our daily routine. Understanding that well-nourished, well moisturized skin-

Carol Pehotsky (05:36):

Mm.

Dr. Mary Montague-MCown (05:42):

... is going to be less prone to breakdown-

Carol Pehotsky (05:42):

Healthier, yes. (laughs)

Dr. Mary Montague-MCown (05:45):

... than very dry-

Carol Pehotsky (05:47):

Mm-hmm.

Dr. Mary Montague-MCown (05:48):

... flaky-

Carol Pehotsky (05:49):

Mm-hmm.

Dr. Mary Montague-MCown (05:50):

... open skin.

Carol Pehotsky (05:51):

Right.

Dr. Mary Montague-MCown (05:51):

So, you know, keeping in mind back to the basics. Daily bathing.

Carol Pehotsky (05:57):

Yeah.

Dr. Mary Montague-MCown (05:57):

Moisturizing the skin is so important that I think it's overlooked-

Carol Pehotsky (06:01):

Sure.

Dr. Mary Montague-MCown (06:01):

... more than it should.

Carol Pehotsky (06:03):

Yeah.

Dr. Mary Montague-MCown (06:03):

But those things keep the skin in good condition.

Carol Pehotsky (06:08):

And though-, you know, some of us use those prefab cloth products, right?

Dr. Mary Montague-MCown (06:08):

Mm-hmm. Mm-hmm. Bath wipes.

Carol Pehotsky (06:13):

Do though-, those come with some of those products in them, right? In terms of moisturization, or not enough?

Dr. Mary Montague-MCown (06:16):

Well, the bath wipes-

Carol Pehotsky (06:18):

Yeah.

Dr. Mary Montague-MCown (06:19):

... you know, do a, a nice job of cleansing.

Carol Pehotsky (06:20):

Mm-hmm.

Dr. Mary Montague-MCown (06:20):

We do have another product in a package-

Carol Pehotsky (06:25):

Mm-hmm.

Dr. Mary Montague-MCown (06:25):

... for incontinence, so those-

Carol Pehotsky (06:26):

Sure.

Dr. Mary Montague-MCown (06:26):

... do have some barrier protection within those.

Carol Pehotsky (06:30):

Sure.

Dr. Mary Montague-MCown (06:30):

Which helps the skin as well.

Carol Pehotsky (06:32):

So maybe we'll pull on that thread a little bit more because we know that sometimes our patients do have incontinence. So obviously we're concerned about that for a lot of reasons. Why, especially as a newer nurse, do I need to be really concerned about that when it comes to skin health?

Dr. Mary Montague-MCown (06:45):

So, incontinence is so very important to get at the beginning.

Carol Pehotsky (06:50):

Mm-hmm.

Dr. Mary Montague-MCown (06:50):

So, when skin has moisture on it for a prolonged period of time, as we all know-

Carol Pehotsky (06:50):

Mm-hmm.

Dr. Mary Montague-MCown (06:57):

... it's going to get red.

Carol Pehotsky (06:58):

Yeah.

Dr. Mary Montague-MCown (06:58):

It's going to get moist. And at some point, that prolonged moisture is going to break the skin open-

Carol Pehotsky (07:04):

Mm-hmm.

Dr. Mary Montague-MCown (07:04):

... and that's, you know, to the point where we don't want to be.

Carol Pehotsky (07:05):

Sure.

Dr. Mary Montague-MCown (07:08):

So, we need to protect the skin before it gets to that open area.

Carol Pehotsky (07:13):

Mm-hmm. Mm-hmm.

Dr. Mary Montague-MCown (07:13):

Or that open episode. So, cleaning up incontinence as soon as it happens.

Carol Pehotsky (07:18):

Mm-hmm.

Dr. Mary Montague-MCown (07:19):

Not allowing patients to lay in urine and stool.

Carol Pehotsky (07:22):

Yeah, yeah.

Dr. Mary Montague-MCown (07:22):

And utilizing our good products.

Carol Pehotsky (07:23):

Right. (laughs)

Dr. Mary Montague-MCown (07:25):

We have great-

Carol Pehotsky (07:25):

Yeah. Mm-hmm.

Dr. Mary Montague-MCown (07:27):

We have great absorbent underpants-

Carol Pehotsky (07:29):

Mm-hmm.

Dr. Mary Montague-MCown (07:30):

... that utilize diaper technology, so any urine, any liquid stool gets wicked into the center of that-

Carol Pehotsky (07:30):

Hm.

Dr. Mary Montague-MCown (07:37):

... and it keeps that pad dry. Hopefully, it keeps the skin dry.

Carol Pehotsky (07:42):

Mm-hmm.

Dr. Mary Montague-MCown (07:42):

But we don't want to let, even though they're good products, we don't want to let patients sit in urine or stool.

Carol Pehotsky (07:42):

Of course not, yeah.

Dr. Mary Montague-MCown (07:42):

So-

Carol Pehotsky (07:47):

And, and those products have come a long way.

Dr. Mary Montague-MCown (07:49):

They've come a long way.

Carol Pehotsky (07:50):

Yeah.

Dr. Mary Montague-MCown (07:50):

Yeah.

