WCET Journal

World Council of Enterostomal Therapists Journal

WCET Journal WCET: a world of expert professional nursing care for people with ostomy, wound or continence needs. ISSN 0819 - 4610

In this issue Selecting the appropriate skin barrier in ostomy care De juiste huidplak kiezen bij stomazorg Choix du protecteur cutané adéquat dans les soins des stomisés Auswahl der geeigneten Hautschutzplatte in der Stomaversorgung Selezione delle barriere cutanee adeguate nella gestione delle stomie ストーマケアにおける適切な皮膚保護剤の選択について Seleccionar la lámina cutánea adecuada para el cuidado del estoma Around the WCET world – WCET UK Product options for faecal incontinence management in acute care Stories from the bedside: Nursing management of a viscerocutaneous fistula (in English and Italian) Abstracts from the 2010 WOCN/WCET Conference WCET Constitution proposed changes for 2012 Translating Research Evidence for WCET Practice: Searching the sea of evidence: Part IV

Print Post 602669/00274

Judy Chamberlain, New WCET Life Member

Volume 32 Number 1 January/March 2012

Matching Individual Needs. That matters.

When it comes to skin barriers, we put the choice in your hands. Matching individual needs is at the core of the skin barrier family from Hollister. No single skin barrier works for everyone. Hollister knows that having the right skin barrier to meet the needs of an individual is an important detail. That is why Hollister offers a comprehensive range of skin barriers. Hollister skin barriers provide you with a choice for the variety of individuals you encounter in your practice. Hollister Ostomy. Details Matter. Hollister and logo is a trademark of Hollister Incorporated. “Hollister Ostomy. Details Matter.” is a service mark of Hollister Incorporated. ©2012 Hollister Incorporated.

www.hollister.com

World Council of Enterostomal Therapists Journal Volume 32 Number 1

January/March 2012

Contents

The World Council of Enterostomal Therapists Journal ISSN 0819-4610 Published quarterly Copyright ©2011 by the World Council of Enterostomal Therapists Printed in Australia

President’s message: Getting the best out of the WCET Congress Louise Forest-Lalande

4

Editorial: Write Right Elizabeth A Ayello

7

Selecting the appropriate skin barrier in ostomy care Paris Purnell

8

De juiste huidplak kiezen bij stomazorg

9

Choix du protecteur cutané adéquat dans les soins des stomisés

10

ANNUAL SUBSCRIPTION RATES

Auswahl der geeigneten Hautschutzplatte in der Stomaversorgung

11

Non-members International all regions (airmail) US$60

Selezione delle barriere cutanee adeguate nella gestione delle stomie

12

ストーマケアにおける適切な皮膚保護剤の選択について 13

Institutional subscriber International all regions (airmail) US$120 Single copies and reprints available on request at US$15 each (includes airmail postage) PUBLISHED QUARTERLY BY

Seleccionar la lámina cutánea adecuada para el cuidado del estoma

14

Around the WCET world – WCET UK Jo Sica

15

Product options for faecal incontinence management in acute care Jan Powers & Donna Zimmaro Bliss

20

Stories from the bedside: Nursing management of a viscerocutaneous fistula (in English and Italian) Mario Antonini & Gaetano Militello

a division of Cambridge Media 10 Walters Drive Osborne Park WA 6017 Australia Tel (61) 8 6314 5222 Fax (61) 8 6314 5299 www.cambridgemedia.com.au Advertising Sales Simon Henriques Email [email protected] Copy Editor Rachel Hoare Graphic Designer Sarah Horton NON-EDITORIAL WCET CORRESPONDENCE WCET Central Office 15000 Commerce Parkway Suite C Mount Laurel, NJ 08054 USA Tel 856-437-0386 Fax 856-439-0525 Email [email protected] Connect with us free on Skype – search for wcetoffice to connect with us or leave an Instant Message. Remittances and notification of change of address to be directed to the WCET Central Office (address above)

26

Abstracts from the 2010 WOCN/WCET Conference Karen Zulkowski

33

WCET Constitution proposed changes for 2012 WCET Constitution Advisory Panel

36

Message from the 2012 WCET Congress Convenor Fiona Bolton

39

Translating Research Evidence for WCET Practice: Searching the sea of evidence: Part IV Robert E Burke & Rona F Levin & Shannon B Kealey

40

Judy Chamberlain, New WCET Life Member Dee Waugh

42

Product news

44

WCET International Delegates

46

The World Council of Enterostomal Therapists Journal is indexed in the Cumulative Index to Nursing and Allied Health Literature. Disclaimer Opinions expressed in the WCET Journal are those of the authors and not necessarily those of the World Council of Enterostomal Therapists, the Editor or the Editorial Board.

WCET: a world of expert professional nursing care for people with ostomy, wound or continence needs.

Journal Sustaining Partnerships

www.wcetn.org 1

World Council of Enterostomal Therapists An Association of Nurses Registered Charity 1057749

Executive officers

Editorial board

President Louise Forest-Lalande RN, MEd, ET 6830 De Lanaudiere Montréal, Québec H2G 3B3 Canada Tel (1) 514 276 4971 (h) Email [email protected]

Journal Executive Editor Elizabeth A Ayello PhD, RN, ACNSBC, CWON, ETN, MAPWCA, FAAN 209-14 82 Avenue, Hollis Hills New York 11427 USA Email [email protected]

Vice-President Susan Stelton MSN, RN, ACNS-BC, CWOCN Clinical Nurse Specialist Banner Good Samaritan Medical Center 1111 East McDowell Road Phoenix, AZ 85006 USA Email [email protected] Secretary Dee Waugh RN, RM, ET Stomal therapist – Private Practice Clinic Address: 2nd Floor GIT Unit, Kingsbury Hospital Claremont, Cape Town, South Africa Postal Address: PO Box 44598, Claremont 7735 South Africa Mobile +27 83 600 9521 Email [email protected] Skype dee.waugh1 Treasurer Walter Lo H2 Ward, Queen Elizabeth Hospital 30 Gascoigne Road, Yau Ma Tei Kowloon, Hong Kong Email [email protected] Tel (852) 295 0595

Journal Board members Judith Weller: Assistant Editor, Ostomy Karen Zulkowski: Assistant Editor, Wounds Sharon Baranoski Pat Black Eva Carlsson Barbara Delmore Sarah Lebovits Kelly Lai-Li Lee Chi Keung Peter Lai Rona Levin Jill Marshall Daniel K O'Neill Deborah Rastinehad Vera Lucia Santos R Gary Sibbald Barbara Suggs Julia Thompson Deidre Waugh Michelle Lee Wai-Kuen Kevin Woo

Chairpersons of Standing Committees Education Carmen George 17 Currawong Avenue Glenalta, SA 5052 Australia Mob (61) 410 370 210 Email [email protected] Norma N Gill Foundation Chi Keung Peter Lai MNurs, RN, ET Queen Mary Hospital Flat C, 34/F, Block 2, Cayman Rise 29 Ka Wai Man Road, Kennedy Town Hong Kong Tel (852) 9400 3275 Email [email protected] Publications and Communications Karen Zulkowski College of Nursing Montana State University Bozeman MSU Billings Campus Box 574, Billings, MT 59101 Email [email protected]

