Tag Archives: ostomy

Ostomy documentation tips

General characteristics

Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skin fold, umbilicus. (See Descriptor reference.)

Describe the type of ostomy:

colostomy (colon)—sigmoid or descending colostomy, transverse colostomy, loop colostomy, ascending colostomy

ileostomy (small bowel)—ileoanal reservoir (J-pouch), continent ileostomy (Kock pouch)

urostomy (bladder)—continent urostomy, Indiana pouch, orthotopic neobladder.

Document the presence and location of bowel sounds.

Stoma information

Note the type:

loop (two openings through one stoma)

end (one stoma)

double barrel (two distinct stomas).

Document the overall appearance (shiny, taut, edematous, dry, moist, pale, textured, smooth, bloody) and the presence of stents, rods, drains (include type and location).

Describe the color (red, beefy red, pink, pale pink, purple, blue, black) and shape (round, oval, budded).

Note the height:

flush—at skin level

prolapsed—telescoped out from the abdominal surface.

Document the size in millimeters:

Round stomas are measured by diameter.

Oval stomas are measured by widest length and width.

Describe the lumen:

location—straight up, side, level with skin, or centrally located

number of lumens, stenosis, or stricture.

Note: Document the location of the lumen by using the clock system, with the patient’s head at 12:00.

Describe the odor—presence or absence of odor, strong, foul, pungent, fecal, musty, sweet.

Note whether the stoma and peristomal skin junction is intact or separated.

Effluent

For a fecal stoma, describe the amount, consistency, and overall appearance of effluent— thick, viscous, liquid, pasty, oily, formed, soft, thin, tarry.

For a urinary diversion, describe urine characteristics, volume, presence of odor (musty, fishy, fecal, acid), color (clear, cloudy, amber, straw, colored, blood tinged), and presence of substances other than fluid (grit, crystals, mucous strands).

Peristomal skin

Describe the characteristics of peristomal skin—color, edema, firmness, intactness, induration, pallor, lesions, texture, scar, incision, rash, staining, moisture.

Assess a minimum of 2 inches out from around the stoma.

Appliance and accessories

Document the type of ostomy appliance and accessories. Include the pouching system product, size, and product number. Note the presence of a spout, the convexity, and whether it’s a one-piece or two-piece system,

Observe and document proper function and adhesion, and complications experienced with appliance systems. Document any modifications to the care plan, implementation of new orders, and referrals.

Other important information

Document pain—location, causative factors, intensity, quality, duration, alleviating factors, patterns, variations, interventions.

Note stoma or peristomal skin complications— mucocutaneous separation, stenosis, necrosis, bleeding, dermatitis, folliculitis, peristomal hernia, caput medusae, peristomal hyperplasia, pseudoverrucous lesions, allergic dermatitis, contact dermatitis, pouch leakage, infection.

Document patient and caregiver education— topics covered, level of understanding, and education materials distributed.

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.

Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), © 2016.

Clinical Notes, September 2016

Electrical stimulation and pressure ulcer healing in SCI patients

A systematic review of eight clinical trials of 517 patients with spinal cord injury (SCI) and at least one pressure ulcer indicates that electrical stimulation increases the healing rate of pressure ulcers. Wounds with electrodes overlaying the wound bed seem to have faster pressureulcer healing than wounds with electrodes placed on intact skin around the ulcer.

A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal cord injuries,” published in Ostomy Wound Managementstates that the overall quality of the studies was “moderate” and that future trials “are warranted.”

Effect of antiseptics on maggot viability

The short-term application of wound antiseptics on wound beds does not impair the viability of maggots, according to a study in International Wound Journal.

Viability of Lucilia sericata maggots after exposure to wound antiseptics” reports that the maggots can survive up to 1 hour of exposure to antiseptics, such as octenidine, povidone-iodine, or polyhexanide.

Global impact of diabetes underestimated

The prevalence of global diabetes has been seriously underestimated by at least 25%, according to a study published in Nature Reviews Endocrinology.

Diabetes mellitus statistics on prevalence and mortality: facts and fallacies” indicates that there may be more than 100 million people with diabetes globally than previously thought.

Axillary evaluation and lymphedema

A retrospective cohort study in Epidemiology reports that women with ductal carcinoma in situ who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit.

Axillary evaluation and lymphedema in women with ductal carcinoma in situ” included 10,504 women.

Topical insulin and pressure ulcers

A randomized, controlled trial to assess the effect of topical insulin versus normal saline in pressure ulcer healing” concludes that topical insulin is safe and effective in reducing the size of pressure ulcers compared to normal saline-soaked gauze.

Participants of the study, published in Ostomy Wound Management, received either normal saline dressing gauze or insulin dressing twice daily for 7 days. The insulin was sprayed over the wound surface with an insulin syringe, allowed to dry for 15 minutes, and then covered with sterile gauze.

Sexual function and ostomy

Sexual function and health-related quality of life in long-term rectal cancer survivors” reports that long-term sexual dysfunction is common in patients who have undergone surgery for rectal cancer, with more problems seen in patients who have a permanent ostomy.

The study, published in the Journal of Sexual Medicine, included 181 patients with an ostomy and 394 patients with anastomosis.

Effect of venous leg ulcers on body image

Many patients with venous leg ulcers have low self-esteem and negative feelings about their bodies, according to a prospective study published in Advances in Skin & Wound Care.

The impact of venous leg ulcers on body image and self-esteem” included 59 participants. The mean score on the Rosenberg Self-esteem Scale was 22.66, indicating low self-esteem.

Clinical Notes

Management of biofilm recommendations

The Journal of Wound Care has published Recommendations for the management of biofilm: a consensus document,” developed through the Italian Nursing Wound Healing Society.

The panel that created the document identified 10 interventions strongly recommended for clinical practice; however, panel members noted that, “there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence.”

Statins reduce CVD risk in patients with diabetes

Statins reduce the risk of cardiovascular disease (CVD) and death in patients with type 1 diabetes without a history of CVD, according to a study published in Diabetes Care.

Association between use of lipid-lowering therapy and cardiovascular diseases and death in individuals with type 1 diabetes” included more than 24,000 individuals from the Swedish National Diabetes Register who were followed for a mean of 6 years.

International diabetes organizations support bariatric surgery

Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations,” published in Diabetes Care, supports including metabolic (bariatric) surgery as a treatment option for people with type 2 diabetes who are obese. The statement notes when metabolic surgery is recommended and when it should be considered.

The 2nd Diabetes Surgery Summit was convened in collaboration with leading diabetes organizations to develop the guidelines. The multidisciplinary group included 48 international clinicians and scholars from leading diabetes associations; 75% were not surgeons. Draft conclusions were presented and opened to public comment. Following comment, they were amended.

Medicare-VHA dual use associated with poorer chronic wound healing

Veterans with chronic wounds who are enrolled in Medicare and access care through Medicare and the Veterans Health Affairs (VHA) experience poorer healing of chronic wounds, according to a study in Wound Repair and Regeneration.

Medicare-VHA dual use is associated with poorer chronic wound healing” was a retrospective study that followed 227 Medicare-enrolled individuals who used the VHA and who had a chronic lower limb wound. Individuals were followed until the wound was healed or up to 1 year.

“Dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use,” the study authors note. The risks of amputation or death were higher for dual users.

Sacral dressing may help prevent ulcers in ICU patients

Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients,” published in the American Journal of Critical Care, reports that the dressing reduced the number of sacral pressure ulcers in three ICUs by 3.4 to 7.6 per 1,000 patient days depending on the unit.

