Guides and collaborates with the nursing staff, medical staff, patient, family and other members of the health team to assess, plan, implement, evaluate, and improve the nursing needs of patients with Wounds, Ostomies, fistulas, drains or altered skin integrity including physical, emotional and spiritual needs. Assesses, plans, implements, and evaluates the plan of care for continuity of care in collaboration with the medical staff, nursing staff, social worker, and other health care teams, including care after discharge.