My first patient is home alone today-his wife is out shopping. We chat for a few minutes before I take his vitals and do a medication review and note the 20 mg of prednisone, which has a direct effect on wound healing. Before I take off his dressing I want to get a good objective wound history. I ask him how and when this wound started. Although it may seem like a lot of senseless questions, my questions are purposeful. I am trying to discover the etiology of the wound, tests or procedures that have been done, how the patient can heal systemically, and what topical therapies have been tried and the response. I discover the ankle wound started about a month ago. He fell in the bathroom and hit his ankle on the pedestal sink. It was initially a blister that evolved into an open sore. It hurts-more when he is sitting with his feet up or in bed and feels better when he walks. It doesn't drain much. His wife does his wound care every morning after his shower. She is very meticulous and sprays it with antibiotic spray before applying the new dressing. I find out now that he had a similar wound in the same spot a year ago. He went to the wound center then and the doctor told him he needed stents in his leg. He has compression socks on both legs with +1 nonpitting edema. His socks are not "real" gradient compression stockings and he tells me he tried to wear those "expensive compression hose," but they just hurt too much and were difficult to get on and off. The wound is round, the size of a dime, and punched out. The base is a pale yellow and smooth. I can get the sterile applicator slightly up inside of the wound around all the edges so I document the edges are not attached. As I was looking in his supplies for a sterile applicator, I noticed many wound care products: silver gels, some sort of antibiotic spray, silver collagen dressing, and betadine. I consider the mechanism of injury, appearance, and location of his wound in order to develop a wound care plan. The pain associated with his activities and his dose of prednisone support my analysis of his wound. With all of these things in mind, I formulate and recommend a wound care regimen that will lead to wound healing and prevention of reoccurrence.

I perform the wound care and reapply his compression sock. We talk at length about the type of wound and the rationale for the wound products being used. His current regimen of cadexomer iodine with a composite dressing daily is appropriate. I recommend he stop using the antibiotic spray (no physician order) because we don't really know how it interacts with the cadexomer iodine. He is happy to hear he does not have to sit with his feet up all day. I let him know that I will follow up with him in 2 weeks for a reevaluation. After I leave I send a note to his physician with my objective information and recommendations.

As I drive up to my second patient's home I notice it doesn't appear on the outside to be "bug infested" as my notes say. From my notes I know he has poorly controlled diabetes, a history of amputations and osteomyelitis, heart failure, osteoarthritis, and chronic pain. He is a talker and delighted to have someone who will listen. It takes me 10 minutes to get to the point of taking his vitals. Next we talk about his wound. He has a diabetic ulcer on his foot at the site of a previous great toe amputation. Once again I ask a series of leading questions. Of note, he lives alone and has several dogs in the home. He has diabetic shoes with inserts but doesn't wear them, (but does wear an off-the-shelf open-toe surgical shoe). A 24-hour diet recall reveals that he eats a well-balanced diet with plenty of vitamin C and protein but doesn't follow his diabetic diet. He is very intelligent and readily admits his "non-compliance" (his words). Dog hair and dirt cling to his outer dressing. I clean, photograph, and measure the wound. I tell him that the wound looks much better than the photo I saw from 2 weeks ago. The wound is irregular somewhat oval, pale smooth pink base, I can get the sterile applicator up 0.6 cm around the edges from 12 to 6 o'clock. As I "think out loud," he asks a multitude of questions about the meaning of undermining, granulation, and hyperkeratosis. I start from scratch and tell him about basic wound care and principles of moist healing. He seems appreciative and takes it all in. We call his physician and get the green light to implement the new wound care. I move on to footwear, which I believe is the root of the problem. I help him find his diabetic shoes and he tries them on. I talk to him about how the shoe doesn't just offload the pressure on the wound or protecting the foot from trauma but helps to keep the bones in the appropriate position when he is walking. I'm pretty sure that he is not going to wear them again. They are big and heavy and awkward. He is going to see his podiatrist soon and I encourage him to take the shoes and ask the podiatrist about the fit. As I am leaving I finally see some semblance of the "bug infestation" that is noted in his chart-one solitary but rather large roach scurrying across the hardwood floor from one saturated puppy pad to another.

I am a home health wound ostomy continence (WOC) nurse. I love my job-talking to people and analyzing why their wounds are not healing. I feel privileged and blessed to be in a position to make my own schedule and practice autonomously. Are you intrigued by wounds? Consider wound care certification. There are many educational program options available now, both traditional onsite and online programs. My educational program required a bachelor's degree in nursing and 1 year of experience. I was eligible to sit for board certification with the wound ostomy continence nurses certifying board (WOCNCB). There are other wound certification programs as well. The National Alliance for Wound Care and Ostomy and the American Board of Wound Management offer varied level of wound certification educational programs for healthcare professionals such as registered nurses, physical and occupational therapists, and physicians.

The WOC role in home healthcare usually includes patient care and administrative functions such as policy and procedure development, quality improvement projects, and formulary development/maintenance. I encourage you to go to http://www.wocn.org and browse the site. Consider membership while you decide if certification is right for you. The WOCN Society offers scholarships for members and some employers will pay fully or partially the cost of the education.