Congress Liaison Elizabeth English RN, CETN Royal Adelaide Hospital North Terrace, Adelaide, SA 5000 Australia Fax (61) 8 8449 1821 Email [email protected]

The WCET mission is to lead the global advancement of specialised professional nursing care for people with ostomy, wound or continence needs

WCET Journal 2

Volume 32 Number 1 – January/March 2012

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*Source: Product evaluation results DK, UK, FI, NL, CH. Total respondents: 218

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The colostomy appliance that follows every body movement SenSura Mio fits individual body contours and follows your body movements. Whether you are bending down, stretching or twisting, this colostomy appliance maintains a secure fit thanks to the elastic adhesive. So you can feel secure. Sign up for free samples of SenSura Mio on www.sensuramio.coloplast.com

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Coloplast a/S, Holtedam 1, 3050 Humlebæk The Coloplast logo is a registered trademark of Coloplast a/S. © 2012-02. all rights reserved Coloplast a/S, 3050 Humlebæk, Denmark.

Watch a video with users’ reactions to trying SenSura Mio.

President’s message

Getting the best out of the WCET Congress

Louise Forest-Lalande RN, MEd, ET WCET President Montreal, Canada [email protected] Dear WCET members, colleagues and friends, The year 2011 has brought joy and new experiences, and for some, also tragic events. I sincerely hope that 2012 will bring positive and constructive challenges, good health, joy and peace. This is an important year for the WCET. It is the year of our biennial congress. Thanks to the tireless work of Fiona Bolton and her team, and of Elizabeth English, WCET congress liaison, the WCET will fulfil its mission and objectives to: • provide opportunities for members to meet together for the purpose of discussing matters of common interest in enterostomal therapy nursing • promote activities which will assist members to engage in and increase their knowledge of and enhance their contribution in the field of enterostomal therapy nursing • promote increased awareness of the role and contribution of the WCET. The WCET Congress indeed represents a great opportunity to meet all of these objectives. It is, however, essential to prepare yourself for this meeting in order to gain the most benefit and, subsequently, transfer any newly acquired knowledge into daily practice. For some of you, it will be your first WCET meeting. To these I say be ready to live an outstanding experience at both a personal and professional level. The WCET meeting is unique in itself because of its Mission and Values, but mostly, because of its membership. Hopefully you have registered for the congress prior to arriving in Adelaide. When arriving at the meeting, pick up your conference registration materials as soon as possible in order to get a copy of the program. Study it carefully and identify the sessions you plan to attend. Doing so will prevent you from missing lectures you would have liked to attend and will enable you to take advantage of sessions. Networking is one of the major benefits of the meeting, so prepare yourself accordingly. Try to meet two or three new people each day and be sure to bring your business cards. WCET Journal 4


Although it is always comforting to be with friends and colleagues we already know, increasing your network is a priceless experience. You never know when you or your patients will need the support or advice of a health care professional living in another country. Attending all the lectures may become overwhelming. Plan to have some free time in order to remain motivated and open to the speakers’ messages. If you are hesitant to ask questions in large groups, meet the speaker after the session. When visiting the posters, chat with the authors. Always keep in mind that it is greatly valuable for a speaker or the author of a poster to get your feedback. This can often create good discussion and new ideas. Be sure to dress comfortably. It is always a good idea to bring a vest or a pashmina to the meeting since providing the perfect room temperature that will accommodate everyone is not always possible. It is very important to attend the General Meeting that will be held on Sunday 22 April at 7:30 am. This meeting is the opportunity for members to voice their concerns and comments and to get answers and feedback from the WCET Board. We need and value your input since it helps us to plan and prioritise our projects and activities according to your needs. The International Delegate (ID) of your country should have been in touch with you to enquire about any concerns, issues or questions you may have and also for your vote on constitutional or other changes. Your reply is very important since your ID will be voting on your behalf. Finally, when returning to your workplace, prepare a summary report to let your colleagues and manager know how beneficial your attendance at the meeting was, what you learned, how it may change your practice and, most importantly, how this can improve the quality of life of the patients as well as the quality of care your hospital is providing. The WCET meeting is also an opportunity to share with colleagues from all around the world what you have done in your own clinical practice such as projects you have been involved with or articles you have published. More than 200 abstracts have been received!! Congratulations to those who sent abstracts and will be taking this opportunity to share with their WCET colleagues. Some will be presenting for the first time. Kudo! This is wonderful! Some are old-timers and we always learn from them. Join us in honouring WCET’s newest life member, Judy Chamberlain! You will also have the chance to attend symposia organised by industry. These are extremely valuable as this is where you will learn about new products and technologies.

As you can see, everything has been planned for another enriching meeting. In addition, there will be some exciting surprises. We hope to see many of you in Adelaide. Your Board colleagues and I are looking forward to meeting you there!!! Finally, I would like to take this opportunity to inform you that Karen Zulkowski is now replacing Carole Abboud as the acting Publications and Communications Chairperson until the elections in Adelaide at the General Meeting. I want to thank Carole for her contribution to the WCET and to the committee and to welcome Karen. I wish you a great meeting; I am sure that it will be an experience you will want to renew!! For more information, please visit the website: wcetn.org

les conférences auxquelles vous auriez aimé assister ainsi que de profiter pleinement du plus grand nombre de communications. La possibilité de réseautage est l’un des avantages majeurs du congrès alors préparez-vous en conséquence. Essayez de faire la connaissance de deux à trois nouvelles personnes à chaque jour et n’oubliez pas d’apporter vos cartes d’affaires. Bien qu’il soit toujours réconfortant d’être avec ses amis et collègues, l’accroissement de votre réseau peut s’avérer une expérience inestimable. Vous ne savez jamais quand vous ou un de vos patients aurez besoin du support ou des conseils d’un professionnel de la santé d’un autre pays.

Chers membres du WCET, collègues et amis,

Assister à toutes les conférences peut s’avérer épuisant. Planifiez des moments de temps libre afin de rester motivés et ouverts aux messages des conférenciers. Si vous hésitez à poser des questions devant un auditoire, rencontrez le conférencier après la séance et lors de la visite des affiches discutez avec les auteurs. Rappelez-vous qu’il est précieux pour un conférencier ou l’auteur d’une affiche d’obtenir vos commentaires. Cela peut souvent donner lieu à des discussions intéressantes et mener à de nouvelles idées.

2011 a apporté ses joies et ses réalisations, et pour certains, elle aura aussi donné lieu à de tragiques événements. Je souhaite sincèrement que 2012 vous apporte des défis positifs, la santé, la joie et la paix.

Portez des vêtements confortables. C’est toujours une bonne idée d’apporter une veste ou un châle à la réunion puisqu’il n’est pas toujours facile d’offrir une température ambiante confortable pour tous dans de grandes salles de conférence.

