By Jackie Doubleman, BSN, RN, CWOCN

Most patients are distressed to learn they need ostomy surgery to divert stool, urine, or both. Adapting to ostomy surgery can be difficult at best, even with today’s advanced technology and the wide assortment of ostomy supplies available. While recovering from the surgery itself, patients must learn how to contain or control feces or urine and how to minimize odor—without feeling like a social outcast.

This article reviews three types of ostomy surgery—colostomy, ileostomy, and urostomy. Subsequent articles will discuss ostomy management and treatment of stomal and peristomal skin complications.

Colostomy

A colostomy may be done on any part of the colon. It may be permanent or temporary.

• A permanent colostomy is done when the rectum must be removed or other health problems prevent colostomy closure.
• A temporary colostomy is created to divert stool away from the diseased portion of the colon or large intestine, giving the affected part of the bowel time to rest and heal. Depending on the healing process, the patient may need the colostomy for a few weeks to a few months. Once the affected area is healed, the colostomy can be closed or reversed. Occasionally, a patient may opt to keep the colostomy due to fear of needing another surgery. (See Colostomy indications by clicking the PDF icon above.)

Types of colostomies include ascending, transverse, and descending and sigmoid colostomy. Refer to the image below, which shows the normal intestines, as you read the descriptions.

Ascending colostomy

In this type of colostomy, the surgeon diverts the bowel to an opening in the abdominal wall, rolls the bowel back onto itself, and stitches it to the abdominal wall. The stoma is on the right side of the abdomen, on the ascending portion of the colon. Because stool is diverted from most of the colon, the output is liquid and full of digestive enzymes. The skin must be protected from the effluent and the patient must wear a drainable pouch at all times.

Transverse colostomy

Two types of transverse colostomies are done—loop transverse colostomy and double-barrel transverse colostomy. Usually, they serve as temporary fecal diversions.

• In transverse loop colostomy, the surgeon creates one stoma with a proximal and distal opening. The proximal opening expels stool while the distal opening eliminates mucus. This procedure allows the distal portion of the colon to rest and heal; once it heals, the colostomy may be closed. Normally, a small amount of stool and mucus is expelled from the anus.
• The double-barrel transverse colostomy rarely is done today. The surgeon completely divides the bowel, leaving two stomas on the abdominal wall—a proximal stoma that expels stool and a distal stoma that passes mucus. The distal stoma also may be called a mucous fistula, with the mucus expelled through the rectum. If the two stomas are separated on the abdominal wall, the patient wears a pouch over the proximal stoma to collect feces and wears a piece of plain gauze, a Vaseline gauze pad, or a small pouch called a stoma cap over the mucous fistula stoma. If the stomas are near each other, a single pouch may cover both.

Descending colostomy and sigmoid colostomy

In these procedures, the stoma is on the left lower abdominal wall. The descending colostomy stoma is located just a few inches higher than the stoma for a sigmoid colostomy. A sigmoid colostomy, the most common colostomy type, may be permanent or temporary.

Abdominal perineal resection of the rectum is done in patients with distal rectal cancer. Today, with advanced technology in surgical instrumentation, surgeons may be able to accomplish a lower anastomosis in the rectum and thus prevent a permanent colostomy. If the rectum has been removed, the sigmoid colostomy is permanent. The patient may have the option to regain control over elimination through colostomy irrigation on a regular basis to stimulate peristalsis and evacuate the colon at a designated time. To be eligible for colostomy irrigation, the patient must have had only one or two bowel movements daily before becoming ill and requiring surgery, and must be functionally able to perform irrigation. Because descending and sigmoid colostomies are done in the left lower quadrant, more of the colon is functional; therefore, fecal output usually has a soft to firm consistency.

Ileostomy

With an ileostomy, bowel diversion surgery is restricted to the small intestine on the lower right abdominal wall and affects only the ileum. An ileostomy may be permanent or temporary, depending on whether the rectum was removed. Indications for ileostomy surgery include ulcerative colitis, Crohn’s disease, familial polyposis, and cancer.

Because the colon is removed or bypassed, stool is liquid to semisoft and appears green. The patient must learn to avoid dehydration and will need to wear an external ostomy bag 24 hours daily for fecal collection. Types of ileostomies include the ileoanal reservoir and the Barnett continent intestinal reservoir (BCIR).

Ileoanal reservoir

Also known as the J-pouch or a continent diversion, the ileoanal reservoir is an internal pouch formed from the small intestine. It’s a widely accepted treatment option for patients with ulcerative colitis and familial polyposis because it eliminates the disease and doesn’t require a permanent ileostomy.

This complex procedure most often is done in two stages. In the first procedure, the surgeon removes the colon but leaves the anus intact and disease free; a temporary ileostomy is created to divert stool from the new J-pouch to promote healing. Usually within 4 to 8 weeks, the second surgery is done to take down the ileostomy. Afterward, the patient has six to ten bowel movements per anus daily. After a few months of adjustment, the patient may have only three to six bowel movements daily.