Data were collected for 7 months and compared to 7 months before the dressings were used, and patients were identified as high risk by using an evidencebased tool. The study authors note that heightened awareness by the care team and increased education also are key in preventing pressure ulcers.

Scale has limited ability to predict pressure ulcers

A study that evaluated the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) found that the scale could predict pressure ulcers occurring within 2 to 3 days after it was administered in acute care, but didn’t predict ulcer development over a longer term within acute or inpatient rehabilitation.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury,” published in NeuroRehabilitation, used retrospective analysis to determine the findings.

Braden Q and Glamorgan scales compared in children

The Journal of Tissue Viability has published A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units,” which found that both work  well in these settings.

The study authors note, however, that the Braden Q may be better at predicting risk in general pediatric units. More than 500 pediatric admissions were included in the study.

Axillary reverse mapping may reduce lymphedema

Researchers report that using axillary reverse mapping during surgery to help identify lymph nodes and vessels reduces the risk of lymphedema in patients undergoing sentinel lymph node biopsy and/or axillary node dissection.

A total of 654 patients participated in Does axillary reverse mapping prevent lymphedema after lymphadenectomy?,” published in Annals of Surgery.

Muslims and QOL after ostomy surgery

Muslims who undergo ostomy surgery experience significant reductions in health-related quality of life (QOL) — greater reductions than seen in non-Muslim patients, according to a study in Journal of Wound Care and Ostomy.

Quality of life after ostomy surgery in Muslim patients: a systematic review of the literature and suggestions for clinical practice” notes that factors associated with the difference include “psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices.”

Chronic venous insufficiency consensus statement

Circulation has published “Investigation of chronic venous insufficiency: a consensus statement,” which “provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations.”

Clinical Notes—May/June 2016

Moldable skin barrier effective for elderly patients with ostomy

A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.

The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.

Risk factors for severe hypoglycemia in older adults with diabetes identified

Risk factors associated with severe hypoglycemia in older adults with Type 1 diabetes” include glucose variability and greater lack of awareness of hypoglycemia.

Participants in the case-control, multi-center study, published in Diabetes Care, were age 60 or older and had a history of diabetes dating back 20 years or more.

Thermal imaging via smartphone helps detect inflammation

Early detection of inflammation in wounds promotes early treatment, and clinicians may have an additional assessment tool available to them. A recent study published in the Journal of Wound Care concludes the FLIR ONE, a thermography device that connects to a smartphone, can be successfully used to assess subclinical inflammation in patients with pressure ulcers and diabetic foot in clinical settings.

Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study” included 16 thermal images from eight patients and found good criterion-related validity and inter-rater reliability when the FLIR ONE results were compared to those from a handheld device. The findings may open the door to more thermal imaging assessment at the bedside.

Role of skin substitutes in treatment of diabetic foot ulcers analyzed

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers,” published in Wound Repair and Regeneration, concludes that skin substitutes “can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcer.”

The authors caution, however, that long-term effectiveness, including limb salvage and recurrence, is not known, and cost-effectiveness is not clear. The review included 17 randomized clinical trials, with a total of 1,655 patients.

Tap water safe alternative for wound cleaning

“Tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting,” concludes a study in the Journal of Wound, Ostomy and Continence Nursing.

Tap water versus sterile normal saline in wound swabbing: A double-blind randomized controlled trial” studied 22 people with 30 wounds. Half were in the tap water group and half in the sterile normal saline group. Researchers found no differences in the proportion of wound infection and healing between the two groups.

Review of skin grafting in patients with chronic leg ulcers

Autologous split-thickness skin grafting remains the gold standard in terms of safety and efficacy for chronic leg ulcers, according to a review article in International Wound Journal.

Skin grafting for the treatment of chronic leg ulcers—a systematic review in evidencebased medicine” also found that skin grafts are more successful in patients who have chronic venous leg ulcers, compared to other types. The researchers noted that skin tissue engineering is “rapidly expanding” and holds promise for better outcomes when treating patients with long-lasting chronic wounds.

C difficile may be risk factor for pouch failure after reconstruction

Patients with a history of preoperative Clostridium difficile colitis may be at higher risk for pouch failure after ileal pouchanal anastomosis reconstruction following total proctocolectomy for ulcerative colitis, according to a study in Inflammatory Bowel Disease.

The authors of “Clostridium difficile infection in ulcerative colitis: Can alteration of  the gut-associated microbiome contribute to pouch failure?” defined pouch failure as permanent ostomy diversion or pouch excision. Of 417 patients in the study, 28 (6.7%) developed pouch failure.

Lymphedema education lacking

Researchers of a study in the Journal of Cancer Education report that only 19.9% of 180 women with lymphedema after breast cancer surgery reported they had received education or information about the condition postoperatively.

The importance of awareness and education in patients with breast cancer-related lymphedema” also reports that, “The degree and duration of lymphedema were lower in patients who had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant.”

Color charts help improve pressure ulcer risk assessment

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development,” published in the Journal of Advanced Nursingconcludes that the color charts provide a “more objective measurement of skin tone than demographic categories.”

The researchers state that use of the charts can improve pressure ulcer risk assessment when current clinical guidelines are less effective.

Role of the ostomy specialist clinician in ileal pouch anal anastomosis surgery

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By Leanne Richbourg, MSN, RN, APRN-BC, CWON-AP, CCCN, GCNS-BC

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is the gold standard for surgical treatment of ulcerative colitis (UC) or familial adenomatous polyposis (FAP). It’s also done to treat colon and rectal cancers, such as those caused by Lynch syndrome (LS). IPAA allows the patient to maintain fecal continence and evacuate stool from the anus after colon and rectum removal. A temporary ileo­stomy may be part of the overall process, but there’s no need for a permanent stoma. (See Understanding ulcerative colitis, FAP, and Lynch syndrome.)

Understanding ulcerative colitis, FAP, and Lynch syndrome

Contraindications for IPAA include:

  • Crohn’s disease, which can recur at any point along the GI tract
  • incompetent anal sphincter tone (most common in older adults)
  • diseases of the distal rectum or anal canal.

Preoperative education

You can help improve your patient’s quality of life and health status by providing education about IPAA. When preparing the patient for surgery, explain the procedure and discuss how it will change GI tract anatomy. Because the patient is likely to have a stoma, describe what the stoma will look like, how to care for it, how to use pouches to contain stoma output, what lifestyle adjustments to expect, and psychological preparation.

Explain that by the 12th postoperative month, the patient’s physical and psychological health, independence level, and general overall quality of life is likely to improve significantly over preoperative levels. By 3 years, quality of life scores most likely will match those of the healthy population in terms of physical health, independence, spirituality, and environment. Psychological health and social relationships scores also typically improve, although not quite to the extent as the healthy population.

Surgical technique

Proctocolectomy with IPAA can be done as a one-, two- or three-stage procedure. (See Comparing types of proctocolectomies).

Comparing one-

Taking care to preserve the pelvic nerves, the surgeon creates a reservoir from 30 cm to 40 cm of distal ileum and connects it to the anal canal at or just above the dentate line (where columnar epithelium transitions to squamous epithelium). The most common pouch configuration is the two-limbed pouch, called the J-pouch.

