2018 Ostomy & Continence Update. By Rhonda Souchek RN, BSN CWOCN, Deb Bussey, RN, BSN, CWOCN

Transcription

1 2018 Ostomy & Continence Update By Rhonda Souchek RN, BSN CWOCN, Deb Bussey, RN, BSN, CWOCN

2 Objectives Ostomy Basics: What s normal & what s not Stoma care Peristomal skin care: pouching & challenging situations Continence Issues today: what nurses should know and how can we make a difference?

3 Diseases which Lead to a Fecal Stoma Colorectal Cancer Remains one of the top three cancers diagnosed in both men & women Rates are beginning to decrease due to better screening & treatment, however the death rate among adults <55 has increased since 2006 (cancer.org, 2018)

4 Inflammatory Bowel Disease Crohn s Disease Inflammation can occur anywhere in digestive tract from mouth to anus Autoimmune Can develop fistulas due to full thickness mucosal involvement May have perianal disease Bleeding & pain Strongly linked to smoking Ulcerative Colitis Inflammation tends to be continuous but superficial Patients still experience crampy pain & bleeding Smoking seems to protect against UC & can develop only after quitting the habit.

5 Diverticular Disease Remove diseased portion of the bowel Diversion for bowel rest and healing Often can be reversed within weeks to months

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8 Stoma: the part of the bowel brought to the outside of the body through the rectus muscle and sutured into place. Mucocutaneous Junction: intersection between the bowel mucosa and the skin.

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10 Loop Stoma This is often used for diversion. Easier to reverse. Used for bowel rest after resection.

11 End Stoma Most often what we pouch End of the bowel turned over on itself & sutured into place

12 Do they always look like this? NO!!

13 Characteristics of a healthy stoma: Pink/red, moist like the inside of our cheek Immediately post op stomas are edematous & look more fluid-filled. May sometimes bleed when washed that s okay No separation between stoma & surrounding skin (mucocutaneous junction) Edema will go down in 6-8 weeks post op.

14 So what s an unhealthy stoma look like?

15 Peristomal Dermatitis Difficult Stomas

16 Flush Stoma

17 Prolapsed Stoma

18 Management : With patient lying down, gently apply pressure to reduce Apply sugar to reduce edema Protect from trauma May need larger pouch

19 Peristomal Separation

20 Peristomal Wound

21 Peristomal laceration from convex wafer

22 Granulomas

23 Pouching challenge! Notice recessed stoma Creases at 3 & 9 o clock

24 Special situations: Morbid Obesity: Marking is important, aim is independence so upper abdomen is usually preferred Incidence of post op complications is higher Full length mirror can be helpful

25 Cognitive Deficits: Degree of ability & independence should be carefully evaluated. Dexterity of hands can make two-piece appliances difficult to manage. Pictures & models can be used for teaching more learning-disabled individuals. These are also used for children

26 End of Life: Assessment of patient s situation is critical as their condition deteriorates. If patient was independent in cares before, a person must be selected to perform ostomy cares when patient is no longer able. Weight loss/change in abdominal contour can lead to leaks. Keep things as simple for caregivers Be available for questions

27 Considerations for Cancer patients: Chemotherapy patients must be watched for signs/symptoms of dehydration related to nausea, vomiting, or diarrhea Chemo can cause peripheral neuropathy leading to difficulty handling the appliance

28 Radiation therapy patients have higher risk of skin damage Moist or Dry desquamation: peeling of skin Erythema Rarely: necrosis Patients should avoid moisturizing creams with lanolin, alcohol, or petroleum-based Avoid anything that might injure stoma such as irrigation

29 What s the goal?

30 PREVENTION of peristomal skin issues Find the right pouch for each individual person Get a good seal & keep it Monitor patients at least annually for pouch fit abdominal contour can change with weight gain/loss, additional surgeries, etc.

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32 How do we care for a stoma? Keep it simple!

33 Warm water wash clothes: no perfumed soaps or baby wipes on peristomal skin Patients may take off appliance & shower. If soap is used in shower, be sure to rinse area thoroughly; must be prepared for messes in the shower If using adhesive removers or solvents of any kind to remove wafer, be sure to get all of it off it can affect the seal

34 Patients need to establish a routine of changing their appliance Change anywhere from every 3 to 7 days no more than 7 days Assess peristomal skin for irritation or denudement use crusting technique Assess the back of the soiled wafer for signs of erosion may need to seal this area better

35 Basic Pouching Principles: think opposites! Soft, doughy abdomen firm convexity Firm abdomen soft, flexible wafer One piece vs. two piece Drainable vs. non-drainable pouch

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42 This Photo by Unknown Author is licensed under CC BY-SA Non-drainable ostomy pouch