For critically ill patients who need emergency surgery, the surgeon may opt to do a three-stage procedure. The first surgery is a total colectomy with rectal sparing and a temporary loop ileostomy. In the second, the surgeon constructs the J-pouch. The third is ileostomy takedown or reversal.

BCIR

An intra-abdominal ileostomy, the BCIR is used for patients who’ve had problems with conventional ileostomy and difficulty wearing an external ostomy bag, as well as those who’ve failed with the Kock pouch, ileoanal anastomosis, or J-pouch. The BCIR was modified from the Kock pouch (a continent ileostomy) by Dr. William Barnett when he constructed the “living collar,” which is made from the small intestine and helps prevent leakage around the stoma. The Kock pouch is an internal pouch that stores liquid stool (600 to 1,000 ml) and is emptied with a catheter at the patient’s convenience two to four times daily. The stoma empties directly into the toilet. Most patients cover the stoma site with a small pad or bandage to absorb the mucus that accumulates at the opening. As with any diversion, mucus formation at the stoma site is natural because the intestine normally produces mucus.

Urostomy

Also called a urinary diversion, a urostomy is indicated for cancer, bladder extrophy, neurogenic bladder, interstitial cystitis, and ureter blockage caused by a kidney stone or tumor. A urostomy can be one of several types. This article describes the ileal conduit, neobladder, Indiana pouch, Miami pouch, and nephrostomy.

Ileal conduit

Because of its low complication rate and high patient satisfaction, an ileal conduit is the most common urinary diversion technique after a radical cystectomy for invasive bladder cancer. The conduit is created from the terminal ileum of the small intestine. The surgeon resects the ureters from the bladder and performs ureteroenteric anastomosis. After closing one end of the conduit, the surgeon brings the other end through a premarked site in the right lower quadrant of the abdominal wall, creating a stoma.

The goal of an ileal conduit is to expel urine directly from the conduit via the stoma into an external pouch. Patients wear a urinary pouch 24 hours daily and must empty it several times a day. Because they don’t feel the urge to urinate, they must learn to empty the pouch when they feel it getting heavy with urine. They empty it directly into the toilet through the spout on the end. Usually, the pouch is changed two or three times per week. Patients with good wear time and no peri­stomal skin irritation may need to change it only once a week but must drink at least eight glasses of liquid daily to prevent ascending urinary tract infection.

Neobladder

This continent urinary diversion is done in patients whose bladder has been removed due to cancer. It closely mimics the urinary bladder’s storage function. The surgeon makes part of the small intestine into an internal reservoir and sews it to the urethra. The ureters are attached to drain into the reservoir, providing a downward urine flow to prevent urine back-up and thus help prevent kidney infection. Urine passes from the kidney down the ureters to the reservoir and through the urethra, as in normal urine passage.

Candidates for neobladder surgery must have a low risk of urethral cancer recurrence and be highly motivated to follow a strict care regimen for the first few months. After surgery, they lack the normal urge to urinate, so for the first few months they must void “by the clock.” Initially, they experience nocturnal incontinence, but urinary leakage during the day is unlikely. The neobladder continues to enlarge and function better over the first few years.

The main advantage of this surgery is that with time and patience, the patient can use the bathroom to urinate the same way as before surgery. Neobladders usually are done on men because the female internal anatomy makes neobladder creation much more difficult.

Indiana pouch

The Indiana pouch is used for urinary diversion after bladder cancer, pelvic exenteration, bladder extrophy, or neurogenic bladder. Patients with this continent reservoir must catheterize it to empty stored urine.

The Indiana pouch is created from approximately 2′ of the ascending colon.
The surgeon brings a small portion of the ileum and the end segment through the abdominal wall to create a stoma. The ileocecal valve is included in the reservoir and functions as a one-way valve to help prevent urinary leakage from the stoma.

The patient leaves the hospital using leg bags connected to one tube through the stoma and into the reservoir, and connected to another tube through a temporary opening into the abdominal wall and reservoir. After sufficient healing, the stomal tube is removed and the patient is taught to catheterize the stoma or pouch every 2 hours. After 1 month, if X-rays don’t show urine leakage from the pouch, the last drainage tube is removed. Then the patient catheterizes the pouch every 3 hours around the clock. As the pouch continues to expand, emptying time may increase to 4 or 6 hours, with pouch capacity up to 1,200 ml.

Patients need to irrigate the pouch daily with 60 ml sterile water to remove mucus, salts, and bacteria. After about 6 months, they usually can sleep through the night without emptying the pouch if they limit liquid intake in the evening.

Miami pouch

Another type of continent urostomy, the Miami pouch is created by a gynecologic oncologist at the time of an anterior or total pelvic exenteration. It’s constructed using the distal ileum and ascending colon. Continence is developed with tapering of the ileum, intussusception of the ileal cecal valve, and detubularizing of the colonic segment. With this pouch, pressure is lower than urethral pressure entering it and lower than that of the
efferent bowel leaving it, reducing risk of urinary reflux.

