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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1784_Библиотеки_им_академика_М_И_Перельмана.pdf
368 Rolstad and Wong
Fistula
Identify (drain or tube) Site
VOLUME
Is output low
or high?
Is ODOR
present ?
LOW Volume
(<100mL in 24/hr)
HIGH Volume
(>100mL in 24/hr)
NO
YES
NO
YES
Management Options:
Absorbent dressings
(e.g., gauze, foam,
alginate) Change
daily or twice a day.
Skin protectant (e.g.,
liquid barrier film,
solid-form skin
barrier, ointment).
Closed pouch.
Management Options:
Ostomy pouching systems with
integrated skin barrier. Open
or closed. One-piece system is
least expensive. Use two-piece
drainable system for access to
the fistula between pouch changes.
Regular or pediatric size. Change
every 5—7 days.
Small wound management system
if the opening is <3 in. Change
every 5—7 days.
Charcoal dressing. Change as
needed.
Management Options:
One or two-piece drainable
ostomy pouching system
with integrated skin barrier
and a fecal or urinary spout.
Specialty pouches that
include straight drainage
spouts (e.g., retracted penis
pouch, female urinary
incontinence pouch, fecal
incontinence pouch.
Management Options:
Two-piece large drainable
ostomy pouching systems
with integrated skin barrier
and a fecal or urinary spout.
Wound management
system, medium or large.
Customized pouching
techniques.
Suction.
Is the fistula
OPENING
>3 in. ?
Figure 4 Algorithm for effluent containment.
Nursing Management of Fistulas 369
Figure 5 Effluent containment with a one-piece ostomy pouching system.
Figure 6 Pouching system with a longer adhesive skin barrier for an enterocuta-
neous fistula within an incision. Paste is applied to the skin barrier.
370 Rolstad and Wong
Figure 7 Pouch applied with access cap open. Note the straight drainage spout
at the bottom of the pouch.
Figure 8 The fistula and stoma within this incision are contained within one
pouching system.
Nursing Management of Fistulas 371
Figure 9 Pouching of the fistula does not require wound packing.
Figure 10 Wound drainage pouching systems with or without integrated skin
barriers. Note the variation in drainage spouts.
372 Rolstad and Wong
Saddlebagging
This technique is designed for fistulas that require a wider adhesive on a
pouch than is commercially available. Upon completion of this pouching
procedure, there will be two pouches attached to the skin lying side-by-side
on the abdomen. Effluent will drain into both pouches. Materials needed
include two flexible drainable pouches with integrated skin barriers and
large adhesive surfaces (approximately 8 by 8 in.) as well as extra paste or
pieces of skin barrier to fill defects in the abdominal topography that will
be under the adhesive. The pouches are aligned side by side on a table with
the adhesives facing up, and the paper covering the adhesive is removed.
The inside edges of the adhesive surface on both pouches are folded to-
gether in a narrow strip of approximately 1 in. so that the adhesives are
permanently stuck together in this area. The paper backing is replaced onto
the adhesive surfaces and flatten out on the table. A pattern the size of the
cutaneous opening of the fistula is traced on the surface of the paper back-
ing and cut out. The paper backing is then removed. Defects in the abdomi-
nal topography are filled as per the usual protocol and the pouching system
is applied to the skin.
Trough Procedure
This technique is used when the midline incision must be included in the
pouching system or when the length of the fistula exceeds that of commer-
cially available adhesives [12]. Upon completion of this pouching proce-
dure, the incision will be covered with a series of transparent dressings,
culminating at the bottom of the incision with regular-size ostomy pouch.
Effluent in the incision drains down to the ostomy pouch and is collected
in that device. Materials needed include large transparent film dressings,
solid-form skin barriers (4 by 4 in. or 8 by 8 in.), and a drainable ostomy
pouch. Skin barriers are applied in pieces to the periwound skin to surround
the wound and provide a platform. Several transparent film dressings are
then applied so that at least 2 in. of adhesive extend onto the skin barrier
platform beyond the opening to the incision. At this point, the entire inci-
sion is covered with the film dressings. An opening is cut in film at the
lower portion of the incision and an ostomy pouch is applied over the open-
ing to collect output.
Access
Occasionally access to the fistula is required between pouch changes to
advance or remove drains, inspect the wound, or perform diagnostic proce-
dures. When access to the fistula is needed, a two-piece pouching system
or a wound management system is recommended. Removal of the system
is not required during observation; instead, the pouch is released from the
skin barrier flange and reattached. In the wound management system, the
access window is opened during observations and then snapped back into
place.
Nursing Management of Fistulas 373
Catheter Access
When a tube or a drain is inserted into the fistula site or is located near the
area to be pouched (e.g., sump), it may be necessary to pouch the tube with
a fistula (Fig. 11). A catheter access port is then used to deliver the tube
through the front of the plastic pouch. This device also seals off potential
sources of leakage from the opening made in the plastic [13].
Suction
When pouching fails, there is a greater risk of mechanical injury to the skin,
increased expense, and increased patient frustration. In these situations, the
use of suction may be useful. Effluent must be predominately liquid, since
the catheter can become clogged with viscous output. A gauze dressing or
a wound contact dressing is placed over the fistula and a suction catheter
over the dressing so as to avoid contact with the wound. Suction may be
intermittent or continuous. A transparent film dressing is then applied that
covers the entire system [14–16]. (Suction is an option in acute care set-
tings. It is not the same type of suction as the vacuum-assisted closure
device that is used to manage large draining wounds.)
