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A Home Care Clinical Challenge in Wound and Colostomy Management:

Its Rewards, Inspiration and Positive Outcomes

A Home Care Clinical Challenge

Presented by: Susan L. Appleby BSN, RN, CWOCN Mary H. Eberhard BSN, RN Margaret A. Spears RN Banner Home Care Loveland, CO

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A Home Care Clinical Challenge

Home Care Challenges Increased acuity levels Aging population Co-morbidities Cost containment

A Home Care Clinical Challenge

This clinical challenge involved the management of an elderly patient who had undergone a complex gastrointestinal surgery

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A Home Care Clinical Challenge

Clinical Scenario Unplanned abdominal surgery Problematic colostomy management Second abdominal surgery Surgical wound dehiscence

A Home Care Clinical Challenge

Plan of Care for the First Episode of Care Incision care Wound care Colostomy care Psychosocial support Time management Cost issues

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A Home Care Clinical Challenge

Goal of the Plan of Care To achieve an optimal outcome towards independence and an increased self-esteem

A Home Care Clinical Challenge

Clinical Scenario Ongoing psychosocial support Cost Control Skilled nursing visits Supply usage

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Colostomy Care Challenge

First Medical Event Highlights Unplanned abdominal surgery Problematic colostomy management Psychosocial support Cost Containment

Colostomy Care Challenge

Diagnostic Evaluation Barium Enema Study CT Scan of abdomen and pelvis

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Colostomy Care Challenge

Complex Abdominal Pathophysiology Separation of rectus muscles Protruding omentum

Colostomy Care Challenge

Abdominal Surgery Perforated diverticulum Rectosigmoid colectomy End colostomy Hartmann pouch Paraumbilical hernia repair

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Colostomy Care Challenge

Colostomy Care Challenge

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Colostomy Care Challenge

Expectations of Viable Stoma Color Size and shape Texture Edema Nerve endings Blood supply

Colostomy Care Challenge

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Colostomy Care Challenge

Colostomy Care Challenge

Expectations of Viable Stoma Color Size and shape Texture Edema Nerve endings Blood supply

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Colostomy Care Challenge

Stomal Complication Compromised blood supply Mucocutaneous separation Retraction

Colostomy Care Challenge

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Colostomy Care Challenge

Plan of Care: First Home Care Episode Incision care Colostomy care Psychosocial support Time management Cost issues

Colostomy Care Challenge

Goal

To achieve an acceptable colostomy management system

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Colostomy Care Challenge

Abdominal and Colostomy Assessment Colostomy in the left lower quadrant Pendulous abdomen Deep abdominal fold Hidden stoma

Colostomy Care Challenge

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Colostomy Care Challenge

Colostomy Management Wear time Center Point Lock Convex Pouching System

Colostomy Care Challenge

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Colostomy Care Challenge

Colostomy Care Challenge

Wound Ostomy Continence Nurse Consulted at SOC Patient visits Communication

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Colostomy Care Challenge

Management Modifications Barrier Ring Strip Paste Skin Bond Cement

Colostomy Care Challenge

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Colostomy Care Challenge

Colostomy Care Challenge

Wound Ostomy Continence Nurse Samples of ostomy and skin products Trials SN visits Physician office appointments

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Colostomy Care Challenge

Stomal Complication Stenosis Adequate output Second Surgery

Colostomy Care Challenge

Planned Second Surgery Colostomy repair Colostomy closure Colorectal anastomosis

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Colostomy Care Challenge

Second Surgical Procedure Colostomy revision Permanent end colostomy

Colostomy Care Challenge

Permanent End Colostomy Left upper quadrant Stomal plane Mucocutaneous junction

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Colostomy Care Challenge

Permanent End Colostomy Visibility Function Location of os

Colostomy Care Challenge

Preparation for Discharge to Home Care conference Planning session Transition to home from TCU

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Colostomy Care Challenge

Colostomy Instruction 2 ­ Autolock Pouching System Drainable pouch Pouch closure

Colostomy Care Challenge

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Colostomy Care Challenge

Patient Instructions Written Organization Mirror

Colostomy Care Challenge

Discharge from Home Care Independence Referral to Ostomy Support Group WOCN Follow-up

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Wound Care Challenges

Nursing Problems Home Care Goals Nursing Interventions Meeting Wound Care Goals

Nursing Problems

Dehisced midline abdominal incision Measurements: 13.0 x 7.0 x 6.5 cm Tunnels Thick yellow slough

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Wound Care Challenge

Nursing Problems

Left lateral abdominal wound Site of old colostomy 2.8 x 6.8 x 3.5 cm Tunnel Close proximity to midline wound and new colostomy

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Nursing Problems

Negative Pressure Wound Therapy Deficit in physical and mental ability to manage therapy Knowledge deficits Dressing placement Safety Issues

Nursing Problems

Stage II Pressure Ulcer on Coccyx Measurements: 2.0 x 2.4 x 0 cm

incontinence Exacerbated by pressure and urinary

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Nursing Problems

MRSA Infection of Abdominal Wounds Present on admission No antibiotic treatment Infection control issues

Nursing Problems

Pain Control Post surgical pain Pain with wound care

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Nursing Problems

Nutritional Issues Wound healing Diabetic management

Home Care Goals

Wounds to Heal Without Further Complication

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Home Care Goals

Management of negative pressure wound therapy 24 hour caregivers Independence with routine management Intact dressings Safety