The Miami pouch has proven to be reliable in terms of continence and protecting the upper urinary tract. The most common complications are urethral stricture, difficulty with catheterization, and pyelonephritis. Quality of life improves after a Miami pouch or Indiana pouch continent urostomy because these procedures avoid an external pouch, even though they require intermittent self-catheterization.

Nephrostomy

A nephrostomy is an artificial opening created between the skin and kidney by a surgeon or interventional radiologist. Using ultrasound guidance or computed-tomography fluoroscopy, the practitioner places a catheter in the renal pelvis.

This procedure is done to prevent kidney damage related to urinary blockage. The nephrostomy tube allows the kidney to function properly and protects it from further damage and possible infection; once the condition necessitating the nephrostomy has been treated or corrected, the tube can be removed. If it must remain in place for an extended time, it must be exchanged periodically.

The patient wears an external urostomy pouch over the tube. Depending on individual circumstances, patients may have bilateral nephrostomy tubes or a left or right nephrostomy tube. If only one kidney is blocked, one neophrostomy tube will be placed; the patient voids normally and has to keep the neophrostomy pouch emptied. The nephrostomy tube may need to be irrigated regularly in a sterile procedure, as ordered by the surgeon.

Help patients resume active lives

When confronted with the need for a fecal or urinary diversion, all patients and their families have concerns and questions, and many feel frightened and isolated. Refer them to a local ostomy support group or the United Ostomy Associations of America to help them get through this transition period.

Every patient has the right to be clean, dry, and odor free. To achieve this goal and resume a normal lifestyle, patients must learn about ostomy management. Quality of life after a fecal or urinary diversion can improve if patients understand about the specific surgery required and learn how to perform self-care. Patients with any type of continent fecal or urinary diversion should wear a medical alert medallion in case they are unconscious in an emergency situation. Once patients know how to care for themselves, they can resume full, active lives. Time, patience, and a good sense of humor can help them live life and enjoy it despite the ostomy.

Selected references
Beitz JM. Continent diversions: the new gold standard of ileoanal reservoir and neobladder. Ostomy Wound Manage. 2004;50(9):26-35.

Beitz JM, Gerlach M, Ginsburg P, Ho M, McCann E, et al. Ostomy Wound Manage. 2010;56(10):22-38.

Colwell JC, Goldberg MT, Carmel JE. Fecal and Urinary Diversions: Management Principles. Philadelphia, PA: Elsevier; 2004.

Costa JA, Kreder K. Urinary diversions and neobladders. Medscape Reference: Drugs, Diseases and Procedures. Updated May 16, 2012. http://emedicine.medscape.com/article/451882-overview. Accessed February 28, 2013.

Geng V, Eelen P, Fillingham S, Holroyd S, Kiesbye B, et al. Good Practice in Health Care: Continent Urinary Diversion. Arnhem, The Netherlands: European Association of Urology Nurses; 2009.

Gordon PH. Intestinal stomas. In: Gordon PH, Nvatvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum and Anus. 3rd ed. CRC Press; 2007.

Gutman N. Colostomy Guide. United Ostomy Associations of America; 2011.

Herlufsen P, Olsen AG, Carlsen B, Nybaek H, Karlsmark T, et al. Study of peristomal skin disorders in patients with permanent stomas. Br J Nurs. 2006; 15(16):854-62.

Nie A, Douglas E. Pediatric Ostomy Care: Best Practice for Clinicians. WOCN Society Annual Conference: New Orleans, Louisiana; 2011.

D’Orazio M, Ozorio C. On the lack of universal ostomy follow-up. J Wound Ostomy Continence Nurs. 2008;35(3):313-15.

United Ostomy Associations of America. What is an ostomy? www.ostomy.org/ostomy_info/whatis.shtml. Accessed February 28, 2013.

Jackie Doubleman is a certified wound and ostomy care nurse at St. Vincent’s Hospital in Birmingham, Alabama.

By Kathleen D. Pagana, PhD, RN

As clinicians, we’re proud of the expert care we provide patients. But we also know that just doing our job isn’t enough to advance our careers. Mastering good communication skills is essential for all clinicians at all career stages—especially with today’s flatter organizational structures and more participatory management styles. Knowing how to communicate in a professional manner can give you the edge you need for career advancement.

Opportunity rarely knocks any more. Instead it may present as a phone call, voice mail, e-mail, or text message. Be sure to use proper etiquette with all communication forms.

Speaking with managers

When dealing with your manager, use a solution-focused approach. Don’t be a complainer. Some communication experts point out that people complain about things they can do something about—not things they have no power over. For example, they don’t complain about their foot size because there’s nothing they can do about it. Yet people often complain about their jobs because they’re unwilling to take the risk of making a change.