2011 est aussi une année très importante pour le WCET puisque c’est l’année de notre Congrès biennal. Une fois de plus, grâce au travail inlassable de Fiona Bolton et de son équipe ainsi que de Elizabeth English, liaison pour le congrès, le WCET peut remplir sa mission et ses objectifs de façon à:

Il est très important d’assister à l’Assemblée générale du WCET qui aura lieu le dimanche 22 avril à 07h30. Cette réunion est l’occasion pour les membres de poser des questions et de demander des clarifications afin d’obtenir des réponses et des explications du Conseil d’administration du WCET. Vos commentaires sont d’une grande valeur pour nous et ils nous aident à prioriser et à planifier nos activités futures en fonction de vos besoins. La Délégué Internationale (ID) de votre pays devrait vous avoir contacté pour s’enquérir de vos préoccupations ou questions ainsi que pour obtenir votre vote sur les modifications constitutionnelles. Votre réponse est très importante car votre Délégué Internationale votera en votre nom.

Kind regards from Canada, Louise Tirer le meilleur du Congrès du WCET

• permettre aux membres de se rencontrer pour discuter de points d’intérêt commun • promouvoir des activités qui inciteront les membres à s’engager et à mettre à jour leurs connaissances ainsi que de renforcer leur contribution dans le domaine de la stomathérapie • promouvoir le rôle et la contribution du WCET. Le congrès du WCET représente une excellente occasion de rencontrer tous ces objectifs. Il est cependant essentiel de vous préparer à ce congrès afin d’en tirer le plus de bénéfices possible et par la suite, de transférer vos connaissances nouvellement acquises dans votre pratique quotidienne. Certains d’entre vous assisteront au congrès du WCET pour la première fois; tout comme pour les habitués du congrès, il est important de se préparer à vivre une expérience exceptionnelle tant au niveau personnel que professionnel. Le congrès du WCET est unique en soi en raison de sa mission et de ses valeurs, mais surtout, en raison de ses membres. Dès votre arrivée au congrès, présentez-vous au kiosque de bienvenue pour obtenir une copie du programme, étudiez-le attentivement afin d’identifier les sessions qui vous intéressent. Cela vous permettra d’éviter de manquer

Enfin, lorsque vous reviendrez dans votre milieu de travail, je vous incite à préparer un rapport sommaire pour vos collègues ainsi que votre gestionnaire afin de l’informer des bénéfices retirés de votre présence au congrès du WCET et de l’influence que cela aura sur votre pratique. Faites ressortir comment cela peut améliorer la qualité de vie des patients ainsi que la qualité des soins offerts dans votre centre. Le congrès du WCET est également une occasion de partager avec des collègues de partout dans le monde vos réalisations, les projets dans lesquels vous avez été impliqué ou les articles que vous avez publiés. Plus de 200 résumés ont été reçus, félicitations à ceux qui en ont envoyés et qui auront saisi cette occasion pour partager avec leurs collègues. Certains présenteront pour la première fois, bravo! Joignez-vous à nous pour honorer notre nouveau membre à vie, Judy Chamberlain! Vous aurez également la chance d’assister www.wcetn.org 5

à des activités éducatives organisées par l’industrie. Ces activités sont très valables car c’est là que vous en apprendrez davantage sur les nouveaux produits et les technologies les plus récentes. Comme vous pouvez le constater, tout a été planifié pour vous offrir un autre congrès enrichissant où il y aura aussi quelques surprises intéressantes. Nous espérons vous voir nombreux à Adélaïde. Mes collègues du Conseil d’administration et moi-même seront ravis de vous y rencontrer! Je profite finalement de cette occasion pour vous informer que Karen Zulkowski remplace maintenant Carole Abboud comme responsable du comité Publications et Communications jusqu’aux prochaines élections qui auront lieu à Adélaïde lors de l’Assemblée générale. Je tiens à remercier Carole pour sa contribution au WCET et accueille chaleureusement Karen. Je vous souhaite un excellent congrès et je suis convaincue que ce sera une expérience que vous souhaiterez renouveler! Pour plus d’informations, prière de visiter le site Web wcetn.org. Meilleures salutations du Canada, Louise

WCET Journal 6


Thank You Since 2011, FOW-USA has allocated funding to support awards of Membership Scholarship of the Norma N. Gill Foundation. This collaborating initiative signifies the close relationship between WCET and FOWUSA and their shared vision to promote ET nursing worldwide. We would like to express our heartfelt thank to FOW-USA for their generosity. NNGF Membership Scholarship recipients include: • Seyedeh Sakineh Seyedpour (Iran) • Sarojini Sharma (Nepal) • Ravin Dela Cruz (Philippine) They are awarded WCET membership status for one year.

Editorial

Write Right Elizabeth A Ayello PhD, RN, ACNS-BC,CWON, ETN, MAPWCA, FAAN Executive Editor, World Council of Enterostomal Therapists Journal New York, NY, USA [email protected]

This editorial is inspired by my WCET UK colleagues. During a skype call to discuss the WCET Journal and the launch of the new column by Jo Sica “Around the WCET world – WCET UK”, which premiers in this issue, it became clear that I needed to write an editorial about our publication process. A journal needs manuscripts to publish. To those of you who have submitted your manuscripts to us, we say thank you. The volunteers who are members of the Editorial Board work hard to peer review the manuscripts and provide feedback. The content Assistant Editors, Karen Zulkowski for wounds and Judith Weller for ostomy, work with me to make a decision about whether or not to publish the manuscript. As volunteers, we are doing our best to continue the quality of the journal that we inherited from the previous editorial team. Because our journal is committed to publishing a wide range of articles from research, case discussions, to practice hints and tips, as well as mentoring new authors and those for whom English is not their first language, the review process takes time. I understand that some members would like more ostomy articles. In order to do that, I am asking those of you that have interesting ostomy cases with photos, please write them up and send them to us for consideration. Judith Weller is retiring from being Assistant Editor for ostomy. The two new Co-editors, Sarah Lebovits (Sarah. [email protected]) and Kevin Woo (kevinywoo@gmail. com) are eager to receive your manuscripts and get working on this. By the way, once manuscripts are accepted and all the content is put into a proof by Sandra Carbone from Cambridge Media and her production staff, on average, it takes six versions of the proof to get everything right. Sometimes, adjustments have to be made for space requirements; this is always challenging! You may find it interesting to know that many people do not know now to write correctly and do not share their knowledge and clinical experiences with their colleagues.

