Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1784_Библиотеки_им_академика_М_И_Перельмана.pdf
358 Rolstad and Wong
mining patterns of fistula function in these patients is particularly important
to effective and efficient pouch changing procedures.
The type of output from the fistula will indicate how aggressive peri-
wound skin protection must be as well as the most appropriate type of
emptying spout. Effluent from a colocutaneous fistula presents minimal risk
of skin maceration, as no active enzymes are present to denude tissue. In
these cases, the skin may be managed by protectants, such as ointments.
However, in the presence of proteolytic enzymes from small bowel con-
tents, a solid-form skin barrier, paste, and pouching system are recom-
mended to protect skin and contain effluent. When effluent is semiformed
or viscous, a drainable pouch with a wide spout that is considered a fecal
pouch is selected.
Abdominal Topography
Assessment of the abdomen is performed with the patient supine, sitting,
and standing. The ideal skin surface for management is flat, extending for
approximately 3 in. around the fistula opening on the skin. However, fistu-
las are rarely found in ideal locations. They emerge within incisions; proxi-
mal to bony prominences, stomas, scars or the umbilicus; or under abdomi-
nal creases and fat folds (Fig. 2). Unlike the well-constructed stoma, which
is properly sited on the abdomen with good protrusion (2.5 cm), the fistula
lacks the benefit of preplanning. Its opening is usually flat or recessed; both
of these characteristics are problematic and will require the use of addi-
tional skin barriers to fill areas and level the skin if pouching is used.
Figure 2 Enterocutaneous fistulas shown here are located in a midline incision
with an ileostomy and mucous fistula.
Nursing Management of Fistulas 359
Abdominal muscle tone is also assessed. If a pouching system is to
be used, this characteristic will affect the degree of support required in the
system. Distinction between a firm, soft, or flaccid abdomen is made in
order to determine the level of support needed to stabilize the pouching
system on the abdomen.
Periwound Skin
Integrity of the skin is assessed within a 3-in. area around the fistula open-
ing. Initially, fistulas present with erythema and tenderness in this area,
with the skin subsequently erupting to form a draining wound. Once the
fistula occurs, skin is at risk. Maceration is the result of skin bathed by
moisture. Skin denudation or erosion occurs secondary to the presence of
active proteolytic enzymes in contact with the skin (Fig. 3). However, these
processes are also observed secondary to trauma caused by the frequent
removal of dressings. When periwound skin is compromised, reassessment
of the current approach is warranted and restorative measures are begun.
Odor
Initial assessment should differentiate between the odor of dressings in need
of change and the odor of stool. The presence of odor will vary depending
on the type of effluent. On occasion, the primary rationale for using a pouch
will be to contain odor.
Figure 3 Periwound skin denudation secondary to effluent in contact with skin.
360 Rolstad and Wong
Pain
Once the fistula has opened, drainage from the site is usually not painful.
Pain is usually associated with periwound skin dermatitis or generalized
abdominal discomfor t from surgical procedures, abscess, or dressing changes.
A pain scale is used to assess the level of pain and, if the pain is associated
with procedures, premedication is necessary.
Emotional Support
Consistent, effective fistula management is the first step in regaining a
sense of control for both the patient and the care team. However, beyond
these issues, patients and their significant others have informational and
emotional needs. Assessment of the patient’s knowledge may be as simple
as determining whether he or she understands the terminology, anatomy,
medications, and rationale for the treatment being given. Effective coping
strategies are evident when the patient seeks answers, expresses concern,
and participates in problem solving. Emotional support and education are
two sides of the same coin. They may be required over the long term for
these patients and are best provided by a multidisciplinary team.
MAINTENANCE AND RESTORATION
OF PERIWOUND SKIN INTEGRITY
The presentation of a fistula merits aggressive, early skin protection in all
patients but particularly in those with additional risk factors such as age,
radiation, immunosuppression, malnutrition, and primary skin disorders.