We need to take charge of our lives. We can accept the fact—without complaining—that we’re making the choice to stay where we are. Or we can make a request or take action to achieve a desired outcome. Suppose you work on a clinical unit and disagree with the way your manager makes clinical assignments. You have several options:

• Complain to coworkers and make the workplace miserable for others.
• Speak with your manager and make suggestions for improvement.
• Leave your job and go elsewhere if you can’t work with your manager to make things better.

If you decide to stay in your job, accept the fact that you’ve made that choice. Take responsibility for it and stop complaining.

Speaking on the phone with physicians

For clinicians who are not physicians, the key to effective communication with physicians is to remember you’re an important member of the healthcare team. An effective way to guide your communication with physicians and other colleagues is to use a tool such as SBAR (Situation, Background, Assessment, Recommendation). Say, for instance, you want to suggest the doctor order an anxiolytic for your patient. Here’s how you might do it using SBAR:

Situation: “Mrs. Smith is complaining of severe anxiety.”
Background: “She is 1 day post-op from a lumbar laminectomy.”
Assessment: “She is alert and oriented and her vital signs are stable. She has no numbness or tingling in her extremities.”
Recommendation: “She said she takes lorazepam 2 mg orally at when she’s anxious. Would you like to order something for her?”

Before ending the conversation, repeat and clarify the medication order (if the doctor gives one).

Telephone

The sound of your voice and your manners are essential components of phone etiquette. Smile—the smile on your face comes through in your voice. Here are five more tips:

1. Get yourself organized before placing the call.
2. Minimize background noise.
3. Immediately identify yourself. Don’t assume the recipient will recognize your voice.
4. Concentrate on listening and avoid multitasking.
5. Schedule phone conversations to avoid playing phone tag.

Voice mail

Voice mail is an efficient way to communicate. Again, five tips:

1. Always be prepared to leave a message. Jot down your key message points before you call, to avoid stuttering and stammering.
2. Be concise and to the point.
3. State your name and the date, time, and purpose of your call.
4. Enunciate clearly and speak slowly.
5. State your name and phone number twice at the end of the message so the recipient doesn’t need to replay your message.

E-mail

In many business settings, e-mail has almost replaced letters and memos. In many cases, an e-mail is a recipient’s first impression of you, so follow these tips:

1. Make the subject line specific. This helps the reader prioritize the message and file it for easy retrieval.
2. Use a greeting and a close. It’s more polite and less impersonal.
3. Keep your message concise.
4. Keep your tone polite and businesslike.
5. Use your e-mail signature function, which provides several ways to contact you.

Text messages

This form of communication can be the most challenging and unpredictable. Some people send text messages routinely, while others may be unfamiliar with this method. You can’t go too far wrong if you take this advice:

1. Get to the point quickly. No one wants to read a long message on a mobile phone.
2. Don’t text during meetings. It’s rude to do so, and others can hear you clicking away or see the light from your screen.
3. Consider the recipient before using text abbreviations. Some people may not understand text lingo.
4. Consider the time when sending a text. Although you may be awake at 5 a.m., the sound of your incoming message might disturb a sleeping recipient.
5. Don’t expect an immediate response to your text. If the message is time sensitive, pick up the phone instead.

Improving the way we speak with managers and physicians can go a long way toward career advancement and professional satisfaction. Common courtesy is just as essential in e-mail, voice mail, and text messages as in face-to-face communication. When you follow the guidelines I’ve given, you’ll elevate your professional communications a few notches.

Selected references
Canfield J, Switzer J. The Success Principles: How to Get from Where You Are to Where You Want to Be. New York, NY: Morrow; 2006.

Kramer M, Schmalenberg, C. Confirmation of a healthy work environment. Crit Care Nurse. 2008 Apr;28(2):56-63.

Pagana K. The Nurse’s Communication Advantage: How Business Savvy Communication Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2011.

Pagana K. The Nurse’s Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2008.

A keynote speaker, Kathleen D. Pagana is a professor emeritus at Lycoming College in Williamsport, Pennsylvania, and president of Pagana Keynotes and Presentations. She is the author of The Nurse’s Communication Advantage and The Nurse’s Etiquette Advantage. To contact her, visit www.KathleenPagana.com.

Here are resources that can help you in your busy clinical practice by giving you information quickly.

Pressure ulcer resources

Instead of searching through Google or another search engine for pressure ulcer resources, start with this comprehensive list on the Centers for Medicare & Medicaid Services website.
Examples of resources included are:

• “Preventing pressure ulcers in hospitals: A toolkit for improving quality of care.” This toolkit from the Agency for Healthcare Research and Quality (AHRQ) is designed to help hospitals in implementing pressure ulcer prevention strategies.
• “On-time pressure ulcer healing project.” Another AHRQ initiative, this resource is designed for those working in long-term care facilities.
• “Pressure ulcer prevention.” This table from the Institute for Healthcare Improvement lists possible mentors you can work with in the area of ulcer prevention.
• “Shawnee Medical Center wound care quick reference guide.” This is a handy one-page reference guide that includes photographs and recommendations.
• “How-to guide: Prevent pressure ulcers—pediatric supplement.” This guide, tailored for pediatrics, describes key evidence-based care components for preventing pressure ulcers and describes how to implement these interventions.