Carol Pehotsky (07:50):

Because it's-

Dr. Mary Montague-MCown (07:50):

Even our-

Carol Pehotsky (07:50):

It's not your mom's Chucks. (laughs)

Dr. Mary Montague-MCown (07:53):

Yeah, and I don't like to use the word diaper, but even our adult briefs-

Carol Pehotsky (07:57):

Mm-hmm.

Dr. Mary Montague-MCown (07:57):

... utilize that technology, so it wicks urine and-

Carol Pehotsky (07:57):

That's amazing.

Dr. Mary Montague-MCown (07:57):

Yeah.

Carol Pehotsky (08:01):

Yeah.

Dr. Mary Montague-MCown (08:02):

But again, we don't want to put a brief on a patient who's lying in bed.

Carol Pehotsky (08:06):

Right.

Dr. Mary Montague-MCown (08:07):

We, you know, keep briefs only for patients who are up out of bed.

Carol Pehotsky (08:10):

Mm-hmm. Mm-hmm. And there's other products that hopefully a lot of us have access to, whether they're fecal management systems or other things that as a nurse we really should be advocating for if we're seeing that. It's, it's not because we don't want to get a patient a bedpan, it's if we truly can't get to this in time, if they've got something else going on-

Dr. Mary Montague-MCown (08:11):

Yeah.

Carol Pehotsky (08:27):

... we need to advocate for those-

Dr. Mary Montague-MCown (08:27):

Yeah.

Carol Pehotsky (08:28):

... products, right?

Dr. Mary Montague-MCown (08:29):

Fecal management systems are great. I do want to say there are many indications-

Carol Pehotsky (08:36):

Mm-hmm.

Dr. Mary Montague-MCown (08:36):

... for that product, and there are just as many contraindications.

Carol Pehotsky (08:41):

Oh, all right.

Dr. Mary Montague-MCown (08:41):

So, we really need to be aware of when we don't want to use that product.

Carol Pehotsky (08:46):

Good point. Yeah.

Dr. Mary Montague-MCown (08:46):

Um, using it correctly-

Carol Pehotsky (08:46):

(laughs) Yeah.

Dr. Mary Montague-MCown (08:48):

... is going to contain that liquid stool for sure.

Carol Pehotsky (08:48):

Mm-hmm.

Dr. Mary Montague-MCown (08:50):

But when we're using it in the wrong patient, it can lead to, unfortunately, perianal mucous membrane pressure injuries, which we-

Carol Pehotsky (08:51):

So that's even worse. Yes. (laughs)

Dr. Mary Montague-MCown (09:00):

Yes, which we don't want to see. So-

Carol Pehotsky (09:01):

That's a great point. Yeah.

Dr. Mary Montague-MCown (09:01):

Yeah.

Carol Pehotsky (09:02):

Absolutely.

Dr. Mary Montague-MCown (09:03):

Yeah.

Carol Pehotsky (09:03):

What are some other things where, you know, as you're consulting with bedside nurses and you're thinking, "Gosh, if you had called me sooner." Or some things that maybe a more novice nurse would overlook when doing a skin assessment or when to call for help?

Dr. Mary Montague-MCown (09:16):

I think the wound team here on main campus never, ever, ever minds getting a consult for anything.

Carol Pehotsky (09:23):

Mm. Mm-hmm.

Dr. Mary Montague-MCown (09:23):

So, if a novice nurse sees something that maybe she's not quite sure-

Carol Pehotsky (09:28):

Mm-hmm.

Dr. Mary Montague-MCown (09:28):

... what it is, you know, we're happy for the consult. We're happy to talk about it over the phone. Maybe we don't need to see it once we talk about it.

Carol Pehotsky (09:28):

Mm-hmm.

Dr. Mary Montague-MCown (09:36):

But if you really think it's something, we're happy to come and see it.

Carol Pehotsky (09:39):

Sure.

Dr. Mary Montague-MCown (09:40):

Certainly, any opening-

Carol Pehotsky (09:42):

Mm.

Dr. Mary Montague-MCown (09:43):

... especially over those bony prominences-

Carol Pehotsky (09:44):

Mm-hmm.

Dr. Mary Montague-MCown (09:45):

... that could cause a pressure injury, we really need to come and take a look at. We want to catch that early so they don't progress-

Carol Pehotsky (09:52):

Yep.

Dr. Mary Montague-MCown (09:52):

... to the deeper pressure injury stages.

Carol Pehotsky (09:55):

Right, right.

Dr. Mary Montague-MCown (09:56):

We get consults a lot for rashes.

Carol Pehotsky (09:58):

Okay.

Dr. Mary Montague-MCown (09:58):

For maybe some certain dermatologic conditions.

Carol Pehotsky (10:02):

Mm-hmm. Mm-hmm.

Dr. Mary Montague-MCown (10:02):

And that's fine, but we can direct you to the appropriate service. So, you know, we aren't trained in dermatology, but we can-

Carol Pehotsky (10:03):

Sure, yeah.

Dr. Mary Montague-MCown (10:11):

... certainly, help you reach out-

Carol Pehotsky (10:11):

Mm-hmm.