I want to let you know that the editorial team at the WCET Journal will work with you, so if you have never written before, do not be afraid to write. In fact you are in good company. From an email from one of the editors from the INANE list serve, I learned that Google released its annual Zeitgeist list of what internet users have been searching for on Google during the past year. As your WCET Editor, I was happy to learn that people everywhere really want help on how to write. The #1 and #3 topics on the list of Top Ten “How to “ searches for 2011 had to do with writing. Claiming the #1 spot for searches was “how to revise”. Number three was “how to reference”. For your information, WCET provides examples of how to reference for our journal style in our guidelines for authors, which you can find on our website. I’m sure you are wondering what was #2; I know I did. It was how to snog. I did not know what that is so I had to Google it, which you can do also. This issue of the journal is our Congress issue. It contains important manuscripts for your consideration including the work in English and Italian in this rendition of stories from the bedside by Mario Antonini and Gaetano Militello, faecal incontinence products by Jan Powers and Donna Bliss, and a short report on selecting appropriate ostomy skin barriers by Paris Purnell in multiple languages (English, Dutch, French, German, Italian, Japanese, and Spanish) which highlights key messages from this journal issue's supplement entitled “Selecting the appropriate Skin Barrier in Ostomy Care“. Dr Zulkowski provides the last of the abstracts from the WCET/ WOCN Phoenix congress, while Dr Levin and colleagues has given us yet another interesting aspect on research for WCET nursing practice in “Searching the sea of evidence, Part IV”. Our next congress is almost here! In preparation for our meeting at the Adelaide Congress, please read the proposed Constitution changes and let your country ID know your comments so they can vote of your behalf. Please also read about our newest Life Member, Judy Chamberlain, who will be celebrated at the Congress. The last installment of "Countdown to Congress" is provided in this issue as well. Fiona Bolton, Elizabeth English, and the rest of the very hard-working Congress planning team are looking forward to seeing you in Adelaide. The scientific programme is outstanding, so make your plans now to attend. And if you need help with 'writing right', come to my session on “Writing for publication”. I will be happy to see you there! www.wcetn.org 7

Selecting the appropriate skin barrier in ostomy care are discussed in greater detail in the supplement article by Rolstad, Ermer-Seltun and Bryant.

Paris Purnell RN, STN Global Marketing Manager Hollister Inc., Libertyville, IL, USA [email protected]

Abstract This article explores the process of ostomy skin barrier selection as it relates to the clinician involved in the care of people with ostomies. It also introduces the Skin Barrier Selector Tool which can enable clinicians proactively to select the appropriate skin barrier.

Today, ostomy product manufacturers use differing formulae and construction methods in the making of skin barriers to achieve differing performance characteristics to address the aforementioned issues. Even within some manufacturers’ product lines, there are several differing skin barrier formulations that have been developed to achieve different outcomes. Such differences include wear time, ease of use or durability. One challenge that can arise for clinicians is the understanding of what these differences are in order to select the most appropriate ostomy skin barrier for their patients.

An important role for ET nurses is determining which skin barrier and pouching system to recommend for a person with an ostomy. While it is well-documented that the maintenance of healthy peristomal skin is one fundamental in achieving good quality of life outcomes for any person who has an ostomy, most discussions around peristomal skin care are reactive rather than proactive1. Some recommended steps that a clinician should make when assessing a patient for a suitable ostomy skin barrier at an earlier stage of management are introduced here and described in more detail in the supplement that accompanies this journal issue.

A simple to use tool (the Skin Barrier Selector Tool) was developed by one manufacturer to aid the clinician in the process of appropriate skin barrier selection3. Based around the differing requirements of stoma output, skin type and change frequency, this tool was evaluated by clinicians across several countries with multiple patients3. Using this tool, the nurses were asked to assess an individual's needs based on these three criteria and then select the skin barrier based on the recommendations made by the tool. Overall, the tool was found to be helpful in choosing the appropriate skin barrier for an individual. These clinicians recommend its use by their colleagues. It could also be argued that selecting the skin barrier earlier for a patient may positively influence clinical outcomes and that this process is a more proactive step in achieving patient goals. The findings of this evaluation are contained in narrative and graphs in the article by Nichols, Menier and Purnell in the journal supplement3.

Peristomal skin

References

Introduction

As the skin is the anchor point for the ostomy skin barrier of any pouching system, it is generally well-accepted that the skin barrier should maintain an adequate skin seal around the stoma to shield and protect the skin from ostomy discharge. However, this is not the sole function of the skin barrier. Ostomy skin barriers should have strong enough adhesion to support an ostomy pouching system and its contents, while being easy to remove without causing mechanical skin trauma from stripping. Skin barriers should also maintain the peristomal skin in an optimal condition by being both absorptive and adherent. Stoma discharge, change frequency, and the differing skin types (of which there are four), may also impact the performance of a skin barrier2. In particular, peristomal skin is often subject to greater stressors than skin that is not generally covered by an adhesive skin barrier as it is subjected to continuous assault from either traumatic removal or stoma output. These particular issues WCET Journal 8


1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

Why read more about this in the supplement? • Compare the four types of skin: oily, normal or combination, dry and sensitive. • Read the data results from a survey of your ostomy nurse colleagues who have already used the Skin Barrier Selector Tool. • Learn how the Skin Barrier Selector Tool can be used proactively to determine the best skin barrier for your ostomy patient.

De juiste huidplak kiezen bij stomazorg Abstract Dit artikel laat aan de professionals, die betrokken zijn bij de zorg rondom de stomadrager, het proces zien dat nodig is bij het selecteren van de soort huidplak. Het is ook een introductie van de huidplakselector die professionals in staat stelt om pro-actief de juiste huidplak te selecteren.

Inleiding Er is een belangrijke rol voor stomaverpleegkundigen weggelegd om te bepalen welke huidplak en welk opvangzakje geadviseerd kan worden aan een persoon met een stoma. Terwijl het goed gedocumenteerd is dat het behouden van een gezonde peristomale huid fundamenteel is om een goede levenskwaliteit te bieden aan iemand met een stoma, zijn de meeste discussies over de peristomale huid eerder reactief dan proactief 1. In de bijlage bij dit artikel worden enkele aanbevolen stappen uitgelegd die de professional zou moeten nemen bij het maken van een keuze voor een huidplak voor een patiënt in een vroeg stadium van de verzorging. Deze stappen worden in detail besproken in het artikel. Peristomale huid Wanneer de huid het startpunt is voor de huidplak, ongeacht het opvangsysteem, is men het over het algemeen over eens dat de huidplak voldoende huid rond de stoma moet bedekken om de huid te beschermen tegen allerlei complicaties. Dat is echter niet de enige functie van de huidplak. De huidplakken moeten voldoende kleefkracht hebben om een stomasysteem en de inhoud ervan te dragen, terwijl ze toch makkelijk te verwijderen moeten zijn en geen huidletsels mogen veroorzaken bij het verwijderen. De huidplakken moeten de peristomale huid ook in optimale conditie houden door zowel te absorberen als te kleven. De frequentie van het ledigen van de stoma en vervangen van de huidplak en de vier verschillende huidtypes, kunnen eveneens een invloed hebben op de doelmatigheid van de huidplak2. Vooral de peristomale huid is vaak onderworpen aan meer stressveroorzakende factoren dan de huid die over het algemeen niet is bedekt met een huidplak, aangezien de stoma voortdurend moet worden vervangen of er lekkages kunnen zijn, wat de huid kan beschadigen. Die specifieke factoren worden gedetailleerder besproken in het bijgevoegde artikel door Rolstad, Ermer-Seltun en Bryant. Va n d a a g d e d a g g e b r u i k e n d e f a b r i k a n t e n v a n stomaproducten verschillende formules en fabricagemethodes bij het maken van huidplakken, zodat ze verschillende kenmerken kunnen verkrijgen om