You can also access case studies from a variety of facilities around the United States.

http://partnershipforpatients.cms.gov/p4p_resources/tsp-pressureulcers/
toolpressureulcers.html

Lymphedema resources

The National Lymphedema Network is a nonprofit organization founded in 1988 to provide education and other information to healthcare professionals and patients with lymphedema, as well as the general public. The site includes an explanation of lymphedema that may be helpful for you to use in teaching your patients. It also includes access to some of the articles from the newsletter LymphLink.

http://www.lymphnet.org

Diabetes clinical practice guidelines

Many patients with chronic wounds have diabetes. To ensure those patients receive the best possible care, you can refer to the 2013 Standards of Medical Care in Diabetes from the American Diabetes Association, which were published in the January issue of
Diabetes Care.

The journal provides a summary of the revisions and an executive summary of the standards related to each area, including diagnosis, testing, prevention, monitoring, and pharmacologic and nonpharmacologic management.

The guidelines include valuable information related to neuropathy screening and treatment and foot care. Recommendations for foot care include performing an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.

http://care.diabetesjournals.org/content/36/Supplement_1

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

Most of us have had days when we jump from meeting to meeting and at the end of the day wonder, “Did I get anything accomplished or am I more behind than ever?”

Many clinicians tell me that although their wound team meets regularly, the meetings aren’t meaningful enough, leaving the team still facing issues with their wound care program. As a consultant, when I review the wound team agenda, it’s typically missing one or more of four key ingredients:

• appropriate member representation
• proactive approach that highlights prevention
• review of the plan of care and update of the medical record
• review of supplies and products. Here’s a closer look at each of these ingredients.

Build a top team

Having the appropriate members on the wound care team is the first ingredient for success. A comprehensive, interdisciplinary team approach is the key to preventing skin breakdown and ensuring good clinical outcomes for residents with skin breakdown. Teams should include representation from nursing, dietary, and physical and occupational therapy, as well as a nurse practitioner or physician.

Nursing representation should include nurses from all three shifts and nursing assistants, who are too often missing from the team. Keep in mind that when it comes to preventing pressure ulcers, nursing assistants carry out most of interventions (for example, turning, incontinence management, heel lift). Even when a patient has a wound, the only intervention carried out by the nurses is the topical treatment; nursing assistants perform all other interventions necessary to ensure healing. Clinicians who empower nursing assistants to have a strong influence with the wound care team—and the program—tend to have very successful prevention programs and good clinical outcomes.

Think prevention

The second key ingredient is prevention. Most wound team meetings only discuss the patients with wounds, missing the bigger goal of preventing wounds in the first place. Once the patients with wounds are discussed, the team should review all high-risk patients to ensure proper preventative measures are in place and care planned. All patients should be quickly reviewed for evidence of:

• decline or change in mobility and activity
• new onset or change in continence status
• decline in nutritional status
• decline or change in cognition.

Any triggers in these areas should prompt a review of the plan of care to ensure they are being effectively addressed.

Review and update the plan

The third key ingredient for success is to use meeting time to review and update the plan of care. I’ve observed highly productive meetings and great discussions of the care the facility is providing. Then I review the medical record and discover that none of the interventions discussed are on the plan of care. Always review the patient’s plan of care to ensure it’s accurate, reflects all interventions, and is up to date. This will give you peace of mind that the medical record reflects all the good work you’re doing and helps make the team meetings feel productive.

Discuss products and supplies

The fourth key ingredient is to take the time to quickly discuss current wound care supplies and products with the team. Ask the team if the current supplies are user-friendly, are adequate, provide good outcomes, and are in good working condition.

Many times staff will not say how they’re struggling with, modifying, or not using something until they’re asked. Remember that the most expensive product is the one that doesn’t work or doesn’t get used.

A recipe for success

Using these four key ingredients will lead you to a successful wound team meeting—and a successful program. The mix may not solve your too-many-meetings days, but will give you peace of mind that at least one meeting is productive.

Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS

Each month, Apple Bites brings you a tool you can apply in your daily practice.

Description

An Unna boot is a special dressing of inelastic gauze impregnated with zinc, glycerin, or calamine that becomes rigid when it dries. It is used for managing venous leg ulcers and lymphedema in patients who are ambulatory. When the patient walks, the rigid dressing restricts outward movement of the calf muscle, which directs the contraction force inward and improves the calf-muscle pumping action, thereby improving venous flow. An Unna boot does not provide compression and is contraindicated for arterial insufficiency.