Dr. Mary Montague-MCown (10:13):

... to the dermatology service for those areas that we're not quite sure-

Carol Pehotsky (10:17):

Right.

Dr. Mary Montague-MCown (10:17):

... what we're looking at.

Carol Pehotsky (10:18):

And then we're nurses taking care of nurses and saying-

Dr. Mary Montague-MCown (10:21):

Right.

Carol Pehotsky (10:21):

... you know, "Thank you for reaching out. Let's-"

Dr. Mary Montague-MCown (10:21):

Yeah.

Carol Pehotsky (10:21):

"... get you pointed in the right direction."

Dr. Mary Montague-MCown (10:23):

We're, yeah, we're in this together.

Carol Pehotsky (10:24):

Yeah.

Dr. Mary Montague-MCown (10:24):

Let's talk about it. We'll find a way to get this looked at by the appropriate person or-

Carol Pehotsky (10:30):

Mm-hmm.

Dr. Mary Montague-MCown (10:30):

... appropriate service.

Carol Pehotsky (10:31):

Fantastic. So, most of us, and I think they still teach it in school, have been taught that one of the best ways to take care of skin and prevent problems is frequent patient turning. Is that still true?

Dr. Mary Montague-MCown (10:41):

That's absolutely the key.

Carol Pehotsky (10:44):

(laughs) Yep.

Dr. Mary Montague-MCown (10:44):

So, in order to prevent pressure, we can have the best products-

Carol Pehotsky (10:44):

Mm-hmm.

Dr. Mary Montague-MCown (10:49):

... we can use the best creams.

Carol Pehotsky (10:51):

Mm-hmm.

Dr. Mary Montague-MCown (10:51):

But if we don't get at the source of the problem-

Carol Pehotsky (10:55):

Mm-hmm.

Dr. Mary Montague-MCown (10:55):

... namely pressure-

Carol Pehotsky (10:56):

Right.

Dr. Mary Montague-MCown (10:56):

... we're going to get nowhere.

Carol Pehotsky (10:58):

Mm-hmm.

Dr. Mary Montague-MCown (10:58):

So, absolutely offloading is essential.

Carol Pehotsky (11:02):

And what do you think about, I know there's some beds out there that claim that they're offloading enough. There's certain devices that help with that. What are your thoughts on those? Do those do the trick, or is the old school (laughs) moving with pillows and, and a friend helping you position that patient still the best way to go?

Dr. Mary Montague-MCown (11:18):

There's a piece of technology on a lot of our ICU beds-

Carol Pehotsky (11:21):

Mm-hmm.

Dr. Mary Montague-MCown (11:21):

... it's called Turn Assist-

Carol Pehotsky (11:23):

Okay.

Dr. Mary Montague-MCown (11:23):

... where, you know, you push a button and it, as the name suggests-

Carol Pehotsky (11:27):

Mm-hmm.

Dr. Mary Montague-MCown (11:27):

... assists the nurse to turn. It is not offloading, because to-

Carol Pehotsky (11:31):

Ah.

Dr. Mary Montague-MCown (11:31):

... truly-

Carol Pehotsky (11:32):

Yeah.

Dr. Mary Montague-MCown (11:32):

... offload an area, namely the sacral coccygeal area-

Carol Pehotsky (11:37):

Mm-hmm.

Dr. Mary Montague-MCown (11:37):

... it needs to be to a 30-degree side lying position.

Carol Pehotsky (11:39):

Sure.

Dr. Mary Montague-MCown (11:40):

Turn Assist does not do that, so good wedges that we've invested in-

Carol Pehotsky (11:44):

Okay.

Dr. Mary Montague-MCown (11:45):

... are manufactured at a 30-degree tilt.

Carol Pehotsky (11:48):

Oh, perfect. So even better than that-

Dr. Mary Montague-MCown (11:49):

So, yeah.

Carol Pehotsky (11:49):

... pillow I'm trying to shove somewhere and make it work. (laughs)

Dr. Mary Montague-MCown (11:51):

Yeah. Pillows. Yeah, I know we, you know, we use pillows in a pinch, but a pillow-

Carol Pehotsky (11:55):

Right.

Dr. Mary Montague-MCown (11:56):

... you know, they can come flat as a pancake. They can come-

Carol Pehotsky (12:00):

Wrinkled.

Dr. Mary Montague-MCown (12:01):

... wrinkled.

Carol Pehotsky (12:01):

Yeah, yeah.

Dr. Mary Montague-MCown (12:02):

They can come fluffy and-

Carol Pehotsky (12:04):

Mm-hmm.

Dr. Mary Montague-MCown (12:04):

... somewhat firm because they're newer pillows.

Carol Pehotsky (12:06):

Sure.

Dr. Mary Montague-MCown (12:07):

But you position a patient on a pillow, there's no 30 degree-

Carol Pehotsky (12:11):

Right, right.

Dr. Mary Montague-MCown (12:12):

... tilt to that pillow.

Carol Pehotsky (12:13):

Mm-hmm.

Dr. Mary Montague-MCown (12:14):

So eventually the patient's going to sink back into the pillow and-

Carol Pehotsky (12:14):

Sure.

