Wound and Ostomy Care

Surgical Interventions - Double-Barrel Stoma

- Bowel is surgically severed - Two separate stomas - wears two bags and two wafers - Proximal drains for fecal material - Distal may drain mucus

Factors that healthcare workers need to take into consideration for wound healing

- Does this patient have the ability to heal? - Consider the overall goals of care? - Etiology of the wound - Factors that contribute to impaired healing: Age, Infection - Sensory Perception: ability to do dressing change at home - Smoking - Nutrition - 0.8 mg/kg/day - this is what is needed for a normal person - Tissue integrity - Independent mobility - Continence - Glucose control

Tunneling

- Extends into tissue in any direction - They do have a termination point - Document direction, number and length Tend to see this more with abdominal wounds, no the same as a fistula

Stomal Characteristics

- Mucosa is rose to brick red (beefy red) - Pale may indicate anemia - Blanching, dark red, or purple indicates inadequate blood supply to the stoma or bowel or excessive tension - Black indicates necrosis - once it's necrotic, there is no going back. A new ostomy has to be created - Stoma should be assessed and color documented every 8 hours - There should be mild to moderate edema in the first 5-7 days post-op - Blood oozing from the stomal mucosa when touched is normal - Stoma doesn't function for 2-4 days post-op - First stomal drainage mucus and serosanguinous fluid - Flatus and fecal drainage returns, usually in 2-4 days

Creates Chronic Wounds

- Repeated trauma - think of a patient with diabetes who can't feel their feet - Local tissue ischemia - Necrotic tissue - once tissue is dead it is dead and gone - Heavy bacterial burden (bioburden) - Tissue breakdown

I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma Difficulty inserting the irrigating tube into the stoma occurs with stenosis of the stoma; forcing insertion if the tube may cause injury. Loss of sensation to touch in the stomal tissue is expected; there is no need to call the clinic. Expulsion of flatus while irrigating fluid is running out is expected; feces and flatus accompany fluid expulsion

A client with a newly formed colostomy, secondary to cancer of the rectum, received instructions regarding ostomy care and management. Which client statement indicates understanding of colostomy care

Education for ileostomy patients

An individual with an ileostomy is going to need at least 3L (could sometimes be 4 or 5L) of replacement fluid a day (orally/replacement electrolyte fluid) and it needs to have electrolytes because they are quickly losing electrolytes by their fecal material not going through the large intestine

The client stares at the stoma during dressing changes

The nurse is caring for a client 5 days after the surgical creation of a colostomy. The client has displayed signs of depression since the surgery. The nurse would determine that there is some movement towards adaptation to the change in body image when the client exhibits which behavior?

- Change the ostomy pouch on a routine basis - Replace the ostomy wafer weekly or sooner as needed - Empty the ostomy pouch before exercise and at bedtime (will help prevent leakage or overfill) Extra notes: shower with the pouch on - keeping the pouch on helps maintain the integrity of the wafer and prevents any stool from leaking onto the skin or into the shower while bathing Empty the pouch before it is 1/2 full

When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include?

Cabbage cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage

Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?

Empty the pouch before it is one-third full

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma?

Alginates - made out of dry seaweed

- Highly absorbent, biodegradable alginate dressings are derived from seaweed - Alginates can be rinsed away with saline irrigation, so removal of the dressing does not interfere with healing granulation tissue - Moderate to heavily exudating wounds

Food Considerations for ostomy patients

- Increase fiber, decrease sugars - May need Metamucil (helps bulk things up), antidiarrheals - May have night incontinence, wear pad - Practice controlling urges to defecate to help increase pouch capacity - need to hold on for it as long as they can (within reason)

Continent Fecal Diversions: Special Considerations

- Kegal exercises to strengthen the pelvic floor / provide muscle control for continence - Meticulous perianal (around the anus) skin care / use barrier cream (zinc oxide) - Eliminate foods known to increase bowel activity / and add foods that slow activity

serosanguinous fluid

Blood + serum Yellow in color w/ some appearance of blood

Continent Fecal Diversions

Ileoanal pull-through: - Ileum anastomosed to anal sphincter Ileoanal Reservoir: - Internal pouch created from ileum - End of pouch anastomosed to the anus

Reinforce the dressing

Which action would the nurse take first after observing serosangiuneous drainage on the abdominal dressing of a client in the post-anesthesia care unit (PACU) who had abdominal cholecystectomy

Changing Wafers/Pouch Care

- No lotions, creams, ointments on the peristomal skin - Clean with water under appliance (wafer) only - Change bag every 3-5 days; change bag before meals - Cut wafer opening to 1/8'-1/16' larger than stoma using template - Stoma size stabilizes 6-8 weeks post-op - Ensure seal, place hand on bag to warm wafer Shave the site continuously if person has hairy abdomen Get the patient to blow their belly out Empty a bag when it is 1/3 full This does not get covered by insurance - wafers = $200 Bags can be cleaned with vinegar and water and can be reused

Cytotoxic Solutions

Cytotoxic = it kills everything good and bad - Dakin's solution - smells like bleach, used for heavily exudated, purulent really dirty wounds - Acetic acid - Hydrogen peroxide - Rubbing alcohol - Betadine (unless diluted) - is cytotoxic unless it is diluted down to 10% or less - has to be a weak solution, which has shown to get rid of the bad stuff and keep the good stuff

ostomates

individual who has an ostomy

Undermining

- Space between the surrounding skin and the wound bed - Usually involves significant proportion of the wound edges - Subcutaneous fat necrosis - Usually indicates a high bioburden

Ostomy: Post-Operative Care

- Assess: type of stoma color, size, location of stoma, and peristomal skin - Protect the skin = from the stickness of the pouch - Select the pouch - Assist the patient with psychological adaptations Immediately postoperatively, use a clear colored bag NOT a flesh colored bag (this can be placed about 6 weeks later)

