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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

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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

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Devitalized Tissue

• Necrotic, Slough, Eschar (“If not red, dead”)

• Debridement– Surgical

– Mechanical (NPWT with Instillation)

– Autolytic (Hydrogels, Hydrocolloids)

– Chemical (Medical Honey, Enzymatic/Santyl ®)

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• Hydrogels

• Hydrocolloids

Dry Eschar without Infection

• Keep dry

• Protect

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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

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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)

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Moisture – Dry

• Hydrogels

• Hydropolymer

• Hydrocolloids

• Impregnated

Wound Edge• Epibole

– Sharp debridement, Silver nitrate

• Maceration– Control drainage, Barrier wipe

• Hypergranulation– Pressure with foam, Silver nitrate

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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

NutritionAdequate 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

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What would you do?

Ostomy - Types of Diversions

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Stoma Characteristics/Pink and Moist

Ostomy Supplies• Pouching Systems

– One piece

– Two piece

– Drainable, Closed-end

– Flat or Convex wafers

• Additional Products– Stoma powder, Stoma adhesive paste, Barrier rings

– Irrigation cone (colostomy only)

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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

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Peristomal Skin Complications http://psag.wocn.org/#home

• www.wocn.org– Resources

– Clinical Tools

Ostomy Concerns – Peristomal Skin

• Folliculitis

• Candidiasis

• Irritant Dermatitis

• Allergic Contact Dermatitis

• Psuedoverrucous

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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 Areahttps://www.wocn.org/page/Nurse_Referral

• 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).

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http://legislature.mi.gov/doc.aspx?mcl-Act-469-of-2008RESTROOM 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, 2009

© 2017 Legislative Council, State of Michigan

Download Travel Card

http://www.ostomyguide.com/tsa-screening-cards-for-ostomates-and-those-with-health-conditions/

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Sexuality/Pouch Covers/Support Groups

http://www.ostomy.org/Home.html

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.

• https://www.coloplast.us/Global/US/Ostomy/Professional/Wellness%20Articles/Reimbursement.pdf

• Meridian Michigan: Binson’s (1-888-246-7667), Beaumont Medical (248-743-9100)

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Thank You!

• Catherine Clarey-Sanford, PhD, RN, CWOCN

• Cell: 269-369-8585

• Email: catherine.clarey-sanford@hc.msu.edu

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 http://psag.wocn.org/#question-one

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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), 205-215. doi: 10.1097/01.ASW.0000482354.01988.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.