Although two-stage surgery with a diverting loop ileostomy is the most common, a three-stage procedure is optimal for patients who are markedly debilitated by disease due to severe exacerbations, nutritional compromise, and high-dose steroid therapy. For those with indeterminate colitis and suspected Crohn’s disease, step one of the three-stage procedure allows for further testing before ileal pouch creation. The one-stage procedure without a diverting ileostomy is linked to increased risk of pouch leakage, pelvic infection, and subsequent pouch failure.

Proctocolectomy with IPAA may be performed through an open abdominal incision or a laparoscopic approach. Laparoscopic surgery takes an average of 80 minutes longer and requires more I.V. fluids. However, it’s associated with shorter hospital stays, shorter time to ostomy closure, shorter operating-room times, shorter stays for ostomy reversal surgery, less adhesion formation, and lower infertility rates. The two methods don’t differ in blood loss, need for postoperative opioids, return of bowel function, or hospital readmission rates. An open abdominal approach usually is done in patients with fulminant colitis or acute colitis complicated by colonic perforation or toxic megacolon.

Complications

During the first postoperative month, symptomatic portal-vein thrombosis occurs in up to 6% of patients; asymptomatic clots may arise in up to 40%. The cause is unknown but may relate to traction on the superior mesenteric vein when the small bowel moves down into the pelvis in patients with systemic inflammation from ulcerative colitis. Signs and symptoms may mimic those of an acute abdomen, including nausea, vomiting, fever, abdominal distention, and pain. Computed tomography is used to identify thrombi. Treatment involves 3 to 6 months of anticoagulation.

Postoperative management after ileostomy creation

Initially, your main role is to provide education about ileostomy self-care. Teach your patient how to apply, empty, and replace the ostomy pouch. (See Providing education to the new ostomate.)

Providing education

After surgery, high stool output from the diverting ileostomy is a common problem. Although definitions of high output differ somewhat, I tell patients that high output means more than 1,200 mL in 24 hours. This condition is most common within the first 2 to 3 postoperative weeks and usually resolves.

Readmission for dehydration typically occurs during the second postop week. To help prevent dehydration, instruct patients to drink eight to ten 8-oz glasses of fluid daily, preferably avoiding fruit juice, soft drinks containing sugar, caffeinated drinks, and alcohol.

Measuring stool output

Advise the patient to keep track of how much stool he or she is passing in 24 hours. I usually advise patients to empty the pouch when it’s one-third to one-half full, four to six times daily. This equates to about 1,200 mL of output. If the pouch requires more frequent emptying, the patient needs to quantify the output further.

I’ve found some discharged patients don’t comply with measuring stool output using a urinal or “potty hat.” So I give patients a photograph of three pouches containing colored water in quantities of 100 mL, 200 mL, and 300 mL. This helps them visually judge how much output is in the pouch. Antidiarrheal medications, such as loperamide, can be titrated to keep output within the normal range.

About 6 weeks after surgery, instruct the patient to practice pelvic floor muscle exercises three times daily, if the surgeon approves. This strengthens the muscles needed for fecal continence once the stoma is closed.

Postoperative management after ileostomy closure

After ileostomy closure, patients with an ileoanal pouch must begin training their new reservoir—a process that can take up to a year. Initially, they may have up to 20 small bowel movements daily and may need to get out of bed multiple times at night to pass stool. Eventually, this decreases to six bowel movements in 24 hours, including overnight. At 1 year postop, about 95% of patients who’ve had ileoanal pouch surgery report being very satisfied with their decision. For the remaining 5%, long-term functional results are poor.

To slowly increase pouch holding capacity, teach patients not to respond to every urge to move the bowels. Initially, advise them to wait 5 minutes after sitting on the toilet before responding. When that’s accomplished, tell them to increase the wait time by another 5 minutes, and then 10 minutes, and to continue increasing it in this manner. Also advise them to begin to move further and further away from the toilet during wait time. The goal is to gain confidence in the ability to withhold stool and avoid accidents.

Complications of ileal pouch surgery include pouchitis; pouch-anal anastomotic strictures; small-bowel obstruction; and intra-abdominal, peri-pouch, and anastomotic cuff abscesses. (See Understanding potential complications.)

Understanding potential complications

Perianal skin care

Stool leakage is common at first, along with trouble differentiating between flatus and stool. Teach patients how to perform meticulous perianal skin care. Tell them to wash the area thoroughly at least once daily using a pH-balanced skin cleanser and warm water. To clean up after each bowel movement, advise them to use alcohol-free moist wipes, which are less abrasive than toilet paper.

Encourage patients to protect perianal skin by applying an ointment containing petrolatum, dimethicone, or zinc oxide after each bowel movement. Alternatively, they may use an alcohol-free liquid skin-barrier film wipe once daily. Aloe vera gel is an effective treatment for skin irritation, providing antimicrobial action, reducing pain, and shortening healing times. Depending on leakage amounts, advise patients to protect underclothes with a panty liner or incontinence-containment product. Encourage them to continue regular pelvic floor muscle exercises, as strong muscles are crucial for preventing leakage.

Dietary guidelines

Advise patients to eat a low-fiber diet for about 4 weeks after ostomy closure, until bowel swelling resolves. Then instruct them to start increasing fiber intake until stools become firmer. Inform them that foods that can contribute to anal irritation include spicy foods and foods high in insoluble fiber, such as stringy fruits and vegetables (oranges, coleslaw, celery, corn, nuts, popcorn, coconut, and Chinese vegetables). Teach patients that stool with a thicker consistency is less likely to leak. (See Foods that thicken stool.)

Foods that thicken stool

When stool is thin and frequent, urge patients to eat potassium-rich foods, such as meat, banana, apricots, tomatoes, milk, and potatoes. Tell them they may need to add salt to their food to replace potassium and sodium lost through diarrhea and other fluid losses.

Explain that foods and beverages high in sugar or caffeine can worsen diarrhea. Tell patients to limit fruit juice, caffeinated tea and coffee, honey, candy, sugary and caffeinated soft drinks, chocolate, and baked goods high in sugar.

Teach patients to add 1 tsp of soluble fiber, such as psyllium husks (Metamucil), to 1 cup of fluid one or more times per day, titrated to maintain a more solid stool consistency. To prevent dehydration, encourage them to continue to drink eight to ten 8-oz cups of fluid daily.

For patients who continue to have large quantities of thin stool, recommend an antidiarrheal medication, such as loperamide (Imodium), if the surgeon permits. Instruct them to start with one 2-mg dose 30 minutes before breakfast, lunch, and dinner and another dose at bedtime. If this isn’t effective, tell them they may double the dose, not to exceed 16 mg per 24 hours. Know that some patients will have to stay on this medication for a long time.

You can improve patient outcomes

As the ostomy specialist clinician, your role is to assist patients along the continuum from illness to heath. Providing thorough patient education throughout this process is crucial to helping them achieve their ultimate goal of wellness.

Selected references

American Society of Clinical Oncology. Familial Adenomatous Polyposis. September 2015. cancer

.net/cancer-types/familial-adenomatous-polyposis

Bartels SA, D’Hoore A, Cuesta MA, et al. Significantly increased pregnancy rates after laparoscopic restorative proctocolectomy: a cross-sectional study. Ann Surg. 2012;256(6):1045-8.

Fajardo AD, Dharmarajan S, George V, et al. Laparoscopic versus open 2-stage ileal pouch: laparoscopic approach allows for faster restoration of intestinal continuity. J Am Coll Surg. 2010:211(3);377-83.

