Schlagwort: Wound picture framing

Management of a faecal fistula in an abdominal wound

Wound pouches in use

Management of a faecal fistula in an abdominal wound

This case study looks at the management of a faecal fistula in an abdominal wound

Submitted by: Kylie Leavy STN, Dandenong Hospital, Victoria, Australia

Patient background

• 44 year old lady who presented to Dandenong Hospital on the 15th of April 2015 with a diagnosis of Pseudomembranous Colitis secondary to Salmonella.

• Proceeded to theatre and she underwent a laparotomy, subtotal colectomy, formation of an end ileostomy and ventral hernia repair.

• Day 9 post op she returned to the operating theatre and had a repeat laparotomy, drainage of intra-abdominal abscess and revision of her ileostomy.

• Day 24 post op she returned to theatre for the third laparotomy with abdominal wash out. Abdomen was left open as a laparostomy wound.

• It was noted at each surgery that the bowel was very friable which resulted in the formation of a faecal fistula in the wound.

This case study outlines the management of the patients wound and fistula during her 426 days in hospital and the strategies used in the attempt to discharge during this time.

Care Management Plan

• eakin fistula appliance (839265) with continuous irrigation (50 ml per hour) and continuous suction (Clements wall suction 100mmhg).

• This system was changed PRN depending on the varying volumes of output from the ileostomy and fistula.

• Wound care training was provided for the nursing staff in the ward to ensure continuity of care.

May 2015
October 2015
October 2015
December 2015
December 2015

As the wound healing continued, changes were made to the wound care management plan: the continuous irrigation was reduced to intermittent irrigation to encourage mobility and rehabilitation.

Attempts were made with the use of other appliances and suction omitted, but the very fluid output of about 1500ml per day from the fistula was problematic. The need for intermittent suction connected to the appliance was imperative to maintain a seal.

Preparation for discharge was coordinated with Hospital in the Home. it was necessary to explore avenues of portable suction devices. A Laerdal suction unit was purchased by the hospital.

The Stomal Therapy Team in the hospital created a step by step care plan to ensure continuity of care for an inexperienced community team.

Careplan

1. Use template on wound dressing to size and cut appropriate opening in the bag as shown below.

2. Protect the peri wound skin by picture framing with strips of Eakin cohesive.

3. Position the appliance appropriately.

4. Seal around edges of wound dressing with Opsite Flexigrid (allergy to Tegaderm).

5. Cut rigid connector off the bottom of the appliance.

6. Place suction tubing into the bottom of the fistula bag and secure with an elastic band.

7. Turn on suction for 5 minutes every 2 hours to clear bag of debris and faecal matter. The suction unit has a single on/off switch and the ability to control the level of suction by adjusting the dial on the left of the unit, if needed.

8. When suction not required, remove suction tubing and use the Alligator clip to seal the drainage bag (see below).

Outcome

The team worked together to nurse this lady at home, however due to the complex nature of the high output wound and an under resourced community team, the lady was readmitted to hospital for management. The care plan using the Eakin wound pouch was successfully continued until reoperation and repair.

The management of the fistula and surrounding wound was a challenge to all members of the multi-disciplinary team.

• Capacity to cope with the effluent.

• Skin protection.

• Comfortable in use.

• Flexible on the body which helped to encourage mobility.

• Option to attach to suction.

One eakin Maxi Wound PouchTM solves the Problem

Wound pouches in use

One Eakin Maxi Wound Pouch™ solves the Problem

This case study examines the role of one single Wound Pouch™ with Release™ Adhesive Remover in significantly improving patient comfort

Submitted by: Nicole Wienhold, RN, Abenraa Sygehus, Denmark.

Patient History

• 2010- 61 year old woman had a hysterectomy performed but surgery was complicated by a perforation of the sigmoid colon and a stoma was created.

• Due to obesity the abdominal scar ruptured and was treated with VAC therapy.

• 2011- a parastomal hernia developed.

• The wound was well managed by homecare nurse team.

The patient was worried about undergoing surgery to close the stoma and the wound. However, after careful consideration and evaluation, the decision was made to proceed with some plastic surgical assistance.

• 7 days post-operative, the wound dehisced. The lady developed severe sepsis and was admitted to the Intensive Care Unit.

• She developed an enterocutaneous fistula.

• Further surgery was carried out to close the stoma and the wound, but the fistula was not touched.

The lady has short bowel syndrome and has a central vein catheter to receive parenteral nutrition. She is NIDDM (Non-Insulin-Dependent Diabetes Mellitus) with unstable blood sugar.

Current Problems

Fig. 1 Coloplast pouches in place
Fig. 1 Coloplast pouches in place

The two Coloplast Fistula Pouches were found to be very rigid (Fig. 1), which meant when the patient moved, they leaked. Mobility is severely restricted due to frequent leakages.

Prior to removing the two Fistula Pouches, pain relief had to be administered to the patient. Morphine was given intravenously in advance of the wound dressing, as the pain was unbearable, even when using Welland Adhesive Remover Spray.

 

 

 

Care Management Plan

Fig. 3 Tracing the wound.
Fig. 3 Tracing the wound.
Fig. 2 Wound cleaned and uncovered.
Fig. 2 Wound cleaned and uncovered.

Eakin Release™ Adhesive Remover Spray was recommended and even before the medication could take effect, the pouches were removed from her skin without any pain experienced. Fig. 2 shows the wound uncovered.

The patient’s large wound had deep cavities to the left and right. To avoid the accumulation of output (>2,000ml/24 hours), a Foley catheter was inserted into the fistula and the tube was allowed to drain out of the bung in the Wound Pouch™ into a drainage bag, which remained attached at all times.

• Tracing guide used to draw the shape of the wound (Fig. 3).

• Wound Pouch™ prepared.

• One Eakin Maxi Wound Pouch™ was a perfect fit for this big wound.

• The wound was picture framed (Fig. 4) with Eakin Cohesive® Skin Barriers cut in two long strips with small slits in one side to make it flexible around the wound.

• Eakin Maxi Wound Pouch™ applied to the wound (Fig. 5).

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