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Clinical Consultation: How Do We Manage Difficult Ostomy Pouching in the Rehabilitation Setting?
Situation: A morbidly obese 30-year-old woman was admitted to our acute rehabilitation hospital after gastric bypass surgery with a diagnosis of general deconditioning. Postoperatively, she had developed abdominal complications, including a dehisced abdominal surgical wound, and she needed an ileal conduit urinary diversion. The urinary diversion was immediately adjacent to the surgical wound and was anatomically severely retracted, posing a great challenge in ostomy pouching and wound care management. According to our nursing staff, the ileal conduit had leaked, resulting in periwound and peristomal maceration and skin breakdown that had further compromised proper maintenance of an ostomy pouch seal. In addition to the denuded skin, the patient had a significant periwound and peristomal fungal rash infection caused by excess ileal conduit effluent and wound exudate. The patient was in great discomfort, bedbound, and could not participate in her therapy sessions.
Consultation: Mary (Mimi) Zeigler, MS RN CRRN CWOCN, clinical nurse consultant, and Eileen T. French, MSN RN CRRN, clinical nurse consultant, both at the Rehabilitation Institute of Chicago, Chicago, IL, reply:
This case required evidence-based nursing intervention guided by the clinical nurse consultation team. The team encouraged the nursing staff to problem-solve strategies to achieve appropriate pouching system with adequate adherence, proper periwound and peristomal skin care, exudate management of the abdominal surgical wound, patient comfort, and full patient participation in her rehabilitation program.
Assessment of the ileal conduit stoma revealed a severely retracted stoma and significant abdominal creases adjacent to the stoma that could benefit from a one-piece extend-wear pouching system with convexity (Hampton & Bryant, 1992) (Figure 1). A one-piece extend-wear pouching system uses an adhesive wafer that provides greater resistance to urine. The convexity is formed by a flange that curves outward against the skin, “pushing out” the stoma and helping to prevent undermining of effluent. Additionally, the patient’s abdominal creases could be caulked with cohesive seal to promote a smoother, flatter pouching surface for improved adherence (Jones & Harbit, 2003). The flexibility of this one-piece pouch versus a two-piece inflexible system makes it a better choice to manage abdominal creasing (Hampton & Bryant, 1992).
Next on our management agenda was to address the periwound and peristomal skin. Before pouching, both areas were protected by a “crusting technique,” which involved application of antifungal powder and skin barrier sealant to absorb moisture, treat the fungal infection, and heal the skin. This approach is supported in the literature for prevention and treatment of fungal and denuded skin (Evans & Gray; 2003, Milne, Corbett, & Dubuc, 2003).
Wound exudate management and promotion of a moist wound environment are essential for healthy tissue repair and generation (Baranoski & Ayello, 2004). The excessive exudate from the dehisced surgical wound of this patient was managed by changing from a woven gauze filler dressing to an absorbent calcium alginate rope filler wound dressing to “wick” the drainage while maintaining a moist wound base (Beitz & Caldwell, 1998). Core staff nurses were present during the consultation with this patient. These nurses assumed the task of learning the prescribed ostomy and wound care management, and served as a support to other nurses on the nursing unit.
All of the aforementioned nursing interventions resulted in prolonged ostomy pouch adherence. As a consequence, the peristomal and periwound areas resolved, the dehisced surgical wound environment became conducive for healing, and the patient no longer experienced physical discomfort. With these problems resolved, the patient was able to participate fully in her rehabilitation program and eventually was discharged to home with a functional level of independence.
Baranowski, S., & Ayello, E.A. (2004). Wound care essentials: Practice principles. Philadelphia: Lippincott Williams & Wilkins.
Beitz, J. M.,& Caldwell, D. (1998). Abdominal wound with enterocutaneous fistula: A case study. Journal of Wound Ostomy Continence Nursing, 25, 102–106.
Evans, E. C., & Gray, M. (2003). What interventions are effective for the prevention and treatment of cutaneous candidiasis? Journal of Wound Ostomy Continence Nursing, 30, 11–16.
Hampton, B.G., & Bryant, R.A. (1992). Ostomies and continent diversions: Nursing management. St. Louis, MO: Mosby.
Jones, E.G., & Harbit, M. (2003). Management of an ileostomy and mucous fistula located in a dehisced wound in a patient with morbid obesity. Journal of Wound Ostomy and Continence Nursing, 30, 351–356.
Milne, C.T., Corbett, L.Q., & Dubuc, D.L. (2003). Wound, ostomy, and continence nursing secrets. Philadelphia: Hanley & Belfus, Inc.