1 THE ET NURSE CLINICAL ROLE
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1 1 THE ET NURSE CLINICAL ROLE 1ai THEORY: STOMAS & CONTINENT DIVERSIONS, DRAINING WOUNDS, FISTULAS & TUBES Anatomy and patho/physiology Of gastro-intestinal (GI) system Of genito-urinary (GU) system Conditions requiring stomas: congenital, acquired, infective, metabolic, neoplastic, traumatic Procedures for diagnosis: endoscopic, laparoscopic, radiographic and surgical Procedures for treatment: endoscopic, laparoscopic, radiographic and surgical Operative procedures resulting in a Stoma Pelvic pouch Continent diversion Types of stomas Temporary/permanent By anatomy oesophagostomy, jejunostomy, caecostomy, ileostomy, colostomy mucous fistula & urostomy By procedure: continent, divided, double-barrel, end, loop Pre-operative period Stoma counselling Stoma site selection Pre-operative bowel preparation Post operative period Stoma and skin care Appliance selection Counselling Teaching Management of stoma complications: ischemia, bleeding, mucocutaneous separation, hernia, prolapse, retraction, trauma, stenosis, granulomas, ulceration, oedema, ileus, ileostomy blockage Management of skin problems: irritation, erosion, allergy, folliculitis, pyoderma gangrenosum, hyperplasia, urinary crystals, dermatitis and pseudovaricose lesions Nurse, not
2 1ai THEORY: STOMAS & CONTINENT DIVERSIONS, DRAINING WOUNDS, FISTULAS & TUBES Nurse, not Problem solving Early post op care Long term care Management of specific conditions ie short bowel syndrome, dehydration Paediatrics Specific paediatric stoma considerations: Stoma types, medical conditions, surgical intervention, products, parent counselling, ongoing care Sexuality Counselling, body image, self concept Pharmacology Constipation, diarrhoea, flatus, high output stoma Nutrition and fluid balance For person with stoma, fistula oral, parental, enteral Fistulae GI: salivary, gastric, biliary, pancreatic, small bowel, large bowel, lymphatic, urinary GU: bladder/vagina, bladder/rectum, recto-vaginal etc Other e.g. thoracic, tracheostomy Fistula complications and management Skin care related to drain and tubes Long term stabilisation Drain/tube management Feeding tubes and buttons: Feeding gastrostomy, jejunostomy problem solving
3 1ai THEORY: STOMAS & CONTINENT DIVERSIONS, DRAINING WOUNDS, FISTULAS & TUBES Human development & diversity across the life span/quality of life: Paediatric, adult, geriatric special needs Dying Paraplegic, quadriplegic - Limited dexterity - Impaired understanding, illiterate - Blind, deaf - Cultural differences religion, customs, language Cancer Staging Radiotherapy and chemotherapy Management of radiation and chemotherapy related problems Nurse, not Products General product information availability, cost, type Ostomy company information re resources, representatives etc Associations Ostomy Association information Ostomy visitor program details ETN Association details WCET information Documentation Written resource information i.e. booklets, diagrams, audiovisuals Other resources Community support group information Community nurse information Financial resources availability Government programs
4 1aii CLINICAL PRACTICE STOMAS & CONTINENT DIVERSIONS, DRAINING WOUNDS, FISTULAS & TUBES Pre-operative period, Counselling, Interviewing Communicating General counselling skills Sexual counselling Grief counselling ( loss of body part, cancer, etc.) Ability to provide accurate information about: 1. Operation 2. Stoma 3. Associated ostomy issues Knowledge of printed or audio visual aids for patient Stoma site selection Bowel preparation Post-operative management Assessment of stoma / skin / function First 24 hours First week Following discharge from hospital Management of post-op complications: ischaemia, bleeding, mucocutaneous separation, hernia, prolapse, retraction, trauma, stenosis, granulomas, ileus, ileostomy blockage, ulceration, oedema Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discussed verbally, not observed Literature provided to read Other Management of skin problems: disease, infection, chemical, allergic, trauma Established stoma ongoing care and problem solving Management of continent diversions First 24 hours First week Following discharge from hospital Teaching ostomate self care Providing discharge from hospital to home information