Maintaining the integrity of periwound skin is similar to the techniques
used in caring for peristomal skin. Appropriate selection and use of adhe-
sives is required. Gentle adhesive removal is performed in the direction of
hair growth with a soft tissue and water or a commercially available skin
solvent. Cleansing the skin, again, is accomplished by nontraumatic meth-
ods, such as use of a soft tissue and tap water or a commercially available
skin cleanser. The skin is then allowed to dry prior to application of a
dressing or pouching system. When the skin is at risk, a skin protectant
product is needed (i.e., skin sealant, barrier, ointment).
Restoration of skin integrity requires knowledge of common dermato-
logical etiologies resulting in periwound skin breakdown and the ability to
recognize each. The three primary etiologies are contact dermatitis, trauma,
and candidiasis. The precipitating factors are skin exposure to effluent and
products used in care (e.g., chemicals or adhesive removal technique) [3].
Following is a discussion of these etiologies and interventions for care.
Contact dermatitis is defined as any pruritic, reactive skin disorder
that occurs when the skin is exposed to a particular substance. There are
Nursing Management of Fistulas 361
two subdivisions of this category that further specify etiology: irritant and
allergic. Irritant contact dermatitis occurs secondary to contact with an of-
fending agent. Clinical observations include erythema, vesicles, papules,
patchy areas of denuded tissue, and pain at the site of contact. In the fistula
patient, effluent and substances used in care are generally the offending
agents. The cutaneous opening may be located at or below skin level and
discharge of corrosive effluent with active proteolytic enzymes occurs di-
rectly onto dry, intact epidermis. The epidermis is additionally compro-
mised by overhydration and contact with fluids having extreme levels of
pH. Examples of other known irritants to the skin include solvents, soaps,
hypochlorite (Dakin’s solution), acetic acid, and tincture of benzoin. Pro-
tection of the skin from effluent is achieved with skin barriers and skin
sealants (see Table 1). Protection from other irritants focuses on removal
of these agents from use and treating the skin with some form of protective
barrier. If ointments and pastes are used, a suggested technique is to apply
the protectant to the skin around the fistula opening, taking care not to
cover the opening. (If this is occluded, the effluent will erode the skin
barrier and expose the skin below without any sign that the clinician might
note.) An absorbent dressing is then applied over the skin protector and
changed as needed. Commonly used absorbent dressings are gauze, poly-
urethane foam, and calcium alginates. If a pouching system is in use, oint-
ments are not recommended, as leakage will occur.
Allergic contact dermatitis occurs from exposure to an allergen or
related compound that results in a hypersensitivity reaction upon re-expo-
sure. Clinical observations include vesicles, bullae, papules, itching, ery-
thema, or denudation at the site contact. Some level of discomfort or pain
is also reported. A few common causes of allergic contact dermatitis in
periwound skin care include substances such as neomycin, bacitracin, para-
bens, and fragrances.
Allergic reactions exhibit acute onset, and the reaction may last up to
21 days. With re-exposure, the cycle repeats [4]. True allergic reactions are
documented through the use of patch tests. The suspected agent is applied
to the opposite side of the abdomen and covered. The skin is then inspected
within 24–48 hr for any reaction. A cautious approach is recommended in
attempting to confirm a true allergic reaction, since the arbitrary identifica-
tion of an ingredient as an allergen may rule out the use of numerous skin
barriers, as most are developed from similar ingredients. The optimal
course of treatment is to identify and remove the allergen while continuing
to protect the periwound skin. The clinician should be knowledgeable about
the most common sensitizing agents and check the patient’s history for any
sensitivities prior to product use.
Traumatic periwound skin injuries in fistula management are usually
confined to skin stripping. The protective characteristics of the epidermis
are removed by physically lifting away layers of the epidermis during adhe-
362 Rolstad and Wong
Table 1 Quick Reference Guide to Skin Care Products for Fistula Care
Product function Category Description and use
Cleanse periwound Skin cleansers Tap water, saline and commercially
skin manufactured cleansers.
Fill irregular Paste skin barrier/ Caulking agents —most contain alco-
contours, edges, strips/puddy hol and may cause burning when
and shallow applied to compromised skin (e.g.,
areas Stomahesive Paste, Coloplast Os-
tomy Paste). Apply skin barrier
powder or a nonalcohol skin seal-
ant first to minimize this affect.
