“Necessity is the mother of invention, and wound and ostomy nurses are experts at creating effective solutions to wounds that develop after exposure to urine or stool,” said Judith Fink, BSN, RN, CWON, a recent retiree from Bon Secours St. Mary’s Hospital, Richmond, VA.
“When our team was caring for a woman with an enterocutaneous fistula that drained copious amounts of effluent each day, we pooled our previous experiences to come up with an effective treatment plan,” Fink recalled.
“I was a home health nurse before coming to the hospital, and thought of a set-up that had worked well for one of my home care patients.”
Forming a Plan
The treatment plan began with a crusting technique that involved layering stoma adhesive powder and skin prep spray to form a base for a drainage system. “To collect the wound drainage so nurses weren’t changing the dressing every hour or two, we applied a wound manager, which is a pouch that adheres to the skin around the wound created by the fistula,” Fink described.
Wound managers come in small, medium and large sizes that can be customized to fit around the edge of any wound. “To capture the drainage from the wound, we attached corrugated tubing that’s typically used for nebulizer treatments,” Fink said. “We selected a large drainage bag, and connected that to the other end of the corrugated tubing.”
As the wound improved, the amount of drainage decreased and the team initiated negative pressure wound therapy using a vacuum device. The woman’s wound healed without complications.
Crusting
Tara Bohannon, MSN, RN, WOCN, and Barbara Twombly, BSN, RN, WCC, wound and ostomy nurses at Scripps Memorial Hospital, La Jolla, CA, have joined forces to come up with a highly effective way of healing wounds caused by incontinence. “I remember one patient who had severe diarrhea that made his backside look like raw hamburger,” Bohannon said. “We started with one product, but weren’t getting the results we needed because of the severity of the problem.”
They started a bowel management program using a rectal tube, and then tried a crusting technique developed at Emory University, Atlanta. “We sprinkled a very light coating of stoma adhesive powder on the wound, then sprayed on a coat of barrier film and let it dry,” Bohannon described. “We repeated these layers two or three times and then lathered the patient’s entire backside with a methanol/zinc oxide moisture barrier ointment.”
While barrier film doesn’t stick to excoriated skin, the crusting technique provides a foundation that it does adhere to. “The crusting procedure is now one of our top weapons for wounds caused by incontinence,” Bohannon said. “Staff love it because the crusted layer doesn’t have to be removed when there’s soiling, or during bathing. We also work closely with nutrition staff who can add fiber, acidophilus or probiotics to tube feeding formula to reduce the diarrhea, and collaborate with the hospitalist or intensivist as well.”
Collaboration Essential
Bohannon described the importance of collaboration between task forces as well. “We have a Hospital-Acquired Pressure Ulcer Task Force made up of wound and ostomy nurses, a physical therapist who is WOC-certified, a nutritionist, quality improvement experts and staff from the OR and ED,” she said.
“We recently focused on preventive measures to reduce wounds caused by incontinence, and found some issues conflicted with what our Catheter-Associated UTI Task Force was recommending. We met and came up with a cohesive plan to insert urinary catheters in patients with significant skin excoriation that are not responsive to other options.”
Hydrofiber
Felix Fonge, DVM, BSN, RN, a wound ostomy and continence nurse at Provena Mercy Medical Center, Aurora, IL, described how he made headway against a wound that was so bad it was literally unstageable. “A lady came into the ICU with hypertension caused by urinary sepsis, and ended up with profuse diarrhea that leaked around the rectal tube,” he recalled. “She was about 260 pounds, so there was a great deal of moisture and pressure that was interfering with good wound healing.”
Fonge worked with nursing colleagues to establish an effective turning and positioning schedule, and set up a wound care regimen based on hydrofiber, a high-purity cellulose product that’s increasingly popular among wound care professionals. Miconazole cream was also used for her contact dermatitis, as well as an air loose mattress.
“The wound itself was about 3 by 2.5 inches, very deep and constantly moist because of the woman’s marked edema,” he described. “The hydrofiber did a great job of absorbing the moisture, helping with the mechanical debridement and promoting tissue regeneration.”
By the time the woman was discharged, her wound had healed to the point that Fonge was able to identify it as a stage 3 decubitus and share his proven procedure with the nurses at the patient’s next facility.
Sandy Keefe is a frequent contributor to ADVANCE.