View: How to apply an Unna boot 

How to apply an Unna boot

Follow these steps:
1 Gently wash and dry the extremity and apply moisturizer.
2 Clean any wound that is draining and apply an appropriate topical dressing. The topical product should be one that can remain in place for several days without changing.
3 Flex the patient’s foot to 90 degrees and maintain that position throughout the application.
4 Begin applying the bandage on the top of the foot at the base of the toes.
5 Wrap twice around the base of the toes without tension.
6 Continue wrapping up the leg using a spiral technique and overlapping each previous layer by 75%. The bandage should be loosely wrapped around the foot and heel and around the leg in a spiral fashion; do not use tension. This technique covers the leg with at least two layers.
7 Continue to wrap to 1 inch below the knee (one fingerwidth below the posterior bend of the knee).
8 As you wrap, smooth and mold the bandage with your hands. Cut the bandage as needed to prevent wrinkles, pleats, and folds. Restart the wrap where the bandage was cut.
9 Cut any excess bandage upon reaching the knee.
10 According to specific product instructions, apply a cover wrap, usually an elastic or cohesive bandage, using 50% overlap.

• Start the cohesive wrap at the center of the ball of the foot, with the lower edge at the base of the toes.
• Continue wrapping up the foot with 50% overlap.
• Upon reaching the heel, pull 6 to 7 inches of bandage away from the roll. While the bandage is stretched, wrap it around the heel area.
• When reaching the ankle, stretch the bandage out another 6 inches followed by relaxing the bandage back to 50% tension.
• Wrap around the ankle two turns at 50% tension.
• Continue wrapping up the leg with 50% tension and 50% overlap, stopping at the top of the paste bandage. NOTE: An overlap of 50% more or less will result in inconsistent higher and lower compression pressures.
• Cut any excess bandage upon reaching the top.

11 Observe the skin distal to the bandage for adequate circulation (color, pulse, warmth).
12 Secure the wrap with tape. Initial and date the wrap.

Tips

These tips will help you apply the Unna boot and manage it appropriately.

• Wrap from the toes upward to below the knee.
• Apply the boot in a spiral fashion, with 75% overlap.
• Apply the boot directly over any wound. You don’t need a separate dressing unless the wound is draining.
• Cut the boot frequently during application to avoid pleats, folds, or wrinkles that may cause skin damage as the boot dries.
• An Unna boot can stay in place for 3 to 7 days, but should be changed when the wrap begins to loosen or if it becomes saturated with drainage.
• If your patient has to take a shower, wrap a towel around the top of the boot, cover the lower leg with a plastic bag, secure the top with an Ace wrap, and drape the excess plastic over the Ace wrap.

How to remove an Unna boot

Here is guidance for removing an Unna boot:

• You can use bandage scissors to remove the boot (or unwrap it).
• Start at the bottom of the boot and cut upward to the ankle.
• Cut on the side opposite of the ulcer, and use caution to keep the scissors away from the anterior tibial area to prevent trauma.

Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur. Read her blog “Wound Care Swagger.”

Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), copyright 2013.

By Donald A. Wollheim, MD, WCC, DWC, FAPWCA

Chronic venous insufficiency (CVI) is the most common cause of lower extremity wounds. The venous tree is defective, incapable of moving all the blood from the lower extremity back to the heart. This causes pooling of blood and intravascular fluid at the lowest gravitational point of the body—the ankle.

This article has two parts. Part 1 enhances your understanding of the disease and its clinical presentation. Part 2, which will appear in a later issue, explores the differential diagnosis of similar common diseases, the role that coexisting peripheral artery disease (PAD) may play, disease classification of venous insufficiency, and a general approach to therapy.

The most common form of lower extremity vascular disease, CVI affects 6 to 7 million people in the United States. Incidence increases with age and other risk factors. One study of 600 patients with CVI ulcers revealed that 50% had these ulcers for 7 to 9 months, 8% to 34% had them for more than 5 years, and 75% had recurrent ulcers.

Thrombotic complications of CVI include thrombophlebitis, which may range from superficial to extensive. If the thrombophlebitis extends up toward the common femoral vein leaving the leg, proximal ligation may be needed to prevent clot extension or embolization.

Understanding normal anatomy and physiology

Lower extremity veins flow horizontally from the superficial veins to the perforating veins and then into the deep veins. Normally, overall venous blood flows vertically against gravity from the foot and ankle upward toward the inferior vena cava (IVC). This antigravity flow toward the IVC results from muscular contraction around nonobstructed veins and one-way valves that close as blood passes them. These valves prevent abnormal backward blood flow toward the foot and ankle region.

The lower extremities have four types of veins. Superficial veins are located within the subcutaneous tissue between the dermis and muscular fascia. Examples are the greater and lesser (smaller) saphenous veins. Perforating veins connect the superficial veins to the deep veins of the leg. The deep veins are located below the muscular fascia. The communicating veins con­nect veins within the same system.