Dr. Mary Montague-MCown (12:18):

... probably land on their back at some-

Carol Pehotsky (12:20):

And undo everything you're trying to do. (laughs)

Dr. Mary Montague-MCown (12:20):

Yeah.

Carol Pehotsky (12:22):

For sure.

Dr. Mary Montague-MCown (12:22):

Right.

Carol Pehotsky (12:23):

And, uh, certainly where Mary and I have interacted quite a bit in the past is really in a perioperative space, where we have patients that can most, at least during the, the surgery cannot offload, cannot reposition. So, should we let people in on some of the conversations we've had about, you know, when patients, whether it's an OR or procedure room or in an ICU patients cannot turn for themselves, can't necessarily be positioned. What are some things that we need to be thinking about?

Dr. Mary Montague-MCown (12:48):

So, in the OR, y-, like you say, Carol, yeah, there's, you know, we're kind of at the mercy of the surgical procedure.

Carol Pehotsky (12:56):

Mm-hmm. Mm-hmm.

Dr. Mary Montague-MCown (12:56):

I mean, I, uh, you can educate me, but I don't think-

Carol Pehotsky (12:59):

(laughs)

Dr. Mary Montague-MCown (12:59):

... there's going to be any surgeon that is going to stop a procedure, you know, because a nurse says.

Carol Pehotsky (13:04):

We're not tilting them side to side. No. (laughs)

Dr. Mary Montague-MCown (13:05):

Yeah, we’ve got to turn the patient now, so you have to stop. We're not going to do that.

Carol Pehotsky (13:09):

Right.

Dr. Mary Montague-MCown (13:09):

But what we can do postoperatively is if a patient can't be turned-

Carol Pehotsky (13:14):

Mm-hmm.

Dr. Mary Montague-MCown (13:14):

... we can do some micro shifting, and that's just-

Carol Pehotsky (13:17):

Mm. Sure.

Dr. Mary Montague-MCown (13:18):

... you know, putting maybe the tip of the wedge under the patient just to relieve pressure.

Carol Pehotsky (13:22):

Mm-hmm. Mm-hmm.

Dr. Mary Montague-MCown (13:23):

Anything that we can do to relieve pressure for any amount of time is going to do more than-

Carol Pehotsky (13:30):

Something's better than nothing.

Dr. Mary Montague-MCown (13:31):

... nothing.

Carol Pehotsky (13:31):

All right. Yeah.

Dr. Mary Montague-MCown (13:31):

Allowing the patient to lay on their back for a-

Carol Pehotsky (13:32):

Right.

Dr. Mary Montague-MCown (13:34):

... prolonged period of time.

Carol Pehotsky (13:35):

Well, and you've been so helpful to us and our patients in really looking at, you know, emerging technologies, how do we map that there might be some pressure going on? How do we look at OR table services to see if they're pressure reducing or, or things like preventative dressings to create some cushion as well.

Dr. Mary Montague-MCown (13:51):

Right.

Carol Pehotsky (13:52):

All right. So, let's flip then to an ostomy and continence nursing, if you don't mind. So, talk to us a little bit about, you said you went to school, what was that like? What's the training like? What is some of the content that learners are exposed to in new and elevated ways?

Dr. Mary Montague-MCown (14:07):

So, when I went to school it was all in person.

Carol Pehotsky (14:10):

Mm-hmm.

Dr. Mary Montague-MCown (14:10):

Currently, the program is entirely online.

Carol Pehotsky (14:13):

Mm.

Dr. Mary Montague-MCown (14:14):

So, you get your didactic portion online-

Carol Pehotsky (14:16):

Okay.

Dr. Mary Montague-MCown (14:16):

... through online learning.

Carol Pehotsky (14:17):

Mm-hmm.

Dr. Mary Montague-MCown (14:18):

Chat rooms, you know, handing in assignments.

Carol Pehotsky (14:22):

(laughs)

Dr. Mary Montague-MCown (14:22):

All of that.

Carol Pehotsky (14:22):

Yeah.

Dr. Mary Montague-MCown (14:23):

And the course is finished with clinical. So, we precept-

Carol Pehotsky (14:27):

Okay, yeah.

Dr. Mary Montague-MCown (14:27):

... some of the students here on main campus.

Carol Pehotsky (14:29):

Wonderful.

Dr. Mary Montague-MCown (14:29):

And, you know, they spend some time with the wound team.

Carol Pehotsky (14:32):

Mm-hmm.

Dr. Mary Montague-MCown (14:32):

They spend some time with... And I should back up and say our WOC team-

Carol Pehotsky (14:38):

Mm-hmm.

Dr. Mary Montague-MCown (14:38):

... now is one combined team. So-

Carol Pehotsky (14:40):

Oh, great. Yes. (laughs)

Dr. Mary Montague-MCown (14:41):

Prior it was separated into-

Carol Pehotsky (14:41):

Mm-hmm.

Dr. Mary Montague-MCown (14:43):

... you know, the wound team and the ostomy team. We are now one team.

Carol Pehotsky (14:46):

Wonderful.

Dr. Mary Montague-MCown (14:47):

So, they spend some time with us, who are still focusing on wound care.

Carol Pehotsky (14:51):

Mm.