Gionchetti P, Calafiore A, Riso D, et al. The role of antibiotics and probiotics in pouchitis. Ann Gastroenterol. 2012;25(2):100-5.

Heikens JT, de Vries, J, Goos, MR, et al. Quality of life and health status before and after ileal pouch anal anastomosis for ulcerative colitis. Br J Surg. 2012;99(2);263-9.

Heikens JT, de Vries J, Goos MR et al. Evaluation of long-term function, complications, quality of life and health status after restorative proctocolectomy with ileo neo rectal and with ileal pouch anal anastomosis for ulcerative colitis. Colorectal Dis. 2013; 15(6);e323-9.

Hiranyakas A, Rather A, da Silva G, et al. Loop ileostomy closure after laparoscopic versus open surgery: is there a difference? Surg Endosc. 2013; 27(1):90-4.

Holubar SD, Cima RR, Sandborn WJ, et al. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2010;6;CD001176.

Hull TL, Joyce MR, Geisler DP, et al. Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Brit J Surg. 2012;99(2);270-5.

Larsen S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management. Ann Med. 2010;42(2):97-114.

National Cancer Institute. Genetics of Colorectal Cancer–for health professionals. Updated July 6, 2015. cancer.gov/types/colorectal/hp/colorectal-genetics-pdq/#link/_89

Psillos AI, Catanzaro J. Ileal pouch anal anastomosis: an overview of surgery, recovery, and achieving postsurgical continence. Ostomy Wound Manage. 011;57(12);22-8.

Sagar PM, Pemberton JH. Intraoperative, postoperative and reoperative problems with ileoanal pouches. Br J Surg. 2012;99(4):454-68.

Stocchi L. Laparoscopic surgery for ulcerative colitis. Clin Colon Rectal Surg. 2010;23(4):248-58.

Wound, Ostomy, and Continence Nurses Society (WOCN). Management of the Patient With a Fecal Ostomy: Best Practice Guideline for Clinicians. Mount Laurel, NJ: WOCN; 2010.

Leanne Richbourg is a wound and ostomy clinical nurse specialist at Duke University Hospital

in Durham, North Carolina.

Online Resources

A. https://www.youtube.com/watch?v=zDXS0QBGoKY

B. https://www.youtube.com/watch?v=F6pqpLRGneE

C. https://www.youtube.com/watch?v=JMApMBY0CfQ

D. https://www.youtube.com/watch?v=rEYzh8VKqEE

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Helping patients overcome ostomy challenges

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By Beth Hoffmire Heideman, MSN, RN

No one wants an ostomy, but sometimes it’s required to save a patient’s life. As ostomy specialists, our role is to assess and intervene for patients with a stoma or an ostomy to enhance their quality of life. We play an active role in helping patients perform self-care for their ostomy and adjust to it psychologically, starting even before surgery.

Preoperative considerations

Preparation for the ostomy is the most critical aspect of a healthy adjustment. When the ostomy is planned, the patient and family members are more likely to process the life changes it will entail. They can learn about anticipated postsurgical changes in the patient’s diet, clothing, and sexuality, and family members can become more sensitive to the change in their loved one.

Assessment

On initial assessment, evaluate your patient’s body configuration, stoma placement, skin integrity, physical limitations, psychological needs, and home caregiving system. Then develop a plan of care to mitigate problems that could impede the patient’s ability to maintain and manage the ostomy system.

The human body comes in many configurations and sizes. Because each person’s body is unique, clinicians may need to get creative to adapt the ostomy system to a patient’s body. Options for adapting it to your patient’s physical characteristics include using:

  • a one-piece vs. a two-piece system
  • a flexible flange, clear drape flange, or moldable flange.

Factors affecting decisions about an ostomy include its location, skin integrity, and physical ability. (See Decision guide for ostomy products.)

Location

The stoma may be located near an incision, under a peniculum, or in an abdominal fold. Ostomies in these areas can be hard to manage because of wound dressings, staples, adhesive strips, and body shape.

If the ostomy system is located next to an incision, you may want to adapt it by using stoma paste strips, moving the flange opening to the right or left, or using a pectin-ring stoma system without a flange. When the stoma is placed under a peniculum, pressure from the weight slows effluence (drainage) flow. To decrease pressure on the stoma and promote flow, an abdominal support binder can be used. (See Case study 1: Stoma location challenge.)

If the stoma is located in an abdominal fold, you can use a one-piece flexible ostomy system to increase adherence. When needed, add stoma paste strips and either medical adhesive spray or a bonding cement.

Skin integrity

Always consider skin integrity when choosing an ostomy system. Take into account the patient’s fragility from such factors as age, medications, an irregular abdominal plane from previous surgeries or scarring, moisture or oily skin that limits flange adherence, and comorbidities (such as psoriasis, fungal infections, and ulcers). Options for maintaining skin and ostomy-system integrity include use of crusting, silicone flanges, stoma paste strips, or topical medication covered with hydrocolloid or extended-wear products.

Physical abilities

Be aware that a patient with limited muscle function may have limited gross and fine motor skills, which makes self-care a challenge. Expect patients with such conditions as multiple sclerosis and muscular dystrophy to have limited strength. Those with amyotrophic lateral sclerosis, Parkinson’s disease, or stroke are likely to have limited muscle control. In each case, rehabilitation support and physical or occupational therapy can help the patient learn how to adapt to the stoma.

Psychological adjustment

Hidden issues can make it hard for patients to adjust to the ostomy system. The patient who undergoes an unplanned ostomy has to relearn life skills while grieving the change in self-image and dealing with a sense of having an imperfect body, loss of control, or feeling like an infant. To this patient, the ostomy system may become the enemy, so to speak. The patient may refuse to learn about self-care and ignore ostomy complications. To help patients regain a sense of control, clinicians must address body image with them and provide education.

The following interventions can help the patient focus on the positive:

    • Suggest that the patient keep a diary of daily activities.
    • Listen actively as the patient expresses thoughts and feelings.
    • Confront false ideations, such as “I’m a baby now,” “No one will ever touch me again,” or “I smell” with such positive statements as “I’m still an adult,” “My wife loves me,” or “I can use deodorizers to make sure the ostomy doesn’t smell.”
    • Recommend ostomy support groups or spiritual or psychological counseling.

Mental illness

Mental illness also can cause ostomy management problems. Mentally ill patients may respond differently to an ostomy than other patients, leading to lack of proper ostomy self-care. If mental illness goes unrecognized and unaddressed, the stoma or peristomal skin may become damaged.

As a wound care clinician, be sure to carefully review reports of unresolving ostomy malfunction issues, note their frequency, and observe malfunction patterns. When these malfunctions occur consistently, assess the patient for mental illness and provide a referral to appropriate support services. (See Case study 2: Effect of psychological distress on ostomy care.)

Depressed patients may avoid the stoma or ostomy system. They may fail to apply the system or, conversely, leave it on for extended periods to avoid thinking about the body-image change it represents. On the other hand, highly anxious patients may be hypervigilant and remove the ostomy system frequently to check on the stoma. In patients with either depression or high anxiety, the stoma and peristomal skin may break down.

Bipolar patients may have difficulty learning about self-care because of their high or low affect. They should receive care from a mental health specialist, along with appropriate medications, to support their ability to learn and adjust to the ostomy.