Strips are moldable adhesive strips
for filling creases or linear con-
tours. A variation of pastes and
strips is a puddy compound that is
a nonadhesive filler (e.g., Carbo
Zinc).
Deep areas Solid form skin Pectin-based wafers and sheets, used
barriers in addition to integrated skin barri-
ers on pouching systems or used
with dressings. Available in 4 by 4
and 8 by 8 in. Durable when in
contact with effluent. May be used
as a “platform” around fistulas, so
that tape is applied to the barrier
rather than the skin. May be cut
and layered to fill deep areas. May
be used in combination with pastes
and powders (e.g., Stomahesive,
Premium Skin Barrier).
Skin barrier rings Pectin or silicone-based rings, mold-
able. May be stretched or cut to fill
irregular surfaces. May be used in
combination with pastes and pow-
ders (e.g., Eakin Cohesive, Adapt
SoftFlex Rings).
sive removal. The result is wet, denuded, painful skin. As a guide for clini-
cians, when dressings are changed three times a day, some form of skin
protection is needed. If a pouching system is in use, it is usually changed
every 3–7 days. Otherwise, skin stripping may result. This is particularly
important if an extended-use solid-form skin barrier is used. When a pouch
Nursing Management of Fistulas 363
Table 1 Continued
Product function Category Description and use
Protection of the Skin barriers Described above.
skin
Liquid barrier film Alcohol and non-alcohol-based prod-
(skin sealant) ucts in liquid form that improve
adherence of adhesives.
• Used in combination with dress-
ings to protect skin (Skin Prep
Skin Gel). Nonalcohol products
may be used on compromised
skin (3M Calvilon No Sting Skin
Barrier Film).
• May be used in combination with
skin barrier powder to create an
artificial “scab.”
Moisture barrier Used with dressings to protect peri-
ointments wound skin. Formulated with in-
gredients such as zinc oxide, di-
methicone, miconazole nitrate, and
petrolatum. (e.g., Calmoseptine,
Critic-Aid) Do not use with adhe-
sives.
Absorb moisture Skin barrier pow- Pectin-based powder that is dusted
from moist or der lightly onto denuded skin to absorb
denuded skin moisture and create tack. Excess
powder is removed (Stomahesive
Protective Powder, Premium Pow-
der).
Remove adhesive Adhesive remover Available in wipes and bottles. Op-
tional product: not required to re-
lease adhesives and must be com-
pletely removed from the skin prior
to next adhesive application.
Improve adhesion Liquid barrier film See description above.
Medical adhesive Available in spray, liquid, and brush-
on forms.
Source: Ostomy Wound Management 2002 Buyers Guide, Manufacturer Websites. 48(7):
2002.
364 Rolstad and Wong
is leaking so that a daily pouch change is required, some other form of skin
protection/containment should be utilized [5].
Prevention of this problem lies with proper selection and use of adhe-
sives. When frequent adhesive removal is anticipated, porous tapes, Mont-
gomery straps, liquid skin barrier film, protective ointment, or a solid-form
skin barrier is indicated. Adhesives are removed in the direction of hair
growth while the skin is supported. For patients with friable skin, a liquid
barrier film is recommended prior to adhesive application. Treatment of
skin stripping usually includes the use of a skin barrier powder to absorb
moisture on the skin and the application of a solid-form skin barrier or
liquid skin barrier film.
Candidal infection is a periwound skin dermatitis observed in fistula
patients because of their general condition (i.e., on antibiotics, immunosup-
pressed) and local conditions (i.e., moist, warm, dark periwound skin envi-
ronment). The proliferation of Candida albicans results in observable mani-
festations—patchy, papular, pruritic lesions that include some satellite
distribution characteristics. If dressings are in use, an antifungal protectant
ointment or paste is recommended. When an adhesive pouching system is
in use, an antifimgal powder is recommended. A typical application tech-
nique for use of an antifungal powder on periwound skin is to dust the
powder on cleased, dried tissue. The powder is gently rubbed in and any
excess is removed. Then a non-alcohol-based liquid skin barrier is applied.