The greater saphenous vein is on the leg’s medial (inner) side. It originates from the dorsal veins on top of the foot and eventually drains into the common femoral vein in the groin region. By way of perforating veins, the greater saphenous vein drains into the deep venous system of both the calf and thigh.

The lesser saphenous vein is situated on the lateral (outer) side of the leg and originates from the lateral foot veins. As it ascends, it drains into the deep system at the popliteal vein behind the knee. Communicating veins connect the greater saphenous vein medially and the lesser saphenous vein laterally.

Intramuscular veins are the deep veins within the muscle itself, while the intermuscular veins are located between the muscle groups. The intermuscular veins are more important than other veins in development of chronic venous disease. Below the knee, the intermuscular veins are paired and take on the name of the artery they accompany—for example, paired anterior tibial, paired posterior tibial, and paired peroneal veins. Eventually, these veins form the popliteal vein behind the knee, which ultimately drains into the femoral vein of the groin.

As the common femoral vein travels below the inguinal ligament of the groin, it’s called the external iliac vein. Eventually, it becomes the common iliac vein, which drains directly into the IVC.

Pathophysiology

Abnormally elevated venous pressure stems from the leg’s inability to adequately drain blood from the leg toward the heart. Blood drainage from the leg requires the muscular pumping action of the leg onto the veins, which pump blood from the leg toward the heart as well as from the superficial veins toward the deep veins. Functioning one-way valves within the veins close when blood passes them, preventing blood from flowing backward toward the ankle. This process resembles what happens when you climb a ladder with intact rungs: As you step up from one rung to the next, you’re able to ascend.

CVI and the “broken rung” analogy

If the one-way valves are damaged or incompetent, the “broken rung” situation occurs. Think how hard it would be to climb a ladder with broken rungs: You might be able to ascend the ladder, but probably you would fall downward off the ladder due to the defective, broken rungs.

Normally, one-way valves ensure that blood flows from the lower leg toward the IVC and that the superficial venous system flows toward the deep venous system. The venous system must be patent (open) so blood flowing from the leg can flow upward toward the IVC. Blockage of a vein may result from an acute thrombosis (clot) in the superficial or deep systems. With time, blood may be rerouted around an obstructed vein. If the acute thrombosis involves one or more of the one-way valves, as the obstructing thrombosis opens up within the vein’s lumen, permanent valvular damage may occur, leading to post-thrombotic syndrome—a form of CVI.

CVI may result from an abnormality of any or all of the processes needed to drain blood from the leg—poor pumping action of the leg muscles, damage to the one-way valves, and blockage in the venous system. CVI commonly causes venous hypertension due to reversal of blood flow in the leg. Such abnormal flow may cause one or more of the following local effects:

• leg swelling
• tissue anoxia, inflammation, or necrosis
• subcutaneous fibrosis
• Compromised flow of venous blood or lymphatic fluid from the extremity.

“Water balloon” analogy

The effect of elevated venous pressure or hypertension is worst at the lowest gravitational point (around the ankle). Pooling of blood and intravascular fluid around the ankle causes a “water balloon” effect. A balloon inflated with water has a thin, easily traumatized wall. When it bursts, a large volume of fluid drains out. Due to its thicker wall, a collapsed balloon that contains less fluid is more difficult to break than one distended with water.

In a leg with CVI, subcutaneous fluid that builds up requires a weaker force to break the skin and ulcerate than does a nondistended leg with less fluid. This principle is the basis for compression therapy in treating and preventing CVI ulcers.

Effects of elevated venous pressure or hypertension

Increased pressure in the venous system causes:

• abnormally high pressure in the superficial veins—60 to 90 mm Hg, compared to the normal pressure of 20 to 30 mm Hg
• dilation and distortion of leg veins, because blood refluxes abnormally away from the heart and toward the lower leg and may move from the deep venous system into the superficial veins.

Abnormal vein swelling from elevated pressure in itself may impair an already abnormally functioning one-way valve. For instance, the valve may become more displaced due to the increase in intraluminal fluid, which may in turn worsen hypertension and cause an increase in leg swelling. Increased pressure from swollen veins also may dilate the capillary beds that drain into the veins; this may cause leakage of fluid and red blood cells from capillaries into the interstitial space, exacerbating leg swelling. Also, increased venous pressure may cause fibrinogen to leak from the intravascular plasma into the interstitial space. This leakage may create a fibrin cuff around the capillary bed, which may decrease the amount of oxygen entering the epidermis, increase tissue hypoxia, trigger leukocyte activation, increase capillary permeability, and cause local inflammation. These changes may lead to ulceration, lipodermatosclerosis, or both.

Visible changes may include dilated superficial veins, hemosiderin staining due to blood leakage from the venous tree, atrophie blanche, and lipodermatosclerosis. (See CVI glossary by clicking the PDF icon above.) Both atrophie blanche and lipodermatosclerosis result from local tissue scarring secondary to an inflammatory reaction of the leg distended with fluid.