Unmedicated schizophrenic patients may have trouble processing the presence of a stoma. They may perceive the stoma or ostomy system as alien and attack it, injuring themselves or damaging the stoma or peristomal skin. This response demands careful mental health observation and medication monitoring to prevent further bodily harm.

Home caregivers’ behavior

The patient’s home caregivers also may be a hidden cause of ostomy system problems. They may be unable to accept the change in their loved one, and their negative reactions may result in the patient’s failure to perform self-care. This lack of self-care reflects the patient’s distress. Observe carefully for disharmony among caregivers and address any issues. Through active listening or referral to a support group or counseling, you can help ease negative behaviors.

Financial constraints

If because of complications, your patient needs additional ostomy supplies beyond what the insurance company allows:

      • Ask the physician to write a letter of medical necessity to the insurance company and vendor that explains the reason for product overage.
      • Contact the ostomy supply vendor to request free samples.
      • Contact ostomy support group members, who may be able to provide samples.

Overcoming adversity

A patient with a malfunctioning ostomy system or a maladaptive response to it can pose a challenge for the ostomy management specialist or the wound, ostomy, and continence nurse. But with careful planning, monitoring, and creativity, such challenges can be overcome so the patient can have the highest possible quality of life.

Selected references

Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Johnson RJ. Finding Health: A Search for Wellness and Longevity. CreateSpace Independent Publishing Platform; 2011.

Shulman L. Brooks/Cole Empowerment Series: The Skills of Helping Individuals, Families, Groups, and Communities. 7th ed. Brooks/Cole Cengage Learning; 2009.

Taylor SG, Renpenning K. Self-Care Science, Nursing Theory and Evidence-Based Practice. Springer Publishing; 2011.

Townsend MC. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. 8th ed. Philadelphia, PA: F.A. Davis; 2105.

Wound, Ostomy and Continence Nurses Society (WOCN). Colostomy and Ileostomy Products and Tips: Best Practice for Clinicians. Mt. Laurel, NJ: WOCN; 2013.

Wound, Ostomy and Continence Nurses Society (WOCN). Peristomal Skin Complications: Best Practice for Clinicians. Mt Laurel, NJ: WOCN; 2007.

Wound, Ostomy and Continence Nurses Society (WOCN). Stoma Complications: Best Practice for Clinicians. Mt. Laurel, NJ: WOCN; 2014.

Beth Hoffmire Heideman is a wound care nurse at McAuley Seton Home Care in Cheektowaga, New York.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clinical Notes

Diabetes carries high economic burden

According to a study published in Diabetes Care, the economic burden associated with diagnosed diabetes (all ages) and undiagnosed diabetes, gestational diabetes, and prediabetes (adults) exceeded $322 billion in 2012, amounting to an economic burden exceeding $1,000 for each American.

The authors of “The economic burden of elevated blood glucose levels in 2012: Diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes” note that the $322 billion number, which comprises $244 billion in excess medical costs and $78 billion in decreased productivity, is 48% higher than the $218 billion estimate for 2007.

Review article on lymphedema published

Recent progress in the treatment and prevention of cancer-related lymphedema,” published in CA: A Cancer Journal for Clinicians, reviews recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema, including breast cancer and other cancer types—melanoma, gynecologic, genitourinary, and head and neck.

The article also discusses the issue of insufficient insurance coverage for the diagnosis and treatment of lymphedema. The authors emphasize the importance of early identification of the condition and early referral.

Preventing breast cancer

Risk determination and prevention of breast cancer,” published in Breast Cancer Research, estimates that half of breast cancers might be prevented in women at high and moderate risk by using chemoprevention (tamoxifen, raloxifene, exemestane, and anastrozole). For all women, lifestyle measures, including weight control, exercise, and moderating alcohol intake, could reduce breast cancer risk by about 30%.

Ostomy can hinder goal attainment in cancer patients

Changes in cancer patients’ personal goals in the first 6 months after diagnosis: The role of illness variables,” in Supportive Care in Cancer, notes that overall, patients reported a “decrease in illness-related hindrance, higher attainability and likelihood of success, a decrease in total number of goals, goals with a shorter temporal range, and more physical and fewer social goals.”

However, patients with more advanced stages of cancer, rectal cancer, or a stoma and receiving additional chemotherapy or radiotherapy reported more difficulty attaining their goals because of their illness. Only patients with a stoma reported “lower attainability, likelihood of success, and more short-term goals.”

Device to prevent parastomal hernia studied

In “A promising new device for the prevention of parastomal hernia,” in Surgical In­novations, researchers from Switzerland report their experience with a new stoma­plasty ring (KORING) that they invented. The ring, which has been used only once, is intended to prevent parastomal hernias.

CDC releases guideline on preventing HIV transmission from those with HIV

The Centers for Disease Control and Prevention (CDC) has released “Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014.” The guideline includes recommendations about biomedical, behavioral, and structural interventions that can help reduce the risk of human immunodeficiency virus (HIV) transmission from persons with HIV by reducing their infectiousness and their risk of exposing others to HIV.

Rate of rising healthcare costs slows

The Centers for Medicare & Medicaid Services reports U.S. healthcare spending in 2013 increased 3.6% to $2.9 trillion, or $9,255 per person. “National health spending in 2013: Growth slows, remains in step with the overall economy,” published in Health Affairs, notes that spending slowed by an 0.05 percentage point, compared with 2012. Health care has been 17.4% of the gross national product since 2009.

The slower growth is consistent with slower growth in private health insurance and Medicare spending. Other reasons include slower growth in spending for hospital care, investments in medical structures and equipment, and spending for physician and clinical care.

Low-glycemic index diet doesn’t improve cardiovascular risk factors

Overweight and obese persons who eat a diet that has a low glycemic index of carbohydrate don’t have improvements in insulin sensitivity, lipid levels, or systolic blood pressure, according to a study in JAMA.

Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity” concludes that “using glycemic index to select specific foods may not improve cardiovascular risk factors or insulin resistance.”

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Make your patient-teaching idea a patented reality

By Joy Hooper, BSN, RN, CWOCN, OMS

Have you ever had an idea for improving patient care that you wanted to market? You may have lacked confidence or know-how, as I once did. But one patient, a crafty idea, and a trip to Walmart put me on the path to becoming a successful nurse entrepreneur.

A challenging patient

Several years ago while employed as an ostomy nurse in an acute-care hospital, I worked with a challenging patient who changed my career path. It was my job to teach patients and willing family members how to manage the new ostomy. This particular patient was distraught about having an ileostomy and a new diagnosis of end-stage renal disease, so was not ready to learn the skills I needed to teach him.

I wished I had a visual teaching tool to use as I explained his surgery. The problem was I couldn’t find any such tool. I searched endlessly online and in every educational resource I could find, but came up empty-handed.

Push came to shove, as they say, on a Friday afternoon when the patient not so politely asked me to leave his room. He told me in a not-so-kind tone, “I don’t want to hear anything about this ostomy thing. Thanks but no thanks.”

I had no choice but to try and make my own teaching tool; I knew what I wanted—a teaching tool that would help me explain how the GI tract functioned before ostomy surgery. I wanted to be able to explain the different parts and their function in practical terms, such as, “This is the small intestine; it eats for you by absorbing the nutrients from the food you eat” and “This is the large intestine; it drinks for you by absorbing the liquid as it passes through” so patients would understand how the surgical changes would alter their digestive process.

I also wanted to be able to explain how the surgery was done and to show the end result—a stoma on the abdomen. I wanted it realistically proportioned to the adult human body so the patient would have a practical point of reference to his or her body.