CONTAINMENT OF EFFLUENT
Containment of effluent results in protected periwound skin, odor control,
and a more accurate measurement of fluid losses. Containment with dress-
ings does not completely achieve these objectives but may be the best ap-
proach in low-output fistulas without odor.
Low-Volume Fistulas: Nonpouching Approach
For the purposes of nursing management, low volume is defined as an out-
put of less than 100 mL in 24 hr. Absorbent dressings are traditionally used
in the management in these fistulas. Gauze, foam, and alginate dressing
materials represent those most commonly utilized. In addition to dressing
selection, however, periwound skin protection is necessary. Numerous
types of skin protectants are used in combination with dressings. Liquid
skin barrier films (i.e., skin preps), ointments, and solid-form skin barriers
are examples of a few.
Solid-form skin barriers are useful as protective platforms when adhe-
sive tapes are in use for a long period of time. An opening is cut in the
center of the wafer to the size of the fistula opening, as in the case of a
stoma. The skin barrier is applied so that the fistula opening is surrounded
Nursing Management of Fistulas 365
by the skin barrier. Absorbent dressings are applied to the site and secured
with tape that is attached to the skin barrier rather than the skin. The skin
barrier is left in place during dressing procedures and changed infrequently
(e.g., once a week).
When output is malodorous, an odor-absorbent charcoal dressing may
be added to the protocol or a pouching system may be necessary.
In most situations, even with low-output fistulas, a pouching system
is the preferred approach. It provides better protection for periwound skin
and adjacent incisions as well as odor containment. Patients experience in-
creased comfort and are usually able to assist with or independently per-
form routine procedures, thereby providing a sense of control and greater
security. Interestingly, another benefit achieved is related to resource con-
sumption. When fistulas are pouched, there is a significant reduction in
nursing time spent on fistula care, and discharge from a care setting may
be facilitated.
Low-Volume Fistulas: Pouching Options
Pouches used in the management of low-volume fistulas are closed or
drainable with wide spouts (i.e., fecal pouches). They are usually clean
rather than sterile. Closed ostomy pouches have a low reservoir capacity
but patients may prefer them to wet dressings. In colostomy care, these
pouches are primarily used for patients who are irrigating. They are “secu-
rity pouches” that contain mucus or small amounts of stool between colos-
tomy irrigations. When adapted to fistula care, closed pouches are effective
and simple to use. They are usually changed once every 1–4 days depend-
ing upon output volume. Most pouching systems manufactured today have
integrated skin barriers, with the skin barrier attached to the pouch during
manufacture. However, many types of closed pouches do not. Therefore,
an additional skin protectant may be needed. In theory, closed pouches are
good options. In practice, they may be difficult to obtain in some care
settings. It is unlikely that product formularies in acute or long-term-care
settings would include these items due to low utilization. However, they
are easily obtainable for outpatients.
When a drainable pouch is selected, a pediatric size (i.e., 6- to 10-in.
length) or regular size (i.e., 12in. length) may be used in these low-output
situations. Drainable pouches usually include integrated skin barriers that
provide skin protection. If the pouch adhesive does not include a skin bar-
rier, a solid-form skin barrier may be attached. (If the area adjacent to the
fistula requires filling or support, see Sec. V, “Preparation of Abdominal
Topography,” below.) Drainable pouches are emptied when they are one-
third full and changed every 3–7 days. Even though a fistula has low out-
put, if the cutaneous opening is greater than 3 in., a wound management
system may be required. These specialized pouching systems are more ex-
366 Rolstad and Wong
pensive and bulky under clothing, yet they provide the adhesive size that
may be required to pouch a malodorous fistula.
Occasionally, access to the fistula is required between pouch changes
to advance or remove drains, inspect the wound, or perform diagnostic pro-
cedures. When access to the fistula is needed, a two-piece pouching system
is recommended. Removal of the system is not required during observation;
instead, the pouch is released from the skin barrier flange and reattached.