Home Care Goals

Prevention of perineal skin breakdown Management of urinary incontinence Pressure relief

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Home Care Goals

Pain Control Management of post surgical pain Management of pain with dressing changes

Home Care Goals

Infection Control with MRSA Signs and symptoms of wound infection Prevent spread of infection Prevent infection of other persons

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Home Care Goals

Improved Nutritional Status Protein supplements Diabetic management

Nursing Interventions

Negative Pressure Wound Therapy Indications Benefits Mechanisms of action Cost containment

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Wound Management

Definition: Negative Pressure Wound Therapy (NPWT) / V.A.C.® Therapy

· Negative Pressure Wound Therapy (NPWT) is the controlled application of subatmospheric pressure to a wound using an electrical pump

­ To intermittently or continuously convey subatmospheric pressure to a specialized wound dressing which includes a resilient, open-cell foam surface dressing ­ Sealed with an adhesive dressing that is meant to contain the subatmospheric pressure at the wound site and thereby promote wound healing

· Drainage from the wound is collected in a canister

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Wound Management

V.A.C.® (Vacuum Assisted Closure®) Therapy

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Nursing Interventions

KCI Freedom VAC Therapy components Removal of old dressing Preparation of wound bed Protection of periwound skin

Wound Management

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Nursing Interventions

KCI Freedom VAC Continued Application of VAC dressing Obtaining occlusive seal Canister change Troubleshooting Pressure settings

Nursing Interventions

Patient and Caregiver Education Familiarization with the Wound VAC Troubleshooting Canister changes Safety

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Nursing Interventions

Education Continued Accessing home care Perineal care Infection control Nutrition

Nursing Interventions

Post surgical pain management Oral analgesia Positioning Comfort measures

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Nursing Interventions

Wound Care Pain Management Scheduling Topical Lidocaine Positioning Moistening of sponge and removal of old dressing

Nursing Interventions

Infection Control Wound assessment Dedicated equipment Universal precautions Policies and procedures

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Nursing Interventions

Infection Control Continued Disposal of contaminated supplies Hand washing VAC as a closed system

Nursing Interventions

Treatment of Coccyx Pressure Ulcer Duoderm Pressure relief

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Nursing Interventions

Prevention of Perineal Skin Breakdown Hygiene Barrier ointment Toileting Changing of disposable briefs

Nursing Interventions

Nutritional Support Protein supplement Diabetic management Diet instruction

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Progression of Healing

Coccyx Pressure Ulcer Healed in 3 weeks No reoccurrence

Progression of Healing

Management of Incontinence No new skin breakdown

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Progression of Healing

Pain Control Post surgical pain controlled Weaned from Rx pain meds Wound care pain controlled while on VAC Wound care pain controlled off VAC

Progression of Healing

Improved Nutritional Status Arginade discontinued Blood sugars controlled

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Progression of Healing

Patient and Caregiver Independence Independent with VAC in 1 week Safety maintained No prn visits

Progression of Healing

Healing of Left Lateral Abdominal Wound Granulation to skin level in 4 weeks Stop VAC and bridging 3 times per week wound care Closure at 6 weeks

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Progression of Healing

Healing of Midline Abdominal Wound Granulation to skin level in 8 weeks VAC discontinued Daily wound care for 2 weeks 3 times per week care thereafter Use of Promogran Fully granulated at 16 weeks

Progression of Healing

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Progression of Healing

Chart 2

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Cubic Wound Area (cm)

7 6 5 4 3 2 1 0 11/03/03 11/10/03 11/17/03 11/24/03 12/01/03 12/08/03 12/15/03 12/22/03 12/29/03 01/05/04 01/12/04

Date

Midline Abdom inal

Progression of Healing

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Progression of Healing

Resolution of MRSA infection No deterioration of wound status Negative wound culture at discharge No spread of infection

Conclusions

Successful Management of Multiple Wound Care Challenges in the Homecare Setting Problems resolved Goals met

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Psych/Social Challenges

Home Care Admission

Psych/Social Challenges

The 1st 24 Hours Assessing emotional status

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Psych/Social Challenges

The 1st 24 Hours Establishing trust

Psych/Social Challenges

The 1st 24 Hours Survival skills

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Psych Social Challenges

Nursing Problems Minimal Pre Op Teaching

Psych/Social Challenges

Nursing Problems Minimal Pre Op Teaching

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Nursing Problems

Minimal Pre Op Teaching

Nursing Problems

Minimal Pre Op Teaching

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Nursing Problems

Fear and anxiety

Plan of Care

Multidiscipline Approach Patient Strengths and Weaknesses Increased Community Support Self esteem/self image Quality of life

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Multidiscipline Approach

Home Care Team Family Community Resources

Patient Strengths

Determination Intelligence Independence Sense of Humor Pride

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Patient Weaknesses

Pride Fear and Anxiety Unprepared Physical limitations Mild short term memory loss

Community Support

Church Friends Private pay caregivers Family Colostomy support group

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Self Esteem Self Image

Body image Sexuality Relationships

Quality of Life

Independence Purpose Community Involvement

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Reaching Goals

Encouragement Consistency Organization Practice, Practice, Practice Independence

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Information

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