Inspiration strikes

Over the weekend, as I was thinking of how I could make the teaching tool, I decided to bake a batch of cookies to get my creative juices flowing. As I put on my apron, an old-fashioned, full-length hand-me-down from my aunt, it hit me: I could make an apron with the GI tract on it! I remember taking off the apron and telling my husband, “No cookies today; I’m headed to Walmart.”

After buying a craft apron, red felt, and some glue, I returned home and started designing a GI tract on the front of the apron. I cut the bottom off the apron and used the fabric to create two small flaps to simulate the front of the abdomen. Since I could only sew a straight stitch, I asked my mother to sew a couple of buttonholes on the front of the apron. I designed the apron so that I could explain a colostomy and an ileostomy. When it was finished, I had the teaching tool I had envisioned.

Introducing the tool

I took the apron to work the next day and used it with my patient who had asked me to leave his room only days before. I walked in his room wearing the apron and explained the digestive process, never giving him a chance to stop me. I was speaking so fast and with so much excitement that he just lay there, eyes wide open, staring at my white apron with the bright red GI tract.

I finished explaining the digestive process and was launching into how stoma surgery was preformed when he slowly began to sit up. By midway through, he was sitting upright on the side of the bed and I realized I had 100% of his attention. He listened intently as I
explained how his GI tract had been changed and how his large intestine was no longer able to “drink for him” as it had done before. When I had completed my explanation of his surgery, I asked if he had any questions. He pointed to my apron and asked, “Yes, did you make that thing?” I replied “Yes, I made this just for you.” His response was, “Well, you need to patent that because you sure just taught me something.”

I used the apron with several patients and family members before I had the courage to show it to other healthcare professionals. My nurse colleagues said, “You need to patent that.” I had no idea how to patent something, so I always just laughed off the thought. Then one day a surgeon came into a patient’s room while I was using the apron to teach. After I finished, he followed me out of the room to tell me what a great idea the apron was and that he had never seen anything like it. He encouraged me to develop the design further, then make and distribute the aprons so others could benefit from them as well.

On the patent path

I was excited but still lacked the courage to move forward. Then a few months later I ran into my WOCN instructor at a regional conference and told her about the apron and how much it was helping me to teach anxious patients. With a big smile she said, “Bring it up and show it to me.” Within a few weeks I visited her, apron in hand. Her response was to tell me to keep the project confidential until I had applied for a U.S. patent number to protect my idea and design. (For more information about patents, go to the United States Patent and Trademark Office.)

I worked and reworked the apron design several times and, with the help of a creative friend, decided on a final version. (See Anatomical Apron.)

I didn’t know anything about obtaining a patent but luckily I was surrounded by friends and family who encouraged me to learn the process. Through friends, I connected with two people in my town who owned patents on products they had developed. One patent was for a closure on a tracheostomy collar and the other patent was for templates for football plays. I spoke to the men about how they had obtained their patents. Both gave me leads on patent attorneys, also known as intellectual property attorneys. It turned out the patent attorneys had retired, but the contacts led me to two intellectual property attorney groups. I spoke with attorneys from both firms about my design and had an immediate connection with one of them.

I worked with the attorney on diagrams and descriptions of my apron and how it was constructed. It took months before we were able to file. We filed for the patent in October 2004. I thought since it was the only thing like it in the world I would go through without a problem. Little did I know I was beginning a 4-year-long journey to reach my goal.

Persistence pays

While the attorney was working on the patent, I started looking for a manufacturer for the aprons. Locating sewing manufacturers is difficult because many textiles are made outside the United States. Fortunately, I found a manufacturer 30 miles from my home.

The attorney filed the patent three times over the next 4 years before it was approved. I attribute the approval to a YouTube video I had posted using the apron to explain colostomy surgery. My patent had been denied twice before because the patent reviewer saw the openings on the abdominal flaps as buttonholes, which they are. I needed him to see them as openings into the abdomen. While on a three-way phone call with my patent attorney, the patent reviewer, and me, the reviewer watched my YouTube video. The video brought the apron to life, and he no longer saw the buttonholes as simple buttonholes. The reviewer agreed to grant my patent.

My attorney patented not only the apron but also the method I use to explain the surgery. This means that anyone who makes an apron duplicating mine and uses it the same way I use mine to teach the surgical process is infringing on my patent claims and risks prosecution.

Success!

I now sell my Anatomical Apron via the Internet all over the world from my website, www.apronsbyjoy.com. Ostomy nursing is not only my passion; I feel it is my calling and enjoy every minute I spend teaching how the surgery changes the body.

Joy Hooper is owner and manager of MedicalCraft, LLC, in Tifton, Georgia.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

A Saudi rehabilitation facility fights pressure ulcers

By Joanne Aspiras Jovero, BSEd, BSN, RN; Hussam Al-Nusair, MSc Critical Care, ANP, RN; and Marilou Manarang, BSN, RN

A common problem in long-term care facilities, pressure ulcers are linked to prolonged hospitalization, pain, social isolation, sepsis, and death. This article explains how a Middle East rehabilitation facility battles pressure ulcers with the latest evidence-based practices, continual staff education, and policy and procedure updates. Sultan Bin Abdulaziz Humanitarian City (SBAHC) in Riyadh, Saudi Arabia, uses an interdisciplinary approach to address pressure-ulcer prevention and management. This article describes the programs, strategies, and preventive measures that have reduced pressure-ulcer incidence.

Committed to excellence

With 409 beds, SBAHC is the largest rehabilitation facility in the Middle East; it treats both inpatients and outpatients. Therapeutic, supportive, and educational services are designed to restore patients’ health and function after acute illness and promote their safe return to the home and community. SBAHC admits adult and pediatric patients who have suffered brain injuries, spinal-cord injuries (SCIs), stroke, and limb loss. The facility also offers other services (such as prosthetics, orthotics, and wound care) at clinics that operate 5 days a week.

SBAHC launched its wound care service in late 2007, with the mission of becoming a center for wound care excellence. To prevent and manage pressure ulcers, it uses guidelines from the National Pressure Ulcer Advisory Panel (NPUAP) (www.npuap.org) and the European National Pressure Ulcer Panel. From the onset, the SBAHC administration has fully supported efforts to eradicate pressure ulcers. It has a well-defined process, studied thoroughly and approved by an interdisciplinary team, for identifying, preventing, and managing pressure ulcers.

Initial evaluation

Before admission, patients are screened with special attention to their rehabilitation potential. (Patients who need acute medical care are transferred to an acute-care facility.) Those admitted with community-acquired pressure ulcers are distinguished from those with hospital-acquired pressure ulcers (HAPUs). Within 2 to 6 hours of admission, all patients undergo a comprehensive, front-to-back and head-to-toe skin assessment to check for wounds. Within 24 hours, a pressure ulcer or other wound must be documented; pressure ulcers found later than 24 hours after admission are considered HAPUs.

Also on admission, patients undergo a risk assessment using the Braden scale, a standardized assessment tool for evaluating pressure-ulcer risk. Early identification of at-risk patients is crucial for early implementation of preventive measures and to establish a baseline for later comparison, as when patients sustain new wounds in the facility. The Braden score corresponds to a prevention protocol that varies with the patient’s risk level. A change in the patient’s condition calls for reevaluation with the Braden scale. All direct-care staff are involved in the process and take an active role in the protocol. Pressure ulcers of all stages are referred to the wound care specialist, who in turn may refer the patient to the consultant surgeon, if needed.