de bovenvermelde kwesties aan te pakken. Zelfs binnen de productlijnen van bepaalde fabrikanten bestaan er verschillende huidplak formules die werden ontwikkeld om verschillende resultaten te behalen. Deze verschillen omvatten draagduur, gebruiksgemak of duurzaamheid. Een uitdaging voor de professional is het begrijpen welke deze verschillen zijn om zodoende de meest geschikte huidplak voor de patiënt te kiezen. Eén fabrikant ontwikkelde een eenvoudig te gebruiken hulpmiddel (de huidplakselector) om de professional te helpen bij het kiezen van een geschikte huidplak3. Dit hulpmiddel, dat gebaseerd is op de verschillende vereisten zoals productie uit de stoma, huidtype en regelmaat van vervanging, werd geëvalueerd door professionals en bij verschillende patiënten 3 . De verpleegkundigen werd gevraagd om, wanneer ze deze tool gebruikten, de behoeften van een persoon in te schatten op basis van deze drie criteria en dan de huidplak te kiezen op basis van de aanbevelingen van het hulpmiddel. et hulpmiddel werd over het algemeen heel nuttig bevonden bij het kiezen van de geschikte huidplak voor een patiënt. Deze professionals raden hun collega’s aan om het hulpmiddel te gebruiken. Men kan aanvoeren dat het vroegtijdig uitkiezen van een huidplak voor een patiënt een positieve invloed kan hebben op de klinische resultaten en dat dit proces een pro-actievere stap is naar het bereiken van de doelstellingen voor de patiënt. De bevindingen van deze evaluatie worden uitvoerig besproken en grafisch geïllustreerd in het artikel door Nichols, Menier en Purnell in de bijlage van het tijdschrift3. Referenties 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

Waarom hierover meer lezen in de bijlage? • Vergelijk de vier huidtypes: vet, normaal of een combinatie van de twee, droog, en gevoelig. • Lees de gegevensresultaten van een enquête bij uw collega-verpleegkundigen die gespecialiseerd zijn in stoma's en de huidplakselector al hebben gebruikt. • Leer hoe de huidplakselector proactief kan worden gebruikt om de beste huidplak voor uw stomadrager te bepalen.

www.wcetn.org 9

Choix du protecteur cutané adéquat dans les soins des stomisés Résumé analytique Cet article explore le processus de sélection du protecteur cutané en cas de stomie, qui s’adresse aux cliniciens chargés des soins des stomisés. Par ailleurs, il présente l’outil de sélection du protecteur cutané (le Skin Barrier Selector Tool) qui permet aux cliniciens de choisir de manière proactive le protecteur cutané adéquat.

Introduction Un des rôles importants des infirmiers stomothérapeutes consiste à déterminer quel protecteur cutané et quel système de poche recommander pour un stomisé. Malgré l’existence de nombreuses preuves démontrant qu’il est essentiel de préserver une peau péristomiale saine afin d’assurer à toute personne porteuse d’une stomie une qualité de vie optimale, la plupart des discussions autour des soins de la peau péristomiale sont réactives plutôt que proactives1. Certaines des étapes recommandées qu’un clinicien doit suivre au moment d’évaluer le protecteur cutané adapté pour un patient stomisé en phase précoce de traitement sont présentées ici et décrites de façon circonstanciée dans le supplément qui accompagne ce numéro. Peau péristomiale La peau étant le point d’ancrage du protecteur cutané de tout système de poche, il est généralement admis que le protecteur cutané doit être constitué d’un adhésif adéquat maintenu autour de la stomie pour faire écran et protéger la peau contre un éventuel écoulement. Il ne s’agit toutefois pas de l’unique fonction du protecteur cutané. Les protecteurs cutanés doivent adhérer avec force et de façon suffisante afin de soutenir le système de poche et son contenu, et présenter en même temps des facilités de retrait sans causer un traumatisme mécanique cutané suite à des éraflures. Les protecteurs cutanés doivent également préserver la peau péristomiale dans un état optimal grâce à des caractéristiques à la fois absorbantes et adhésives. Les fuites sous l’appareillage, la fréquence de changement et les différents types de peau (au nombre de quatre) peuvent aussi avoir des répercussions sur la performance d’un protecteur cutané 2. En particulier, la peau péristomiale est souvent soumise à des agents stressants plus importants qu’une peau généralement non recouverte d’un protecteur cutané adhésif, et elle est l’objet d’une agression continue suite à un retrait traumatique ou à une sortie de la stomie. Ces problèmes particuliers sont abordés plus en détail dans le supplément par Rolstad, Ermer-Seltun et Bryant. De nos jours, les fabricants de produits pour stomies utilisent différentes formules et méthodes de construction dans la confection des protecteurs cutanés afin de parvenir WCET Journal 10


à des caractéristiques diverses et régler les problèmes susmentionnés. Au sein même des gammes de produits de certains fabricants, nombreuses sont les différentes formulations des protecteurs cutanés, toutes élaborées afin d’obtenir des résultats variés. Parmi de telles différences figurent le seuil d’usure, la facilité d’emploi ou la durabilité. Les cliniciens peuvent se retrouver confrontés à un défi, à savoir comprendre quelles sont ces différences afin de choisir le protecteur cutané le mieux adapté pour les patients stomisés. Un fabricant a développé un outil convivial (le Skin Barrier Selector Tool) afin d’aider les cliniciens dans le processus de sélection des protecteurs cutanés adéquats3. Articulé autour des diverses exigences de sortie pour stomies, de type de peau et de fréquence de changement, cet outil a été évalué par des cliniciens sur de multiples patients dans plusieurs pays3. Les infirmiers ont été invités à évaluer, au moyen de cet outil, les besoins d’une personne en fonction de ces trois critères, puis à sélectionner le protecteur cutané d’après les recommandations faites par l’outil. L’outil s’est révélé globalement utile dans le choix du protecteur cutané adéquat pour une personne. Ces cliniciens recommandent son usage à leurs collègues. On pourrait par ailleurs affirmer que le choix du protecteur cutané à un stade précoce pour un patient peut influer positivement sur les résultats cliniques, et que cette méthode constitue une étape plus proactive pour atteindre les objectifs du patient. Les résultats de cette évaluation figurent dans l’exposé de faits et les diagrammes de l’article par Nichols, Menier et Purnell dans le supplément du journal3. Références 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

Pourquoi en lire davantage à ce sujet dans le supplément ? • Comparez les quatre types de peau : peau grasse, peau normale ou mixte, peau sèche et peau sensible. • Lisez les résultats d’une enquête effectuée auprès de vos collègues infirmiers stomathérapeutes qui ont déjà utilisé l’outil de sélection du protecteur cutané (le Skin Barrier Selector Tool). • Apprenez à vous servir de manière proactive de l’outil de sélection du protecteur cutané (le Skin Barrier Selector Tool) pour déterminer le protecteur cutané le mieux adapté à votre patient stomisé.