Lipodermatosclerosis refers to scarring of subcutaneous tissue in severe venous insufficiency. Induration is associated with inflammation, which can cause the skin to bind to the subcutaneous tissue, causing narrowing of leg circumference. Lymphatic flow from the leg also may become compromised and inhibited in severe venous hypertension, causing additional leg swelling.

Patient history

In a patient with known or suspected CVI, a thorough history may lead to a working diagnosis. Be sure to ask the patient these questions:

• Do you have pain?
• Is your pain worse toward the end of the day?
• Is the pain relieved with leg elevation at night?
• Is it relieved with leg elevation during the day?
• Do you have leg pain that awakens you at night?
• How would you describe the pain?
• Does the skin on your leg feel tight or irritated?
• Have you noticed visible changes of your leg?
• Do you have a leg ulcer?

Also determine if the patient has comorbidities that may exacerbate CVI, including PAD, renal failure, venous thrombosis, lymphedema, diabetes mellitus, heart failure, or malnutrition. (See CVI risk factors by clicking the PDF icon above .)

Common CVI symptoms

Approximately 20% of CVI patients have symptoms of the disease without physical findings. These symptoms may include:

• tired, “heavy” legs that feel worse toward the end of the day
• discomfort that worsens on standing
• legs that feel best in the morning after sleeping or after the legs have been
• elevated during the day.

Although patients may report leg discomfort, the history indicates that it doesn’t awaken them at night. Be aware that discomfort from CVI differs from that caused by PAD. With PAD, patients may report pain on exercise (claudication), pain with elevation (nocturnal pain), or constant pain (resting pain).

Signs of CVI (with or without ulcers) include:

• leg swelling (seen in 25% to 75% of patients)
• skin changes (such as hemosiderin staining or dermatitis)
• telangiectasia, reticular veins, or both; while these are the most common signs, they represent an overall less severe finding
• varicose veins with or without bleeding, occurring in one-third of patients with CVI.

Venous ulcers

Venous ulcers are the most common type of lower extremity ulcer. They’re commonly found on the medial aspect of the lower extremity, from the ankle to the more proximal calf area. Usually, they arise along the course of the greater saphenous vein, but also may be lateral and may occur at multiple locations. They aren’t found above the knee or on the forefoot. Venous ulcers are shallower than arterial ulcers and have considerable exudate consistent with drainage from a ruptured water balloon. They may extend completely around the leg.

CVI: From a heavy sensation to visible changes

In patients with CVI, blood flows within a lower extremity in an abnormal, reverse direction, causing build-up of blood and intravascular fluid around the ankle. Initially, this may cause only a sensation of heavy legs toward the end of the day, with no visible changes. Eventually, it may lead to venous ulcers or other visible changes. This abnormal blood flow results from dysfunction of the normal mechanisms that drain blood from the leg against gravity into the IVC.

Selected references

Alguire PC, Mathes BM. Clinical evaluation of lower extremity chronic venous disease. UpToDate. Last updated April 18, 2012. http://www.uptodate.com/contents/clinical-evaluation-of-lower-extremity-chronic-venous-disease?source=search_result&
search=Clinical+evaluation+of+lower+extremity+chronic+venous+disease&selectedTitle=1%7E150.  Accessed March 3, 2013.

Alguire PC, Mathes BM. Diagnostic evaluation of chronic venous insufficiency. UpToDate. Last updated May 7, 2012. www.uptodate.com/contents/diagnostic-evaluation-of-chronic-venous-insufficiency?source=search_result&search=Diagnostic+evaluation
+of+chronic+venous+insufficiency&selectedTitle=1%7E127. Accessed March 3, 2013.

Alguire PC, Mathes BM. Pathophysiology of chronic venous disease. UpToDate. Last updated April 12, 2012. www.uptodate.com/contents/pathophysiology-of-chronic-venous-disease?source=search_result&search=Pathophysiology+of+chronic+venous+disease
&selectedTitle=1%7E127. Accessed March 3, 2013.

Alguire PC, Scovell S. Overview and management of lower extremity chronic venous disease. UpToDate. Last updated June 27, 2012. www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?source=search_
result&search=Overview+and+management+of+lower+extremity+chronic+venous+disease&selectedTitle=1%7E150. Accessed March 3, 2013.

Moneta G. Classification of lower extremity chronic venous disorders. UpToDate. Last updated October 22, 2011. www.uptodate.com/contents/classification-of-lower-extremity-chronic-venous-disorders. Accessed March 3, 2013.

Sardina D. Skin and Wound Management Course; Seminar Workbook. Wound Care Education Institute; 2011:92-112.

Donald A. Wollheim is a practicing wound care physician in southeastern Wisconsin. He also is an instructor for Wound Care Education Institute and Madison College. He serves on the Editorial Board for Wound Care Advisor.