5 1aii CLINICAL PRACTICE STOMAS & CONTINENT DIVERSIONS, DRAINING WOUNDS, FISTULAS & TUBES Product selection for Conventional stomas Difficult stomas: bridges / rods, odd shapes Drain tubes Fistulae Draining wounds Procedures Stoma intubation digital examination, enema, suppository Specimen collection from ileal conduit Feeding gastrostomy / jejunostomy management of skin problems, leakage, feeds, skin level devices and tubes Draining gastrostomy / jejunostomy - management Colostomy irrigation teaching Distal bowel washout through loop stoma Lavage (ileostomy) Tube stabilization without skin suture Long term drain tube management Ante grade continent enemas (ACE) management Appliances Appliance selection for: Colostomy, Ileostomy, Urostomy Fistula Drain & tubes Large draining wound Self made appliance Skin protection products Accessory products for the ostomate Education Patient education Staff education Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discussed verbally, not observed Literature provided to read Other
6 CHECKLIST FOR STOMA AND WOUND CARE REP CONTENT 1Bi THEORY: WOUNDS & SKIN Nurse, not Anatomy and pathophysiology of the skin Factors affecting wound healing Endocrine Cardiovascular CNS Immunosuppressive Nutritional Altered tissue/skin integrity Prevention of altered tissue / skin integrity Risk assessment tools, protocols Assessment and grading Wound healing phases Management Types of altered tissue / skin integrity, wounds & specific interventions Enzymatic Friction Maceration ( perspiration, urine, wound drainage) Infectious ( herpes, monilia) Neuropathic: diabetic foot Pressure/shear Radiation therapy Traumatic (accidental, excoriation, tape) Vascular: arterial / venous Intervention for altered tissue/skin integrity: causative, local, systemic Nursing Medical: growth factors, hyperbaric, pharmacologic Surgical Products ie special beds, other aids Others: Vacuum- Laser- Hydrotherapy, Electrical stimulation,etc
7 1Bi WOUNDS AND SKIN PRACTICE Prevention Assessment of risk Assessment of skin Assessment of wounds History of altered tissue/skin integrity Pharmacological Physical Psychosocial Diagnostic data Hydration/nutrition Wound/skin documentation Procedures Ankle/brachial index Compression application Culturing Debridement Wound cleansing Products Product selection Ostomy appliances for wound care Skin protection techniques Compression product selection Pressure reduction/relief aids Wound care multidisciplinary team Education Patient education Staff education Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discussed verbally, not observed Literature provided to read Other
8 2 THE ET NURSE EDUCATOR ROLE 2i THEORY Nurse, not Principles of teaching-learning Developing educational programs Client education Designing patient education materials Checking literacy levels Colleague education Writing for publication 2ii PRACTICE Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discussed verbally, not observed Literature provided to read Other Design/use audio visuals: overheads, slides Design/use education program: ostomy drain tube wounds skin care continence
9 3 THE ET NURSE RESEARCH ROLE 3i Theory Research Nurse, not ETN lecture Para-medical lecture Self directed study Classroom discussion Included in exam or quiz Types Evaluation 3ii PRACTICE RESEARCH Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discussed verbally, not observed Literature provided to read Other Literature review
10 4 THE ET NURSE ADMINISTRATOR ROLE 4i THEORY ADMINISTRATIVE Nurse, not Critical thinking / dilemmas / decision making Ethical issues Policy issues / trends, legal issues / regulation Financing: cost accountability Practice standards Reimbursement Team building
11 4ii ADMINISTRATIVE PRACTICE Supervised practise real situation Supervised practise simulated on model Student observes expert practitioner Included in clinical exam Discusses verbally, not observed Literature provided to read Other Advocating Communicating Consulting / networking Evaluating products Managing/maintaining an ET nursing service Cost accounting / budgeting Developing new programs Keeping records Marketing Developing a fee schedule Contracting/negotiating / justifying Functioning as a specialist nurse Grant (submission) writing Maximizing computer use Setting up an ET nursing service Writing a job description
12 5 ET NURSE PROFESSIONAL PRACTICE ROLE Nurse, not History of profession Professional accountability Continuing professional development Participating in consumer organizations Participating in legislative forums Participating in professional organizations Joining (or establishing) local ET nurse association Joining WCET Attending ETN, Wound, Continence conferences
1 THE ET NURSE CLINICAL ROLE
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