Auswahl der geeigneten Hautschutzplatte in der Stomaversorgung Zusammenfassung Dieser Fachartikel untersucht den Prozess zur Auswahl einer Hautschutzplatte in der Stomaversorgung durch klinisches Fachpersonal, die in der Versorgung von Stoma-Patienten tätig sind. Er stellt ebenfalls das Auswahltool für Hautschutzplatten vor, mit dessen Hilfe klinische Fachkräfte die geeignete Hautschutzplatte auswählen können.

Einleitung Eine bedeutende Aufgabe für Fachpflegekräfte im Bereich Enterostomatherapie ist es, festzulegen, welche Hautschutzplatte und welches Beutelsystem für einen StomaPatienten empfohlen werden soll. Es ist zwar ausführlich dokumentiert, dass die Pflege einer gesunden peristomalen Haut grundlegend für eine gute Lebensqualität von Stoma-Patienten ist, jedoch sind die meisten Diskussionen zu peristomaler Haut eher reaktiv als proaktiv 1. Einige empfohlene Schritte, die eine Fachpflegekraft bei der Untersuchung eines Patienten hinsichtlich einer geeigneten Stoma-Hautschutzplatte in der frühen Phase der Behandlung ergreifen sollte, werden hier vorgestellt und im Beiheft zu dieser Ausgabe ausführlicher erläutert. Peristomale Haut Da die Haut als Befestigungspunkt für die StomaHautschutzplatte eines Beutelsystems dient, ist es weithin anerkannt, dass die Hautschutzplatte die stomaumgebende Haut hinreichend abdichten sollte, um die Haut vor Ausscheidungen aus dem Stoma zu schützen. Dies ist jedoch nicht die einzige Aufgabe der Hautschutzplatte. Stoma-Hautschutzplatten müssen eine ausreichend starke Haftfähigkeit aufweisen, um ein Stoma-Beutelsystem und dessen Inhalt halten zu können, und dabei einfach zu entfernen sein, ohne eine mechanische Verletzung der Haut durch das Abziehen zu verursachen. Ferner sollten Hautschutzplatten den optimalen Zustand der peristomalen Haut durch ideale Absorptionsfähigkeit und Haftfähigkeit bewahren. Ausscheidungen aus dem Stoma, häufiges Wechseln und die unterschiedlichen Hauttypen (von denen es vier gibt) können sich ebenfalls auf die Leistungsfähigkeit einer Hautschutzplatte auswirken2. Vor allem die stomaumgebende Haut ist oftmals stärkeren Stressfaktoren ausgesetzt als Haut, die nicht mit einer haftenden Hautschutzplatte abgedeckt ist, da sie einer ständigen Belastung entweder durch Trauma durch Abziehen der Hautschutzplatte oder Ausscheidungen aus dem Stoma unterliegt. Diese speziellen Probleme werden ausführlich im ergänzenden Artikel von Rolstad, Ermer-Seltun und Bryant diskutiert. Hersteller von Stomaprodukten verwenden heute unterschiedliche Zusammensetzungen und Konstruktionen bei der Herstellung von Hautschutzplatten, um unterschiedliche Leistungsmerkmale zur Behebung der

vorgenannten Probleme zu erzielen. Selbst innerhalb der Produktgruppen einiger Hersteller gibt es verschiedene Zusammensetzungen von Hautschutzmixturen, die entwickelt wurden, um unterschiedliche Resultate zu erzielen. Dabei gibt es u. a. Unterschiede bei der Tragezeit, Benutzerfreundlichkeit oder Strapazierfähigkeit. Eine Herausforderung für Pflegepersonal besteht darin, diese Unterschiede zu kennen, um die am besten geeignete Hautschutzplatte für den Patienten auswählen zu können. Von einem Hersteller wurde ein einfach zu verwendendes Hilfsmittel (der Hautschutznavigator) entwickelt, um Pflegekräften bei der Auswahl der geeigneten Hautschutzplatte behilflich zu sein3. Dieses Tool, das auf den abweichenden Anforderungen Stoma-Ausscheidungen, Hautzustand und Wechselhäufigkeit basiert, wurde von Pflegepersonen in verschiedenen Ländern anhand zahlreicher Patienten beurteilt 3. Die Pflegekräfte wurden gebeten, unter Verwendung dieses Tools die Bedürfnisse der einzelnen Personen ausgehend von diesen drei Kriterien zu untersuchen und anschließend die Hautschutzplatte ausgehend von den Empfehlungen des Tools auszuwählen. Im Großen und Ganzen erwies sich das Tool bei der Auswahl der geeigneten Hautschutzplatte für eine Person als hilfreich. Diese Pflegekräfte empfehlen ihren Kollegen die Verwendung des Tools. Es könnte außerdem argumentiert werden, dass die frühere Auswahl einer Hautschutzplatte für einen Patienten einen positiven Einfluss auf den klinischen Erfolg hat und einen proaktiveren Schritt zur Erreichung der Ziele des Patienten darstellt. Die Ergebnisse dieser Beurteilung sind in Form von Berichten und Grafiken im Artikel von Nichols, Menier und Purnell im Beiheft enthalten3. Quellenangabe 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

Weshalb Sie mehr zu diesem Thema im Beiheft lesen sollten: • Vergleich der vier Hauttypen: fettige, normale oder Mischhaut, trockene und empfindliche Haut. • Lesen Sie die Ergebnisse einer Befragung Ihrer Kollegen in der Stomaversorgung, die das Auswahltool für Hautschutzplatten bereits verwendet haben. • E r f a h r e n S i e , w i e d a s A u s w a h l t o o l f ü r Hautschutzplatten für die proaktive Bestimmung der besten Hautschutzplatte für Ihren Stoma-Patienten eingesetzt werden kann. www.wcetn.org 11

Selezione delle barriere cutanee adeguate nella gestione delle stomie Abstract Il presente articolo descrive il processo di selezione delle barriere cutanee per stomia da parte del personale sanitario attivo nella cura di pazienti stomizzati. Viene inoltre presentato lo Strumento di Selezione delle Barriere Cutanee, che consente al personale sanitario di selezionare proattivamente la barriera cutanea appropriata.

