Wound and Ostomy Care: Basics and Troubleshooting

Transcription

1 Wound and Ostomy Care: Basics and Troubleshooting Catherine Clarey-Sanford, PhD, RN, CWOCN Conflict of Interest No conflict of interest exists No commercial interest No financial benefits Specific wound care and ostomy product names will be used during the presentation without bias 1

2 Learner Outcome RNs will accurately assess wounds and peri-stomal skin complications, and identify appropriate topical applications or healing skin care/pouching regimes to promote wound/ostomy healing in their facility/practice. Learning Objectives Describe the tissue treatment pathways of DIME (Debridement/Devitalized Tissue, Infection or Inflammation, Moisture Balance, and Edge of Wound Preparation) Select appropriate topical wound management based on wound characteristics Discuss three types of incontinent diversion stoma characteristics Identify the correct skin care/pouching regime for three peristomal skin conditions 2

3 Devitalized Tissue Necrotic, Slough, Eschar ( If not red, dead ) Debridement Surgical Mechanical (NPWT with Instillation) Autolytic (Hydrogels, Hydrocolloids) Chemical (Medical Honey, Enzymatic/Santyl ) 3

4 Hydrogels Hydrocolloids Keep dry Protect Dry Eschar without Infection 4

5 Infection Sharp Debridement Culture and Sensitivity / X-ray, CT, MRI Systemic Antibiotics NPWT with Instillation and Dwell Time Antimicrobial Impregnated Bismuth/Silver/Hypertonic Antiseptic Dressings Iodine/Hypertonic Saline Collagen Matrix Dressings Endoform, Fibracol, Prisma 5

6 Odor Typically the result of necrotic tissue or bacterial colonization Assess drainage blue/green: Dakin's 0.25% Most wound odors are thought to arise from the metabolic processes of anaerobic bacteria Silver dressings, Charcoal dressings Hydrofera Blue, CarboFlex, Charcoal dressings Crushed flagyl tablets Certain dressings such as hydrocolloids also tend to produce a characteristic odor Evaluate after cleansing In chronic wounds, such as pressure injuries, leg ulcers, and diabetic foot ulcers, the odor may also be due to tissue degradation - gangrene ABI, blood flow studies, General and/or Cardiovascular Surgeons Sharp debridement if needed (think of goal) Moisture Wet Barrier Wipes/Strip Paste Calcium Alginate Kaltostat, Algisite, Curasorb Hydropolymer Foams, Silicone-based (Mepilex) 6

7 Moisture Dry Hydrogels Hydropolymer Hydrocolloids Impregnated Wound Edge Epibole Sharp debridement, Silver nitrate Maceration Control drainage, Barrier wipe Hypergranulation Pressure with foam, Silver nitrate 7

8 Five Essential Factors for wound healing Maintain Moist wound bed Keep warm at body temperature Decrease of 2 Celsius Timing of dressing changes Protect from secondary trauma Protect for contamination/manage bacteria Remove non-viable tissue Adequate Nutrition Nutrition Vitamin C helps the body make collagen and is essential to wound healing because it helps the body form new tissue Vitamin E and Zinc promote wound healing L-arginine has been used to improve healing time Complete nutritional assessment SOS: stop and offer a sip of water if no fluid restriction Lab tests: pre-albumin levels (values of <16 mg/dl are associated with malnutrition) Registered Dietician consults Percentage of food eaten including supplements Weight loss or gain 8

9 What would you do? Ostomy - Types of Diversions 9

10 Stoma Characteristics/Pink and Moist Pouching Systems One piece Two piece Drainable, Closed-end Flat or Convex wafers Ostomy Supplies Additional Products Stoma powder, Stoma adhesive paste, Barrier rings Irrigation cone (colostomy only) 10

11 Stoma Complications Necrotic Watch and wait, Surgical intervention Mucocutaneus Junction Separation Stoma Powder/Wound Care Regime Recessed in Skin Fold Barrier ring, Convex or Flexible wafer Ostomy Concerns - Leakage Appliance regime What has changed? Contact supplier with Lot Numbers Switch to a new box Refer to a Certified Ostomy Nurse Time for a stoma reassessment Weight gain or weight loss Hernia 11

12 Peristomal Skin Complications Resources Clinical Tools Ostomy Concerns Peristomal Skin Folliculitis Candidiasis Irritant Dermatitis Allergic Contact Dermatitis Psuedoverrucous 12

13 What would you do? Itching under wafer with scattered red rash? Pouching system leaking after 2 years without leakage? Patient takes off wafer and you see this: Find a WOCN in Your Area Patient Information link on website Find a WOC Nurse To find a WOC Nurse in your area, please search either by: Zip code + Zip Code Within 25 miles or more ONLY OR State ONLY LEAVE ALL OTHER FIELDS BLANK! When searching by state, please type the full name, not an abbreviation (e.g., New Jersey not NJ). 13

14 RESTROOM ACCESS FOR PERSONS WITH MEDICAL CONDITIONS Act 469 of 2008 AN ACT to provide for restroom access for persons with certain medical conditions; to provide immunity from liability for permitting restroom access; and to prescribe penalties. History: 2008, Act 469, Eff. Mar. 31, Legislative Council, State of Michigan Download Travel Card 14

15 Sexuality/Pouch Covers/Support Groups Ostomy Supply Coverage If you have Medicare Part B coverage, then your ostomy supplies are covered. (As noted above, Medicare pays 80% and you pay 20%.) Individuals may separately buy a supplemental insurance policy to help pay for this 20% of costs. You must have a prescription, signed and dated by your doctor, on file with your supplier. It is important to make sure that your supplier is enrolled in Medicare and has a Medicare supplier number. Otherwise your claim will not be paid by Medicare. ent.pdf Meridian Michigan: Binson s ( ), Beaumont Medical ( ) 15

16 Thank You! Catherine Clarey-Sanford, PhD, RN, CWOCN Cell: Ostomy References Wound, Ostomy, Continence Society. (2017). Clinical guideline: Management of the adult patient with a fecal of urinary ostomy. Mount Laurel, NJ: WOCN. Wound, Ostomy, Continence Society. (2017). Clinical tools for the WOC nurse: Peristomal skin assessment guide. Retrieved from 16

17 Wound References Bryant, R. A., & Nix, D. P. (2012). Acute and chronic wounds: Current management concepts. St. Louis, MO: Elsevier. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers: Quick reference guide. Osborne Park, Australia: Cambridge Media. Snyder, R.J., Fife, C., & Moore, A. (2016). Components and quality measures of DIME (devitalized tissue, infection/inflammation, moisture balance, and edge preparation) in wound care. Advances in Skin and Wound Care, 29(5), doi: /01.ASW b4 Wound, Ostomy, Continence Society. (2008). Guideline for management of wounds in patients with lower-extremity arterial disease. Mount Laurel, NJ: WOCN. Wound, Ostomy, Continence Society. (2010). Guideline of prevention and management of pressure ulcers. Mount Laurel, NJ: WOCN. Wound, Ostomy, Continence Society. (2011). Guideline for management of wounds in patients with lower-extremity venous disease. Mount Laurel, NJ: WOCN. Wound, Ostomy, Continence Society. (2012). Guideline for management of wounds in patients with lower-extremity neuropathic disease. Mount Laurel, NJ: WOCN. 17