Dr. Mary Montague-MCown (14:51):

They spend some time with the nurses-

Carol Pehotsky (14:51):

Okay.

Dr. Mary Montague-MCown (14:54):

... f-, y-, still focusing-

Carol Pehotsky (14:55):

Sure.

Dr. Mary Montague-MCown (14:55):

You know, we're not totally integrated yet, but they spend time with the nurses focusing on ostomy care.

Carol Pehotsky (15:01):

Mm.

Dr. Mary Montague-MCown (15:03):

Ostomy and wound, we deal with incontinence in both-

Carol Pehotsky (15:06):

Mm-hmm.

Dr. Mary Montague-MCown (15:06):

... specialties.

Carol Pehotsky (15:07):

Right, right.

Dr. Mary Montague-MCown (15:07):

So, you know, nurses have a chance to see, you know, patients coming right from-

Carol Pehotsky (15:07):

Mm-hmm.

Dr. Mary Montague-MCown (15:12):

... ostomy surgery.

Carol Pehotsky (15:13):

Mm-hmm.

Dr. Mary Montague-MCown (15:14):

You know, changing that first post-op pouch.

Carol Pehotsky (15:16):

Right.

Dr. Mary Montague-MCown (15:17):

Educating patients on how to become independent in-

Carol Pehotsky (15:20):

Right.

Dr. Mary Montague-MCown (15:20):

... taking care of their ostomies.

Carol Pehotsky (15:21):

Absolutely.

Dr. Mary Montague-MCown (15:22):

Yeah.

Carol Pehotsky (15:22):

And you come into the OR sometimes too. (laughs)

Dr. Mary Montague-MCown (15:24):

Right, right, right.

Carol Pehotsky (15:25):

We've seen you in there, so-

Dr. Mary Montague-MCown (15:26):

Yeah.

Carol Pehotsky (15:27):

Um-

Dr. Mary Montague-MCown (15:27):

It's fascinating to watch these surgical procedures.

Carol Pehotsky (15:27):

Yeah. We love having you in there.

Dr. Mary Montague-MCown (15:31):

Yeah.

Carol Pehotsky (15:31):

(laughs) Because the nurses go, "Oh, good, somebody from wound ostomy is here to help." (laughs) So, in the spirit of that, one of our f-, wound ostomy continence nurses who has since retired was, was a clinical instructor of mine also a few years ago, and he really taught me so much about negative wound pressure therapy. Spend a little time, if you would, talking about that and the training that you have and, and some tips maybe for nurses that are interacting with that technology.

Dr. Mary Montague-MCown (15:57):

Negative pressure wound therapy is a great method for helping stalled wounds or hard to heal wounds heal-

Carol Pehotsky (16:06):

Hm.

Dr. Mary Montague-MCown (16:06):

... a bit quicker. So, it's a great technology. We use it a lot.

Carol Pehotsky (16:10):

Mm-hmm.

Dr. Mary Montague-MCown (16:11):

That technology has come a long way. Now we have technology where you can instill m- medication-

Carol Pehotsky (16:18):

Oh, yeah?

Dr. Mary Montague-MCown (16:18):

... antibiotics-

Carol Pehotsky (16:19):

Hm.

Dr. Mary Montague-MCown (16:20):

... anti-infectives right through that machine to the wound-

Carol Pehotsky (16:23):

Huh.

Dr. Mary Montague-MCown (16:23):

... bed to clean that up. So-

Carol Pehotsky (16:24):

That has come a long way then. (laughs)

Dr. Mary Montague-MCown (16:26):

Right. There is a portable unit, so it's-

Carol Pehotsky (16:29):

Mm-hmm.

Dr. Mary Montague-MCown (16:29):

... put on post-op surgical incisions-

Carol Pehotsky (16:33):

Mm-hmm.

Dr. Mary Montague-MCown (16:33):

... on top of a closed incision-

Carol Pehotsky (16:33):

Oh, wow.

Dr. Mary Montague-MCown (16:35):

And what that negative pressure does is it decreases the edema around that incision.

Carol Pehotsky (16:40):

Hm. Okay.

Dr. Mary Montague-MCown (16:40):

So that wound can heal quicker.

Carol Pehotsky (16:42):

Wonderful.

Dr. Mary Montague-MCown (16:42):

It's left in place for seven days and then taken off.

Carol Pehotsky (16:45):

Okay. Wow.

Dr. Mary Montague-MCown (16:46):

So-

Carol Pehotsky (16:47):

It's come a long way.

Dr. Mary Montague-MCown (16:47):

It's come a long way.

Carol Pehotsky (16:47):

That's excellent.

Dr. Mary Montague-MCown (16:49):

Yeah.

Carol Pehotsky (16:49):

So, we've spent a little time talking about that and ostomies, so what are some of the situations where a bedside nurse should reach out to their local wound, ostomy and continent nurse for some help?

Dr. Mary Montague-MCown (16:59):

Again, if they're not comfortable-

Carol Pehotsky (17:01):

Mm-hmm.

Dr. Mary Montague-MCown (17:02):

... treating a wound.

Carol Pehotsky (17:03):

Mm-hmm.