Introduzione Per gli enterostomisti (ET) è importante stabilire quale barriera cutanea e quale sistema di sacca di raccolta consigliare ai pazienti stomizzati. Se è ormai noto che è fondamentale mantenere sana la pelle peristomale, affinché i pazienti stomizzati mantengano una buona qualità di vita, la maggior parte delle discussioni sulla cura della pelle peristomale sono reattive invece che proattive1. Nel presente articolo vengono indicati alcuni suggerimenti, destinati agli operatori sanitari, da tenere in considerazione in una fase precoce della gestione, per la corretta valutazione delle barriere cutanee per i pazienti stomizzati; l’argomento viene poi trattato più in dettaglio nel supplemento allegato a questa rivista. Pelle peristomale Dato che la pelle è il punto di ancoraggio della barriera cutanea per stomia (con qualunque sistema di sacca di raccolta), è generalmente noto che la barriera cutanea deve isolare la parte circostante allo stoma, per difendere e proteggere la pelle dal materiale che fuoriesce dallo stoma. In ogni caso, questa non è l’unica funzione della barriera cutanea. Le barriere cutanee per stomia devono aderire sufficientemente bene alla pelle, in modo tale da sostenere il sistema di raccolta per stomia e il suo contenuto e, allo stesso tempo, essere facili da rimuovere, in modo da non causare traumi meccanici alla pelle durante la rimozione. Le barriere cutanee devono anche mantenere la pelle peristomale in condizioni ottimali: devono essere assorbenti e aderenti. Anche il materiale che fuoriesce dallo stoma, la frequenza di sostituzione e il tipo di pelle (ne esistono quattro) possono influenzare il rendimento della barriera cutanea2. In particolare, la pelle peristomale è spesso soggetta a un maggiore stress rispetto alla pelle che non è generalmente a contatto con una barriera cutanea adesiva, in quanto continuamente soggetta ai traumi derivanti dalla rimozione della barriera o al materiale che fuoriesce dallo stoma. Questi problemi vengono affrontati più in dettaglio nel supplemento a cura di Rolstad, Ermer-Seltun e Bryant. Oggi, per affrontare questo insieme di problemi, i fabbricanti di prodotti per stomia utilizzano varie formule e metodi produttivi nella fabbricazione delle barriere cutanee, in modo da ottenere diverse caratteristiche. Anche all’interno della linea di prodotti di un unico produttore, esistono WCET Journal 12


varie formulazioni per le barriere cutanee, appositamente sviluppate per ottenere risultati diversi. Tali differenze includono il tempo di usura, la facilità d’uso e la durata. Un’area critica per il personale sanitario è la comprensione di queste differenze, per scegliere la barriera cutanea per stomia più adeguata per ogni paziente. Un produttore ha sviluppato uno strumento semplice da utilizzare (lo Strumento di Selezione delle Barriere Cutanee), per aiutare il personale sanitario nella selezione di una barriera cutanea adeguata3. Basato su un insieme di requisiti derivanti dal materiale che fuoriesce dallo stoma, dal tipo di pelle e dalla frequenza di sostituzione, questo strumento è stato valutato in molti paesi dal personale sanitario che segue vari pazienti stomizzati 3. Con questo strumento, agli enterostomisti è stato chiesto di valutare le necessità individuali sulla base di questi tre criteri, per poi selezionare la barriera cutanea sulla base delle raccomandazioni fornite dallo strumento. In generale, lo strumento è stato ritenuto utile nella scelta della barriera cutanea adeguata per ogni persona. Il personale sanitario che lo ha provato ne consiglia l’uso ai propri colleghi. Se ne può derivare che la scelta precoce della corretta tipologia di barriera cutanea è un fattore concomitante nell’influenzare positivamente i risultati clinici, attraverso un’azione proattiva per raggiungere gli obiettivi dei pazienti. I risultati di questa valutazione sono contenuti nel testo e nei grafici dell’articolo di Nichols, Menier e Purnell, nel supplemento della rivista3. Riferimenti 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

Perché leggere gli articoli nel supplemento? • Per confrontare i quattro tipi di pelle: grassa, normale o mista, secca e sensibile. • Per leggere i risultati di un’indagine su vostri colleghi infermieri che si occupano di stomia, i quali hanno già utilizzato lo Strumento di Selezione delle Barriere Cutanee. • Per sapere come utilizzare proattivamente lo Strumento di Selezione delle Barriere Cutanee, al fine di stabilire quale sia la migliore barriera cutanea per un determinato paziente stomizzato.

ストーマケアにおける適切な皮膚保護剤の選択について要約本論文ではストーマ保有者をケアする医療従事者にとっての皮膚保護剤の選択について探求する。また、適切な皮膚保護剤を医療従事者が積極的に選択できる皮膚保護剤の選択ツールについても紹介する。序論 ETナースの重要な役割の一つはストーマ保有者のQOL向上のために、個々のストーマ保有者に適した皮膚保護剤とストーマ袋を選択することである。健康なストーマ周囲皮膚を保持することが優れたQOLを実現する一つの原則であることはよく知られているが、一方でストーマ周囲のスキンケアに関しての議論の多くは受け身である。1ストーマ管理において、早い段階で患者に適切な皮膚保護剤を選択する際に医療従事者が行うべき手順がここに紹介されており、より詳細についても記載されている。ストーマ周囲皮膚皮膚は皮膚保護剤にとっての評価基準であり、一般的に皮膚保護剤はストーマ周囲の皮膚を覆い、ストーマからの排出物から皮膚を保護するのに適した物として知られている。しかしながら、これは皮膚保護剤の唯一の機能ではなく、排泄物とストーマ袋を支えるために強い粘着性を持つ必要がある。一方で剥がす際には機械的刺激がなく簡単に剥がせる必要がある。皮膚保護剤は吸収性と粘着性の両方の機能を用いてストーマ周囲皮膚を最良の状態を保持する。ストーマからの排泄物、頻繁な交換、異なる皮膚のタイプが皮膚保護剤の機能に影響を与えるかもしれない。2特に、ストーマ周囲皮膚は剥離刺激やストーマからの排泄物の両方から継続的な刺激にさらされるため、皮膚保護剤貼付部外の皮膚よりも、しばしば強いストレスにさらされる。これらの特殊な問題は追加の記事で詳細にわたってRostad、Ermer-Seltun、Bryant によって考察されている。今日、ストーマ装具メーカーは前述の問題に対応するための様々な性能、特性を持つ皮膚保護剤の製造において、異なる製法や工法を用いている。さらにいくつかのメーカーは、異なる排泄物の性状に対応するために装着期間、使いやすさ、耐久性を考慮した様々な皮膚保護剤を有している。最も適した皮膚保護剤をストーマ保有者に選択するために皮膚保護剤の違いを理解することは医療従事者の課題である。簡単なツール（スキンバリアセレクター）は適切な皮膚保護剤の 3 選択する過程で医療従事者をサポートするために開発された。ストーマからの排泄物、皮膚のタイプ、交換頻度の様々な観点を基にしている。このツールは数カ国のストーマケアを行う医療従事者によって評価されている。3このツールを使用することで医療従事者は、これら 3 つの基準に基づいた個々のニーズを診断し、ツールに基づいて皮膚保護剤を選択することができる。結果としてこのツールは個々にとっての適切な皮膚保護剤の選択する際の助けになることが分かり、同僚に使用することを薦めた。患者にとって早期に皮膚保護剤の選択が行われることは治療結果にも良い