Wound management systems also have attached access caps and may be
indicated for low-volume fistulas with openings greater than 3 in.
High-Volume Fistulas
High-volume fistulas in nursing care are defined as having an output greater
than 100 mL/24 hr. Dressings are not the first line of intervention in these
situations. The preferred approach is pouching.
PREPARATION OF ABDOMINAL TOPOGRAPHY
Fistulas are frequently characterized by poor abdominal location and irregu-
lar topography proximal to the opening (e.g., retention sutures, drains, sto-
mas, retraction, folds of fat, open wounds). Ideally, a flat skin surface for
approximately 3 in. around the fistula opening is achieved in order to secure
adhesives. Establishing such a flat surface may require the use of a skin
barrier material to caulk creases and recessed areas. Skin barrier strips and
paste are very effective for this. Solid-form skin barriers or skin barrier
rings may also be layered into a recessed area for deeper filling. Solid-form
skin barriers or conformable skin barrier rings may also be individually
fashioned to the fistula size and then attached to the pouch adhesive [6,7].
If the skin is moist, a skin barrier powder may be dusted onto the surface,
with any excess removed. This results in a tacky surface. Whatever tech-
nique is utilized, the goal is to fill in creases and recessed areas and provide
a flat, dry surface for adhesives.
Beyond creases and recessed areas, abdominal muscle tone also plays
a role in stabilizing pouching systems. When the muscle tone is firm, a
flexible skin barrier and pouch are usually effective. The flaccid abdomen,
however, will usually require additional support from the pouching system.
This is available in the form of convexity or plastic gaskets on the pouching
system itself [2,8–11].
SELECTING A POUCHING SYSTEM
Once abdominal topography has been adequately addressed, pouching se-
lections are made. Most drainable pouches have integrated skin barriers
Nursing Management of Fistulas 367
attached to provide skin protection. If the pouch adhesive does not include
a skin barrier, a separate solid-form skin barrier may be attached. The
pouching system is usually changed every 1–4 days, depending on the in-
tegrity of the seal. That is, the frequency with which a fistula pouch is
changed is prompted by impending leakage rather than on a predetermined
schedule.
Decision points about pouching systems are related to the volume of
effluent and size of the cutaneous opening (see Fig. 4).
Volume of Effluent
Drainable pouches have either a wide emptying spout (i.e., fecal pouch) or
a straight drainage spout (i.e., urinary pouch). In some situations, straight
drainage spouts, tubing, and bedside collection bags may also be indicated
to manage volume. However, the tubing and bedside drainage bags do not
provide the level of odorproofing found in pouch materials. Therefore a
liquid deodorizer may be required in the system. Most commonly, the wide
emptying spout is utilized, as it accommodates variations in stool consis-
tency. In addition to ostomy pouches, wound management systems and spe-
cialty systems are also available to meet individualized needs. The specialty
pouches listed in the algorithm (Fig. 4) for this type of fistula all have
straight drainage valves, so that a bedside bag may be used to increase
volume storage capacity.
Size of the Cutaneous Opening
A fistula with an opening less than 3 in. in diameter is appropriate for a
one- or two-piece drainable ostomy pouching system. The one-piece sys-
tems are usually the least expensive and provide all necessary functions
except access to the fistula between pouch changes (Fig. 5).
When the size of the cutaneous opening is greater than 3 in., the
pouching systems available become somewhat bulky. Large two-piece os-
tomy pouching systems are available, and medium- to large-size wound
management systems also accommodate these larger sizes. A few ostomy
manufacturers also have pouches with oversized adhesive surfaces that are
actually designed for fistula management. These pouches usually include
an integrated skin barrier (Figs. 6 and 7). When multiple fistulas are present
in an incision, the entire incision should be pouched (Fig. 8). It is not neces-
sary to pack the incision once the fistula is pouched (Fig. 9). The emer-
gence of pouches with larger adhesive surfaces has obviated the need for
many specialty procedures and adaptations once considered routine (Fig.
10). Saddlebagging and troughing are two such procedures. They are in-
cluded here for situations where the clinician is unable to locate the larger
adhesive surface pouching systems.