Dr. Mary Montague-MCown (17:03):

Usually when we see a patient, we will do a complete skin assessment. We take photos.

Carol Pehotsky (17:08):

Sure.

Dr. Mary Montague-MCown (17:08):

Those photos are now uploaded into the chart.

Carol Pehotsky (17:11):

Nice.

Dr. Mary Montague-MCown (17:11):

We do measurements.

Carol Pehotsky (17:12):

Mm-hmm.

Dr. Mary Montague-MCown (17:12):

We provide recommendations. And we stage.

Carol Pehotsky (17:15):

Nice.

Dr. Mary Montague-MCown (17:15):

Staging is a big thing.

Carol Pehotsky (17:16):

Sure.

Dr. Mary Montague-MCown (17:17):

So, we do ask that if a nurse comes in and possibly thinks the stage might have changed since our-

Carol Pehotsky (17:24):

Mm. Okay.

Dr. Mary Montague-MCown (17:24):

... last assessment-

Carol Pehotsky (17:24):

Mm-hmm.

Dr. Mary Montague-MCown (17:25):

... please reach out to us.

Carol Pehotsky (17:26):

Yeah. (laughs)

Dr. Mary Montague-MCown (17:27):

If they see that the topical wound therapy may not be right for-

Carol Pehotsky (17:33):

Mm.

Dr. Mary Montague-MCown (17:34):

... their particular wound assessment, please reach out to us.

Carol Pehotsky (17:34):

Mm-hmm.

Dr. Mary Montague-MCown (17:38):

Because we would like that dialogue.

Carol Pehotsky (17:40):

Sure.

Dr. Mary Montague-MCown (17:40):

You know-

Carol Pehotsky (17:41):

Tell them what's going and-

Dr. Mary Montague-MCown (17:42):

You know, the wound looks a little bit-

Carol Pehotsky (17:42):

... what do we need to do now. Yeah.

Dr. Mary Montague-MCown (17:43):

... different from when you saw it last.

Carol Pehotsky (17:45):

Mm-hmm.

Dr. Mary Montague-MCown (17:45):

Can you come and take a look? Maybe we can update the recommendations.

Carol Pehotsky (17:48):

Sure.

Dr. Mary Montague-MCown (17:49):

Let's talk about the staging. So-

Carol Pehotsky (17:51):

Mm-hmm.

Dr. Mary Montague-MCown (17:52):

Anytime.

Carol Pehotsky (17:53):

More.

Dr. Mary Montague-MCown (17:53):

You know, as I said, we enjoy that two-way communication.

Carol Pehotsky (17:57):

Yes.

Dr. Mary Montague-MCown (17:57):

And, because we're all here for the patient-

Carol Pehotsky (18:00):

That's right.

Dr. Mary Montague-MCown (18:00):

... and we, you know-

Carol Pehotsky (18:00):

Mm-hmm.

Dr. Mary Montague-MCown (18:02):

We really want that wound to get going and get better.

Carol Pehotsky (18:04):

Absolutely. Circling back to skin before we wrap this up. You know, we are very fortunate at the clinic to have a program called Skin Care Resource Nurses, and we know we also do Prevalence Day. Can you talk a little bit about what those programs are for those who aren't familiar with them?

Dr. Mary Montague-MCown (18:20):

Sure. So, our Skin Care Resource Nurse program, or SCRN, is a program for nurses who have an interest in wounds.

Carol Pehotsky (18:30):

Mm-hmm.

Dr. Mary Montague-MCown (18:30):

And, you know, I realize people either hate wounds or they love wounds.

Carol Pehotsky (18:30):

(laughs)

Dr. Mary Montague-MCown (18:34):

And that's fine.

Carol Pehotsky (18:35):

It's not a lotta gray area, you're right.

Dr. Mary Montague-MCown (18:36):

Yeah. You either love it or you hate it, and that's fine because we all have our niche.

Carol Pehotsky (18:40):

Mm-hmm.

Dr. Mary Montague-MCown (18:40):

We can all find what we're interested and good at.

Carol Pehotsky (18:43):

Yeah.

Dr. Mary Montague-MCown (18:43):

So, but the SCRNs have a, have an interest in wounds.

Carol Pehotsky (18:47):

Mm-hmm.

Dr. Mary Montague-MCown (18:47):

So, we provide them with some additional education, which hopefully allows them to function as a resource-

Carol Pehotsky (18:55):

Mm-hmm.

Dr. Mary Montague-MCown (18:55):

... as the name suggests-

Carol Pehotsky (18:56):

Mm-hmm.

Dr. Mary Montague-MCown (18:56):

... a resource on their units to may- maybe troubleshoot. You know, a nurse would come up to an SCRN and say-

Carol Pehotsky (19:03):

Mm.

Dr. Mary Montague-MCown (19:03):

... "I'm not quite sure of the stage. Can you help me?"

Carol Pehotsky (19:06):

Sure.

Dr. Mary Montague-MCown (19:06):

Or "What do you think about, you know, putting an FMS in this patient?"

Carol Pehotsky (19:06):

Mm-hmm. Mm-hmm.

Dr. Mary Montague-MCown (19:10):

Or "Do you think this wound might be appropriate for negative pressure?"