43 One-piece ostomy pouch

44 Instructions for CHANGING AN OSTOMY APPLIANCE 1. Gather supplies. 2-3 warm, wet washcloths (no soap) 1 bath towel Stoma measuring guide Appropriate appliance (wafer, pouch & clip if needed) 2. Remove pouch/wafer Using the push/pull, two-handed method gently pull the wafer off the skin Wash the stoma & surrounding skin with warm water washcloths only. Avoid lotions, creams, perfumes, ointments, etc. ALLOW SKIN AROUND STOMA TO DRY THOROUGHLY 3. Apply new appliance Measure your stoma using stoma measuring device Cut hole in your wafer to fit (not necessary if using a pre-cut wafer) If you are using Eakin s ring press that around edge of wafer opening Line up lower edge of hole with lower edge of stoma & gently press wafer to your skin. HOLD GENTLE BUT FIRM PRESSURE ON WAFER FOR 1-2 MINUTES TO ASSURE A GOOD SEAL! DO NOT SKIP THIS CRITICAL STEP! Peel off tape backing (if applicable) and press tape edges down as flat as you can. A few wrinkles are okay. Apply belt if using

45 Instructions for Pouch Emptying 1. Sit on toilet, as far back as possible. 2. Hold up the pouch and remove/open the bottom of the pouch (clamp or plug tip). 3. Turn up the end of the pouch back on itself to form a cuff plug tip or self-closure mechanisms form a spout when opened. 4. Place a piece of toilet paper into the toilet and drain pouch into the toilet (reduces splash back). 5. Clean cuffed end of the outlet with toilet paper or wipe rinsing pouch is not necessary. 6. Undo the cuff close the end of the pouch or fasten plug tip. If needed, inpouch deodorant may be used at this time.

46 Continence Refers to self control: the ability to hold it all in, holding back bodily functions

47 Incontinence Loss of bladder and/or bowel control that is a significant healthcare problem, which affects an individual s physical and psychological life

48 Incontinence Associated Dermatitis (IAD)

49 IAD can be painful, hard to properly identify, complicated to treat, and costly What is it? Skin damage caused by prolonged or recurrent contact with stool and/or urine and containment devices on the skin e.g. adult diapers or briefs

50 How does this happen?

51 Incontinence Associated Dermatitis Overhydration (maceration) of the skin Inflammation caused by irritants and enzymes (stool) Fungal or bacterial infections Friction damage (rubbing against the linens) Improper absorbent pads that keep the skin wet and occluded

52 PEARLS: Individuals with double or both urinary and fecal incontinence are at higher risk for IAD than those with FI or UI alone Wet skin is much more vulnerable to friction damage and to invasion by organisms such as Candida Albicans or yeast While IAD can potentially contribute to pressure ulcer development, the clinician (we) must be aware that IAD lesions are moisture lesions rather than pressure ulcers, and they should not be classified or staged as pressure ulcers

53 Where do we see IAD? IAD can occur wherever urine or stool contacts the skin. In contrast, pressure ulcers arise over bony prominences in the absence of moisture.

54 More ways to tell the difference! IAD Affected skin is red or bright red Skin damage is usually diffuse The depth of skin damage usually is partial thickness without necrotic tissue Pressure Ulcer Skin may take on a bluish purple, red, yellow, or black discoloration Edges are well defined The depth of skin damage may vary

55 Prevention is the goal!

56 1. Cleanse The Three Essentials of IAD Prevention 2. Moisturize 3. Protect

57 Cleanse Cleanse the skin with a mild soap that is ph balanced and contains surfactants: compound that lowers the surface tension Clean the skin routinely and at the time of soiling Use warm water; avoid using hot water, and avoid excess force and friction to prevent further skin damage Paper wipes can be less damaging than rough washcloths

58 Moisturize Moisturize the skin daily and as needed Moisturizers may be applied alone or incorporated into a cleanser Typically they contain an emollient such as lanolin to replace lost lipids at the surface of the skin

59 Protect To protect the skin, apply a moisture barrier cream or spray if the patient has significant UI or FI or both The barrier may be zinc-based, petrolatum-based, dimethicone-based, or an acrylic polymer; use what is supplied by your facility It is important to follow the manufacturers instructions for application Leave the base coat on the skin when cleansing. Do not try to vigorously wipe/rub ointment off Reapply additional layer after cleansing

60 Protect To help prevent urine or stool from contacting the patient s skin, consider using a male external catheter, a female urinary pouch or external collection device, or a bowel management system Avoid containment devices If a patient has an absorptive pad, make sure it is highly absorbent and not layered, to decrease pressure under the patient

61 Managing IAD: It takes a team A comprehensive multidisciplinary approach to IAD is essential to the success of any skin care protocol Incorporate: administrators who ideally support your skin care program at your facility Physicians who oversee protocol development and prescribe additional treatment Nursing staff who identify patients at risk and direct appropriate care Therapists who address function, strength and endurance issues to improve the patient s self care abilities in ADLs to manage or prevent episodes of incontinence

62 Severe Inflammation Topical dressings such as foam dressings may be used along with topical corticosteroids

63 Complex IAD Antifungals or antibiotics may be required if a secondary fungal or bacterial infection is suspected

64 What if treatment fails? The patient should be referred to an appropriate skin care specialist promptly Referral can also be made to a Continence Specialist (CWOCN) such as Deb or Rhonda

65 Questions..

66 References: Core Curriculum Ostomy Management: WOCN Society, Wolters Kluwer. (2014) Core Curriculum Continence Management: WOCN Society, Wolters Kluwer. (2016) Module II: Postoperative Care of the Patient with a Fecal and/or Urinary Diversion. WebWOC Images from Google Images & Bing Images