Debridement

- Biological - maggots (steril) - Surgical debridement - scalpel cutting away tissue - Mechanical - hydrotherapy, wet-dry dressing, monofilament pads - Autolytic Dressings - Enzymatic (Chemical) - Collagenase (Santyl)

Surgical Interventions - Loop Stoma

- Typically temporary - One loop - Two openings - Proximal - drains fecal material - Distal - drains mucus - Loop sutured to abdominal wall; plastic rod 7-10 days Rod will be there until the loop forms a membrane and it won't stick to the abdominal wall

Timing of Wound Dressing Changes

- Want the dressing to be most efficacious for the patient - Something they can afford - Want to minimize the frequency of dressing changes - minimize hypothermia, wound beds that are open to air become hypothermic and healing stops, it takes 4 hours for a wound to become normothermic again

Cleanse the wound with wet, sterile gauze from the center of the wound outward

A client has a large, open abdominal wound. The healthcare provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing?

Limited water reabsorption caused by removal of intestine

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery?

Continent

Able to control - this is the goal

Fistula

Abnormal connection in the body; forms between two bodily structures that are lined with epithelial cells - Between hollow organs - Skin and organ Causes: - Congenital - babies can be born with fistulas - Surgical complication - Disease producing Very common in developing countries (if a woman is allowed to labor for too long) to develop a fistula between their bladder and the vaginal wall. This leads to leaking urine constantly

Bowel Diversions

An ostomy is anastomosis between a segment of the GI tract and the skin of the anterior abdominal wall Most common ostomies: - distal small intestine (eg, ileostomy) - completely bypasses large intestine - large intestine (i.e., colostomy)

compare/contrast ostomies

Ascending colostomy - semi-liquid Transverse colostomy - semi-formed Sigmoid colostomy - formed (irrigation possible) Ileostomy - liquid/semi-liquid Outcome: Differentiate between the various types of bowel diversions.

No, it's non-controllable - so they will have to use an appliance like a drainage bag

Can someone with an ascending colostomy manage with irrigation?

How to clean a non-oozing wound

Clean with soap and plain water

Moisture and Exudate Management

Dessication - Solosite gel Maceration - Excessive exudate may lead to breakdown of surrounding skin Maceration under the breasts or abdominal folds is a partial thickness breakdown / skin loss but it is NOT a pressure ulcer Want to use the dressing change that is cost effective Want to keep the wound moist but not wet

Wound Care Products

Gauze - Woven / non-woven cotton / non-cotton - May adhere to the wound Transparent Dressings - A waterproof dressing that is permeable to O2 and moisture - skin does not macerate, protects the skin Tend to see these over IVs Hydocolloid - An occlusive and adhesive wafer dressing for moderate amounts of exudate Ag = Silver - Natural antimicrobial Wound bed can turn a dusty/gray color - it is tarnish from the silver - this is not a worry, the product is doing what it is supposed to do This is for dirty wounds

Wound bed

Granulation Bruising Slough - yellow/gray stuck material (negative) Eschar - leathery necrotic tissue (negative)

Phases of Wound Healing

Hemostasis - Blood vessels constrict, and clotting occurs - If a person has liver issues (alcohol abuse) this phase could be interupted and disrupt wound healing Inflammation - vasodilation follows bringing more blood; white blood cells and fibroplastin to the wound site Proliferation - (aka fibroblastic phase) Epithelial cells begin to form and reestablish blood flow; collagen fibers continue to strengthen the wound Maturation - (aka remodeling phase) scar becomes flat, smaller, and white This phase can take up to a year Scar tissue is less strong (30% less strength) than intact skin. We want good approximation - want the wound to heal together smoothly Outcome: Review the phases of wound healing

Chronic Wound - "she calls them stuck wounds" - stuck in some phase

It is a wound that fails to proceed through an orderly an timely repair process to produce anatomic and functional integrity typically a chronic wound is stuck in the proliferation phase sometimes it can take 18 months to heal

Wound Assessment

Location Exudate - drainage Wound bed Wound pain Tissue involvement - Undermining - Tunneling - Fistula Peri-wound skin - around the wound Dimensions - length, width, depth Edges - describe the edges, maybe take pictures

Lifestyle Adjustments with an ostomy

Nutrition: - Limit high fiber - BRAT diet - Fruits with skins, popcorn (called a particulate, can get caught in the folds on the bag and cause a blockage), dried fruits, nuts, raw veggies Partial Obstructions - Warm baths / heating pads - Walking - Positions (knee to chest, side lying) Sexual Activity - Empty bag - Avoid sexual activity after meal time - NOTHING goes into the stoma - you can get an STD if a penis is put in there, can also can an infection and people can die A woman can get pregnant but it is a nigh risk pregnancy because of the lack of nutrients/electrolytes

Color of the stoma

The stoma should be rosy pink to red in color. A blanching, dark red to purple stoma indicates inadequate blood supply to the stoma or bowel and should be reported to the healthcare provider

Exudate - Think TACO

Type - Serous - Purulent - Serosanguinous Amount Color Odor - some bacteria have a specific odor

ileostomy

distal small intestine bypasses the large intestine - very liquidy Missing out on electrolytes, minerals, and vitamins

sigmoid colon

irrigation can be performed when the colostomy is located on the they have a really good change of controlling their bowel movements by irrigation and/or diet so that a appliance is not required

colostomy

large intestine

Location of ostomies

sigmoid colon (right before the rectum) is the only possible irrigation Outcome: Differentiate between the various types of bowel diversions.

anastomosis

two things are connected segment of Gi tract to wall in this case