Carol Pehotsky (19:10):

Mm-hmm.

Dr. Mary Montague-MCown (19:15):

You know, they're resources, and they're our eyes on the unit because-

Carol Pehotsky (19:15):

Yeah.

Dr. Mary Montague-MCown (19:18):

... we can't be on the units 24/7.

Carol Pehotsky (19:18):

(laughs) Right.

Dr. Mary Montague-MCown (19:21):

So, we really do appreciate-

Carol Pehotsky (19:21):

Mm-hmm.

Dr. Mary Montague-MCown (19:24):

... you know, the interest and the role that they take.

Carol Pehotsky (19:26):

Wonderful.

Dr. Mary Montague-MCown (19:27):

Prevalence.

Carol Pehotsky (19:27):

Yeah, let's talk about prevalence-

Dr. Mary Montague-MCown (19:27):

You mentioned prevalence.

Carol Pehotsky (19:28):

Yeah, thanks.

Dr. Mary Montague-MCown (19:29):

Prevalence is a one-day snapshot of-

Carol Pehotsky (19:32):

Okay.

Dr. Mary Montague-MCown (19:32):

... patients. Here it's the third Wednesday of every month.

Carol Pehotsky (19:35):

Okay. (laughs)

Dr. Mary Montague-MCown (19:36):

So, every single patient is assessed on that day.

Carol Pehotsky (19:39):

Mm.

Dr. Mary Montague-MCown (19:39):

Their skin is looked at. Pressure injuries are documented. We're not documenting anything other than pressure injuries-

Carol Pehotsky (19:46):

Mm. Sure.

Dr. Mary Montague-MCown (19:46):

But all of our pressure injuries are documented on that day-

Carol Pehotsky (19:49):

Mm-hmm.

Dr. Mary Montague-MCown (19:49):

... and it gives us a prevalence rate.

Carol Pehotsky (19:51):

Okay.

Dr. Mary Montague-MCown (19:51):

Which again, is just a one-day snapshot.

Carol Pehotsky (19:55):

But also, it's so nice to have resources coming to the unit saying-

Dr. Mary Montague-MCown (19:58):

Right.

Carol Pehotsky (19:58):

... "We're another set of eyes to really look at your patients-"

Dr. Mary Montague-MCown (19:59):

Right.

Carol Pehotsky (20:01):

"... and what's going on."

Dr. Mary Montague-MCown (20:01):

Right, and it's the SCRNs who do the prevalence-

Carol Pehotsky (20:04):

Right, right.

Dr. Mary Montague-MCown (20:04):

... every month.

Carol Pehotsky (20:05):

So, we're so fortunate to have these programs. There are probably nurses listening that maybe don't know if they have those types of resources in their hospital, or maybe they don't. What's some advice that you'd have for folks who say, uh, "I'm interested in skin." Or "I'd like to learn more." Or "I'm not sure I have those types of resources in my hospital." How do they advocate for that?

Dr. Mary Montague-MCown (20:24):

Well, our organization, the WOCN-

Carol Pehotsky (20:25):

Mm-hmm.

Dr. Mary Montague-MCown (20:28):

... Wound, Ostomy, Continence Nurses Society-

Carol Pehotsky (20:30):

Mm-hmm.

Dr. Mary Montague-MCown (20:31):

... has a great website. And-

Carol Pehotsky (20:31):

Oh, great.

Dr. Mary Montague-MCown (20:32):

... if you go on that website-

Carol Pehotsky (20:32):

Mm-hmm.

Dr. Mary Montague-MCown (20:33):

... you can search for WOC nurses in your area that-

Carol Pehotsky (20:33):

Oh, okay.

Dr. Mary Montague-MCown (20:37):

... might-

Carol Pehotsky (20:38):

Yeah.

Dr. Mary Montague-MCown (20:38):

... be able to see patients in your hospital-

Carol Pehotsky (20:39):

Okay.

Dr. Mary Montague-MCown (20:41):

... if, you know, your hospital isn't fortunate enough to have a WOC nurse.

Carol Pehotsky (20:45):

Sure.

Dr. Mary Montague-MCown (20:46):

And they can provide information if they see inpatients.

Carol Pehotsky (20:50):

Mm-hmm.

Dr. Mary Montague-MCown (20:50):

Outpatient care is so important, so-

Carol Pehotsky (20:52):

Gosh, yeah.

Dr. Mary Montague-MCown (20:53):

... if you're in an area that might need some outpatient help-

Carol Pehotsky (20:57):

Mm-hmm.

Dr. Mary Montague-MCown (20:57):

... you know, the WOCN website could provide that information as well.

Carol Pehotsky (21:00):

Wonderful, and, you know, I, I would imagine a, a hospital that doesn't have a skin care resource type program could certainly build one. But what a great opportunity for some shared governance and evidence-based practice at the same time.

Dr. Mary Montague-MCown (21:11):

Correct. Correct, yeah. The NPIAP, National Pressure Injury Advisory Panel, is another great-

Carol Pehotsky (21:17):

Oh, okay. Yeah.