Pink clover status

A communication process alerts all SBAHC care providers that a patient has developed a pressure ulcer or is at increased risk. A rotating pink clover icon (chosen to symbolize that healthy skin is pink and that the patient requires repositioning and checking of the skin) is activated for patients with Braden scores of 18 or below. This alert icon appears across the patient’s name and medical-record number in the electronic system, signaling caregivers to use caution because certain types of care or other activities may cause or exacerbate existing pressure ulcers in at-risk patients.

Campaign to lower HAPU rates

The alarming rate of pressure ulcers impelled the SBAHC wound care team to
review and revise existing preventive measures, develop new policies and procedures (which are reviewed annually and revised every 3 years or as necessary), and fine-tune its prevention and management protocols. HAPU incidence became an internal quality indicator. In 2012, an initiative was implemented to reduce HAPU incidence to less than 1% of the monthly total average census. The project had three goals:

  • to educate at least 80% of all direct-care staff (including nursing, medical, and rehabilitation staff) on pressure-ulcer identification and prevention
  • to reduce pressure-ulcer incidence in patients with SCIs to less than 27% of the total incidence (monthly report trends and data from other hospitals worldwide indicate most pressure ulcers occur in SCI patients)
  • to reduce the number of pressure ulcers in patients permitted to go on therapeutic-leave pass to 50% or fewer monthly, within 1 year.

The HAPU prevention team took on the challenge of lowering the incidence. At monthly meetings, staff receive updates on issues related to pressure ulcers. The team addresses these issues, identifies factors that contribute to pressure ulcers, discusses updated evidence-based practices in areas that may need improvement, and provides input on implementation with team members’ consensus.

By the end of 2012, about 82% of direct-care staff had received education. From 2011 to 2012, pressure-ulcer incidence in SCI patients dropped significantly to 18.6%. Also that year, no pressure ulcers were reported in patients who had therapeutic-leave passes. Overall, the project has achieved its goals. Average HAPU incidence for 2012 was 1.8%. Incidence for 2013 was 1.05%—a 41.6% decrease.

Because a lower HAPU incidence reflects a facility’s high standards of care, these initiatives have placed SBAHC’s quality of care in the spotlight. In published data, HAPU rates in long-term care facilities range from 2.2% to 23.9%. At SBAHC, the goal is a rate below 1%.

Pressure-ulcer surveys

Monthly HAPU incidence reports are compiled for monitoring and reference. The
facility also conducts a quarterly point-prevalence survey. The survey measures the proportion of individuals in a defined population who have a pressure ulcer at a given time, such as a particular date.

For the second year, a hospital-wide prevalence survey was conducted simultaneously in all in-patient units, with a thorough skin check of all patients admitted on a designated day. Total prevalence included all patients with preexisting pressure ulcers and those with HAPUs. (However, not all patients could participate. Some were in therapy sessions or undergoing procedures outside the unit; others simply refused to be assessed.) Inter-rater reliability testing using kappa statistics has been adopted and results are submitted quarterly, with the goal of comparing reliability of pressure-ulcer identification by the nursing and medical staff to that of SBAHC wound care specialists.

Staff training and testing

As part of our continual staff education on pressure ulcers, all newly hired direct-care staff receive initial training and competency testing in wound care procedures. Topics include frequency of skin inspections and reinspection in patients at risk for pressure ulcers, use and implementation of pressure-ulcer prevention plans and protocols, identification of pressure-ulcer stages based on NPUAP guidelines, and completion of the comprehensive wound-assessment tool. Annual competency checks are done for staff who have been with SBAHC for more than 1 year to ensure their current practice is evidence-based and doesn’t deviate from standards. Nursing staff (including nurses’ aides) re­ceive weekly wound care education sessions, with greater emphasis on pressure-ulcer prevention and identification. Physicians and rehabilitation staff are educated in separate sessions. The goal is to ensure that at least 80% of all direct-care staff receive education aimed at reducing or eliminating pressure ulcers.

Expanding the wound care service

Currently, the wound care unit at SBAHC has four beds and admits patients with stage 3 or 4 pressure ulcers or unstageable ulcers who have rehabilitation potential. The goal is to treat patients capable of sustaining an optimal functioning level after their debilitating pressure ulcers heal. Later, the service will expand to up to 11 beds, with patient stays of at least 6 weeks.

The first patient admitted to the service had a stage 4 pressure ulcer on the right trochanter; after 1 month of wound management, he was discharged with the ulcer healed and was able to participate in intensive rehabilitation sessions. Other patients have been admitted with multiple and more severe pressure ulcers; their wounds have improved significantly. (See Photos tell the story.)

Some patients’ wounds aren’t totally healed at discharge because of expired fund­ing, noncompliance with management, or refusal to cooperate. They are advised to return to the wound care clinic to ensure continuity of care. SBAHC plans to implement benchmarking to compare its performance against that of other facilities and help gauge the success of its pressure-ulcer practices.

100 Days campaign

Around the same time SBAHC opened its wound care unit, the hospital launched the “100 Days—100% HAPU Free” Campaign. The goal was to reach zero HAPUs in all hospital units for 100 days and to empower all healthcare providers in all disciplines to use effective pressure-ulcer prevention strategies. This campaign was the first of its kind in the Middle East. Spearheaded by the SBAHC wound care team, the campaign spotlights our facility as a role model for evidence-based, innovative wound care.

The authors work at Sultan Bin Abdulaziz Humanitarian City in Riyadh, Saudi Arabia. Joanne Aspiras Jovero is a wound and stoma care specialist and educator. Hussam Al-Nusair is director of nursing. Marilou Manarang is a senior wound and stoma care specialist and educator.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Guidelines for safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC

Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria.

Every day, countless healthcare providers apply NPWT devices during patient care. More than 25 FDA Class II approved NPWT devices are available commercially. If used safely in conjunction with a comprehensive wound treatment program, NPWT supports wound healing. But improper use may cause harm to patients. (See Risk factors and contraindications for NPWT.)

Lawsuits involving NPWT are increasing. The chance of error rises when inexperienced caregivers use NPWT. Simply applying an NPWT dressing without critically thinking your way through the process or understanding contraindications for and potential complications of NPWT may put your patients at risk and increase your exposure to litigation.

Proper patient selection, appropriate dressing material, correct device settings, frequent patient monitoring, and closely managed care help minimize risks. So before you flip the switch to initiate NPWT, read on to learn how you can use NPWT safely.

Understand the equipment and its use

Consult your facility’s NPWT protocols, policies, and procedures. If your facility lacks these, consult the device manufacturer’s guidelines and review NPWT indications, contraindications, and how to recognize and manage potential complications. Ideally, facilities should establish training programs to evaluate clinicians’ skills. Enhanced training should include comprehension of training materials, troubleshooting, and correct operation of the device, as shown by return demonstration of the specific NPWT device used in the facility.

Assess the patient thoroughly

The prescribing provider is responsible for ensuring patients are assessed thoroughly to confirm they’re appropriate NPWT candidates. Aspects to consider include comorbidities, contraindicated wound types, high-risk conditions, bleeding disorders, nutritional status, medications that prolong bleeding, and relevant laboratory values. The pain management plan also should be evaluated and addressed.

