As an RN who works in the community, I provide care to an elderly client recently diagnosed with diabetes. During my last visit, I found a deep wound on his sacral area. The client has wound care supplies in his home from when I treated a previous wound. Do I have the authority to initiate a packing dressing?

An RN would have the authority to independently initiate wound care below the dermis (including cleansing, packing and dressing) for this client.

Both RNs and RPNs can initiate some care below the dermis; however, there are differences in the number of  procedures below the dermis that RNs and RPNs can initiate. Before proceeding, review any relevant practice-setting policies from your employer that support you in performing the procedure. You would need to determine if initiating the procedure is the best course of action for the client.

A nurse must:

• assess the client and identify the problem
• consider all options to address the problem
• address the risks and benefits of each option
• decide on a course of action
• anticipate the management of the outcomes
• accept responsibility for deciding that a particular procedure is required
• ensure the management of the outcomes 

A nurse must also follow the legislation relevant to her or his practice setting. As a nurse practising in the community, you can initiate according to the Nursing Act, 1991. (Under the Public Hospitals Act, though, a nurse practising in a hospital must have an order to perform wound care.)

After treating the wound, you need to put a mechanism in place to manage the outcomes of the treatment. For instance, you could ask the client to phone the nursing agency if he notices a change in his sacrum before your next scheduled visit. You are accountable for the initiation, and for documenting both the initiation and the outcome in the client record.