POUCHING TIPS AND TECHNIQUES
Selection of a pouching system requires knowledge of available equipment
and indications for its use. Not to be minimized, however, is application
technique (see Fig. 12). Patient positioning during procedures can deter-
Figure 11 The access port for a drainage catheter is seen here attached to
straight drainage.
374 Rolstad and Wong
Nursing Management of Fistulas 375
Figure 12 Procedure for changing a fistula pouch. The pouching system must
be changed (1) when leakage occurs or (2) on a scheduled basis (e.g., every 3–7
days). Impending leakage is signaled by a skin barrier that appears to be water-
logged or by a patient’s complaints of burning or excessive itching. For scheduled
pouch changes, a time of the day when function is minimal should be selected. If
necessary, suction should be kept on hand to control output. Otherwise, wicking
drainage away with 4-by 4-in. sterile pads is effective. If the protocol is expected
to be painful, arrangements should be made for analgesia. The analgesic agent
should be administered 1 hr before the procedure or topical lidocaine should be
available. This is a clean procedure and does not require a sterile setup. The patient
is placed in a supine position to smooth out abdominal contours and create flat
surfaces.
376 Rolstad and Wong
mine the difference between an intact pouch or leakage. Similarly, it is
fundamental to understand that using too much adhesive or paste will im-
pede rather than strengthen a seal. Close patient monitoring is key to estab-
lishing a workable solution and recognizing when the fistula has changed
and technical adjustments are needed.
Pouch leakage may occur as a result of several factors. When pouches
leak prematurely, abdominal topography is frequently the cause. Contours
of the abdominal surface and abdominal muscle tone supporting the pouch-
ing system may require reconsideration. Other causative factors are related
to the application and maintenance of an intact pouching system by the
caregiver. Technique during pouching procedures may be new to the care-
giver. For example, abdominal fistula pouching procedures are done with
the patient lying flat. If the patient is in a semi-Fowler’s position during
pouch application, skin creases will usually be present when the adhesive
is applied. Leakage will be the result. Adhesives require time to “set up”
after procedures are completed. If the patient moves immediately after the
adhesive is applied, the skin will become creased and leakage will result.
Therefore patients should be instructed to lie flat for 20–30 min following
a procedure with one hand held over the pouch to make sure that the seal
is well secured. Ironically, the simple activity of emptying the pouch may
be the cause of pouch leakage. Pouches should to be emptied when one-
third full and will become detached from the skin if overfilling occurs.
Caregivers need specific instructions on when and how to empty pouches.
Concern may arise that patients who are confused, medicated, or ex-
hausted may not be able to alert the nursing staff to empty a pouch. If this
becomes a problem, a straight drainage system may be helpful. A pouch
with a tube spout (i.e., urinary or wound management pouch) that connects
to straight drainage tubing and a bedside collector may be useful. Effluent
must be liquid, however, to avoid clogging the tube. Deodorizers may be
necessary when urinary pouches and straight drainage systems are used, as
they are odor-resistant rather than odorproof.
Pouching a fistula is a procedure that requires the use of gloves and
clean technique. Use of sterile technique and equipment means an added
expense that has not been supported in the literature.
ODOR CONTROL
Odor control is a concern with patients who have fecal fistulas. It is rou-
tinely the most common patient complaint, because the odor is pungent and
tends to linger. When a dressing is being used to contain effluent, there is
no odor barrier. A charcoal-impregnated dressing may be placed over the
gauze dressings to control odor. A distinction must be made between
pouches with odorproofing vs. odor-resistant characteristics. Most pouches
Nursing Management of Fistulas 377
are odorproof. However, urinary pouches and some large fistula drain
pouches are odor-resistant. In either case, offensive odors require attention.
Deodorants may be taken orally (e.g., bismuth subgallate, chlorophyllin),
placed in pouch (e.g., liquids, powders), or sprayed in the room. The pre-
ferred methods are pouch deodorization and room sprays, which avoid the
risk of potential systemic interactions. Deodorants used in the pouch must
be instilled after every pouch emptying in order to be effective. Room de-
odorizers should neutralize rather then mask odors (Fig. 13).
Simple, often overlooked methods of odor control are related to hy-
giene. When pouches are in use, the spouts should be rinsed with water and
wiped dry after each emptying and the seal on the pouch checked fre-
quently, as leakage is a cause of odor. Soiled pouches or dressings are
disposed of according to the agency health care setting’s infection control
policies. However, they should be removed from the room after procedures.
At home, pouches and dressings should be disposed of in a plastic bag and
put in the trash.
Some pain may be procedure-related for individual patients. Efforts
should be made to reduce the time required to perform the procedure and
to use techniques that will minimize patient discomfort. Patients who expe-
rience pain with the procedure should be medicated 30 min prior to a pouch
change.
Figure 13 Products used to deodorize effluent include charcoal-impregnated
dressing, room spray, tablet and liquid deodorizers that are instilled into the pouch,
and a charcoal filter for a pouch.