Assess the order

Before NPWT begins, make sure you have a proper written order. The order should specify:

  • wound filling material (foam or gauze dressing and any wound adjunct, such as a protective nonadherent, petrolatum, or silver dressing)
  • negative pressure setting (from -20 to-200 mm Hg)
  • therapy setting (continuous, intermittent, or variable)
  • frequency of dressing changes.

Follow all parts of the order as prescribed. Otherwise, you may be held responsible if a complication arises—for example, if you apply a nonadherent dressing when none is ordered and this dressing becomes retained, requiring surgery for removal; or if you set a default pressure when none is ordered and the patient suffers severe bleeding or fistula formation as a result.

Assess the wound

If you know what your patient’s wound needs, you can take proactive measures. What is the wound “telling” you? With adept assessment, you can become a “wound whisperer”—a clinician who understands wound-healing dynamics and can interpret what the wound is “saying.” This allows you to see the wound as a whole rather than just maintaining it as a “hole.”

  • If the wound tells you it’s too wet, take steps to absorb fluid or consider increasing negative pressure, as ordered.
  • If it’s telling you it’s dry, consider decreasing negative pressure, as ordered. If the wound bed remains dry, you might want to take a NPWT “time out”. Apply a moisture dressing for several days and assess the patient’s hydration status before restarting NPWT.
  • If the wound says it’s moist, maintain the negative pressure.
  • If it tells you it’s infected, treat the infection.
  • If it tells you it’s dirty, debride it.
  • If it says it’s malnourished, feed it.

The DIM approach

To establish a baseline evaluation, develop a systematic approach for assessing
the wound before NPWT. This will help optimize wound-bed preparation, enhance NPWT efficacy, and prevent delayed wound healing. (See Assessing with DIM.)

Take a time-out
Before you apply the NPWT dressing, be a STARStop, Think, Act, and Review your action. This time-out allows you to critically think your way through the application process and consider potential consequences of your actions.

Ongoing patient assessment and monitoring

Follow these guidelines to help ensure safe and effective NPWT:

  • Follow the device manufacturer’s instructions and your facility’s NPWT protocol, policy, and procedures.
  • Identify and eliminate factors that can impede wound healing (poor nutritional status, limited oxygen supply, poor circulation, diabetes, smoking, obesity, foreign bodies, infection, and low blood counts).
  • Evaluate the patient’s nutritional status to ensure protein stores are adequate for healing.
  • Assess and manage the patient’s pain accordingly.
  • Protect the periwound from direct contact with foam or gauze.
  • Prevent stretching or pulling of the transparent drape to secure the seal and avoid shear trauma to surrounding tissue.
  • Prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes.
  • Use protective barriers, such as multiple layers of nonadherent or petrolatum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
  • Don’t overpack the wound too tightly with foam. Compressing the foam prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
  • Position drainage tubing to avoid bony prominences, skinfolds, creases, and weight-bearing surfaces. Otherwise, a drainage tubing related pressure wound may develop.
  • Bridge posterior wounds to the lateral or anterior surface to minimize drainage tubing related pressure wounds to the surrounding tissue.
  • Count and document all pieces of foam, gauze, or adjunctive materials on the outer dressing and in the medical record, to help prevent retention of materials in the wound.
  • Ensure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure at the time of initial patient assessment and when rounding.
  • Address and resolve alarm issues. If you can’t resolve these issues and the device needs to be turned off, don’t let it stay off more than 2 hours. While the device is off, apply a moist-to-dry dressing.
  • With a heavily colonized or infected wound, consider changing the dressing every 12 to 24 hours.
  • Monitor the patient frequently for signs and symptoms of complications.

Evaluate patient comprehension of teaching

A proactive approach to education can ease the patient’s anxiety about NPWT. Unfamiliar sounds and alarms may heighten anxiety and cause unwarranted concerns, so inform patients in advance that the device may make noise and cause some discomfort. An educated and empowered patient can participate actively in treatment. Improved communication may enhance outcomes and help identify errors in technique before they cause complications.

Be prepared to answer patients’ questions, which may include:

  • Am I using the device correctly?
  • How long will I have to use it?
  • What serious complications could occur?
  • What should I do if a complication occurs? Whom should I contact?
  • How do I recognize bleeding?
  • How do I recognize a serious infection?
  • How do I tell if the wound’s condition is worsening?
  • Do I need to stop taking aspirin or other medicines that affect my bleeding system or platelet function? What are the possible risks of stopping or avoiding these medicines?
  • Can you give me written patient instructions or tell me where I can find them?

View: Patient Education

Be a STAR

To avoid patient harm and potential litigation, be a STAR and a wound whisperer. If you’re in doubt about potential complications of NPWT or how to assess and monitor patients, stop the therapy and seek expert guidance. “Listen” to the wound and assess your patient. This may take a little time, but remember—monitoring NPWT, the wound, and the patient is an ongoing process. You can’t rush it. Sometimes, to go fast, you need to go slowly.

Access more information about NPWT.

Selected references
Agency for Healthcare Research and Quality. Technology Assessment: Negative Pressure Wound Therapy Devices. Original: May 26, 2009; corrected November 12, 2009. Available online at: www.ahrq.gov/research/findings/ta/negative-pressure-wound-
therapy/negative-pressure-wound-therapy.pd
f. Accessed January 30, 2014.

Daeschlein G. Antimicrobial and antiseptic strategies in wound management. Int Wound J. 2013; 10(Suppl 1):9-14.

Food and Drug Administration. Guidance for Industry and FDA Staff—Class II Special Controls Guidance Document: Non-powered Suction Apparatus Device Intended for Negative Pressure Wound Therapy. November 10, 2010. Available at: www.fda.gov/MedicalDevices/DeviceRegulationand
Guidance/GuidanceDocuments/ucm233275.htm
. Accessed January 30, 2014.

Food and Drug Administration. FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. November 13, 2009. Available at: www
.fda.gov/MedicalDevices/Safety/AlertsandNotices/
PublicHealthNotifications/ucm190658.htm
. Accessed January 30, 2014.

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems. February 24, 2011. Available at: /www.fda.gov/MedicalDevices/Safety/
AlertsandNotices/ucm244211.htm
. Accessed January 30, 2014.

Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers—a consensus
paper from the International Expert Wound Care Advisory Panel©. Adv Skin Wound Care. 2010;23(11):493-507.

Improving the Safety of Negative-Pressure Wound Therapy. Pa Patient Saf Advis. 2011;8(1):18-25. Available at: http://patientsafetyauthority.org/
ADVISORIES/AdvisoryLibrary/2011/mar8(1)/Pages/18.aspx
. Accessed January 29, 2014.

Krasner D. Why is litigation related to negative pressure wound therapy (NPWT) on the rise? Wound Source. Posted November 11, 2010. Available at: www.woundsource.com/article/why-litigation-related-negative-pressure-wound-therapy-npwt-rise. Accessed January 30, 2014.

Lansdown AB. A pharmacological and toxicological profile of silver as an antimicrobial agent in medical devices. Adv Pharmacol Sci. 2010; Article ID 910686. Available at: www.hindawi.com/journals/aps/2010/910686/

Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-9.

RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: An update©. Adv Skin Wound Care. 2011;24(9):415–36.

Sibbald RG, Woo KY, Ayello EA. Clinical Practice Report Card: A Survey of Wound Care Practices in the U.S.A. Ostomy Wound Manage. April 2009 Suppl:12-22.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Institute of the Cleveland Clinic in Cleveland, Ohio.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.