Dr. Mary Montague-MCown (21:18):

... website for information on, um, they have a lotta documents, white papers that can certainly help you get started with programs at your institution if you're not lucky enough to have one of us.

Carol Pehotsky (21:30):

Wonderful. Well, all of you masters or doctoral candidate students that are looking for a good project, that might be a good place to start.

Dr. Mary Montague-MCown (21:36):

Absolutely. Yeah.

Carol Pehotsky (21:37):

To, to really make a big, big difference for your patients.

Dr. Mary Montague-MCown (21:37):

Absolutely.

Carol Pehotsky (21:40):

Well, Mary, as expected, you've been incredibly helpful and knowledgeable, and I'm so glad you've been here. We're now going to move into what we call the speed round portion of, of the episode to l-, help our audience get to know you a little bit more about, uh, the f- fabulous human being you are in addition to-

Dr. Mary Montague-MCown (21:40):

Oh, thank you, Carol.

Carol Pehotsky (21:54):

... being such a subject matter expert.

Dr. Mary Montague-MCown (21:55):

Yeah.

Carol Pehotsky (21:56):

So, we'll start with if you weren't a nurse, what would your passion career be?

Dr. Mary Montague-MCown (22:01):

My answer's not going to be along those lines because I can't think of doing anything other than being a nurse. I-

Carol Pehotsky (22:09):

Yeah.

Dr. Mary Montague-MCown (22:09):

My grandmother lived with us for a couple years before she died.

Carol Pehotsky (22:13):

Aw.

Dr. Mary Montague-MCown (22:14):

Unfortunately, she had heart disease and diabetes-

Carol Pehotsky (22:16):

Mm.

Dr. Mary Montague-MCown (22:16):

... and she was in and out of the hospital. And in grade school I was in the hospital with her, and I saw-

Carol Pehotsky (22:22):

Aw.

Dr. Mary Montague-MCown (22:22):

... what nurses did.

Carol Pehotsky (22:24):

Yeah?

Dr. Mary Montague-MCown (22:24):

And I thought, "That's what I want to do." And I never looked back. So that-

Carol Pehotsky (22:29):

You were born to do this.

Dr. Mary Montague-MCown (22:30):

Uh, yeah. I can't think of doing anything other than this.

Carol Pehotsky (22:32):

I love it. Wonderful. And so, it's you, you do so much for our patients, for our organization, for our community, it's finally time for you to unwind and take care of yourself. What do you do to recharge?

Dr. Mary Montague-MCown (22:44):

So, I have a golden retriever.

Carol Pehotsky (22:47):

Aw.

Dr. Mary Montague-MCown (22:47):

Her name is Aggie.

Carol Pehotsky (22:49):

Ooh.

Dr. Mary Montague-MCown (22:49):

Love her to death.

Carol Pehotsky (22:50):

(laughs)

Dr. Mary Montague-MCown (22:50):

We walk all over.

Carol Pehotsky (22:52):

Mm-hmm.

Dr. Mary Montague-MCown (22:52):

She's a great stress reliever-

Carol Pehotsky (22:54):

Mm.

Dr. Mary Montague-MCown (22:55):

... at the end of the day.

Carol Pehotsky (22:56):

Mm-hmm.

Dr. Mary Montague-MCown (22:56):

I love getting out in the yard doing yard work.

Carol Pehotsky (22:59):

In Cleveland, it's finally about time to do that.

Dr. Mary Montague-MCown (22:59):

Y- yeah.

Carol Pehotsky (22:59):

(laughs)

Dr. Mary Montague-MCown (23:02):

Yeah. I knit.

Carol Pehotsky (23:03):

Oh, how nice.

Dr. Mary Montague-MCown (23:04):

And I sew.

Carol Pehotsky (23:04):

Okay.

Dr. Mary Montague-MCown (23:04):

So again, those are things that kind of relieve stress a little bit and help me to relax.

Carol Pehotsky (23:10):

Wonderful.

Dr. Mary Montague-MCown (23:10):

Yeah. Uh, a lotta home improvement projects.

Carol Pehotsky (23:13):

All right.

Dr. Mary Montague-MCown (23:13):

In the middle of painting a living room and dining room. So-

Carol Pehotsky (23:16):

Whew, good luck with that. (laughs)

Dr. Mary Montague-MCown (23:17):

Yeah. I mean, that might be, not be stress relieving, but it's... (laughs)

Carol Pehotsky (23:21):

You at least can see the-

Dr. Mary Montague-MCown (23:22):

Yeah.

Carol Pehotsky (23:22):

... outcome of it.

Dr. Mary Montague-MCown (23:23):

Yeah. It's, y- you know, it, it helps kind of take my mind off of things. So-

Carol Pehotsky (23:27):

Absolutely. Well, thank you so much, and thank you for joining us today.

Dr. Mary Montague-MCown (23:30):

Oh, I appreciate the invitation, as always, Carol. Thank you.

Carol Pehotsky (23:37):

As always, thanks so much for joining us for today's discussion. Don't miss out, subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@CCF.org. To learn more about nursing at Cleveland Clinic, please check us out at ClevelandClinic.org/nursing. Until next time, take care of yourselves and take care of each other.

(24:11):

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.