影響をもたらす。この評価の所見はNichols、Menier、Purnell が補足した説明とグラフに含まれている。3 参考文献 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

補足 • 4 つの皮膚タイプを比較:（脂性、正常、乾燥、敏感、またはそれらの組み合わせ)。 • すでにスキンバリアセレクターツールを使用した経験のある看護師からの調査結果を参考にする。 • スキンバリアセレクターツールを積極的に使用することで、ストーマ保有者に最適な皮膚保護剤を選択する方法を習得する。

Renew your WCET membership Dont miss out on the benefits of WCET membership including: • 4 issues of the WCET journal • Access to back issues of the WCET journal in the library section of the WCET website • Ability to apply for NNGF scholarships • Membership rates for congress • Networking with colleagues around the world Log onto www.wcetn.org now to renew

www.wcetn.org 13

Seleccionar la lámina cutánea adecuada para el cuidado del estoma Resumen Este artículo analiza el proceso de selección de las láminas cutáneas de ostomía, en lo que hace referencia al profesional de enfermería responsable del cuidado de los pacientes ostomizados. Asimismo, presenta un Selector de Láminas Cutáneas que permite a los profesionales seleccionar de forma activa la lámina cutánea más adecuada.

Introducción Una de las funciones importantes de los enfermeros Estomaterapeutas es determinar qué lámina cutánea y qué sistema de bolsa deben recomendar a las personas ostomizadas. Si bien está comprobado que mantener la piel periestomal en buen estado es básico para conseguir buenos resultados de calidad de vida en cualquier persona portador de un estoma, la mayoría de argumentos acerca del cuidado de la piel periestomal son más reactivos que proactivos 1. A continuación se presentan algunos pasos recomendados que debe seguir el personal de enfermería a la hora de evaluar la lámina cutánea de ostomía adecuada al estoma de un paciente en una fase previa del tratamiento y que se describirán de forma más detallada en el suplemento que acompaña a este ejemplar. Piel periestomal Dado que la piel es el punto de fijación de la lámina cutánea de cualquier sistema de bolsa colectora de ostomía, en general está bien aceptado que la lámina cutánea mantenga un sellado adecuado alrededor del estoma para proteger la piel de los efluentes. Aunque no es la única función de la lámina cutánea, pues también debe adherirse con suficiente firmeza para sostener el sistema de bolsa de ostomía y su contenido, al tiempo que facilita su retirada sin causar lesiones mecánicas en la piel. Además debe ser absorbente y adherente para mantener la piel periestomal en óptimas condiciones. El tipo de efluente, la frecuencia de cambio y los distintos tipos de piel (de los cuatro que existen) pueden también influir en el funcionamiento de la lámina cutánea2. En especial, la piel periestomal acostumbra a estar expuesta a factores más estresantes que la piel que no suele estar cubierta por una lámina cutánea adhesiva, al someterla a continuas agresiones tanto por la retirada traumática como por los fluidos del estoma. Estos temas concretos se tratan de forma más detallada en el artículo del suplemento de Rolstad, Ermer-Seltun y Bryant. En la actualidad, los fabricantes de productos de ostomía utilizan fórmulas y métodos de fabricación diferentes en la creación de las láminas cutáneas para conseguir funcionamientos distintos y corregir los problemas WCET Journal 14


mencionados anteriormente. Incluso en algunas líneas de producto, existen diferentes formulaciones de láminas cutáneas que se han desarrollado para conseguir resultados diferentes. Estas diferencias abarcan el tiempo de uso, la facilidad de utilización o la durabilidad. Uno de los retos que se les puede plantear a los profesionales de enfermería es comprender las diferencias que hay para poder elegir la láminas cutánea de ostomía más adecuada para sus pacientes. Un fabricante desarrolló una sencilla herramienta de uso (el Selector de Láminas Cutáneas) para ayudar a los profesionales de enfermería en el proceso de selección de la lámina cutánea más adecuada3. Teniendo en cuenta las distintas necesidades en cuanto al fluido, el tipo de piel y la frecuencia de cambio, los profesionales evaluaron esta herramienta en varios países y con múltiples pacientes 3. Mediante esta herramienta, se pidió a los profesionales de enfermería que evaluaran las necesidades de los individuos basándose en estos tres criterios y que posteriormente eligieran la lámina cutánea según las recomendaciones de la herramienta. En general, la herramienta resultó ser útil para elegir la lámina cutánea adecuada para un individuo, por lo que los profesionales de enfermería recomiendan utilizarla a sus colegas. También se podía alegar que seleccionar con antelación la lámina cutánea para un paciente puede influir de forma positiva en los resultados clínicos y que este proceso es un paso más proactivo para alcanzar los objetivos del paciente. Los resultados de esta evaluación se incluyen en el texto y los gráficos del artículo de Nichols, Menier y Purnell en el suplemento de la publicación3. Referencias bibliográficas 1. Purnell P. Proactive Decisions vs Reactive Responses. WCET 2012; 32(1 Supplement):S17-S18. 2. Rolstad BS, Ermer-Seltun J & Bryant RA. Relating knowledge of anatomy and physiology of the skin to peristomal skin care. WCET 2012; 32(1 Supplement):S4-S10. 3. Nichols T, Menier M & Purnell P. Evaluating the process of skin barrier selection through use of a specific tool. WCET 2012; 32(1 Supplement):S11-S16.

¿Por qué debería leer más sobre este tema en el suplemento? • Comparar los cuatro tipos de piel: grasa, normal o mixta, seca y sensible. • Leer los resultados de los datos procedentes de una encuesta realizada a sus colegas Estomaterapeutas que ya han utilizado el Selector de Lámina Cutánea. • Aprender de qué manera el Selector de Lámina Cutánea puede utilizarse de forma proactiva para determinar la mejor lámina cutánea para su paciente ostomizado.

Around the WCET world – WCET UK The 2011 WCET UK conference As the late John Lennon once said, "My love of New York is something to do with Liverpool. There is the same quality of energy in both cities."

Jo Sica [email protected]

Editor’s note: We are pleased to introduce in this issue of the WCET Journal a new section dedicated to WCET UK. Thank you Jo Sica for providing your WCET colleagues around the world with this important information about stoma care nursing in the UK and news from our WCET UK members.

Introducing the UK Stoma Care Nurses WCET UK would like to thank the WCET board for the opportunity to share the UK news with our global colleagues. In the UK, we have over 400 qualified stoma care nurse specialists (SCN). There are many ways in which we work. Most nurses are directly employed by the National Health Service (NHS), but many of these posts are financially supported by company sponsorship. A more limited number

The 2011 WCET UK conference was held in Liverpool on 4 and 5 October with the conference dinner on Tuesday evening. The conference venue was the purpose-built Arena and Convention Centre (ACC), which sits in a stunning waterside location, at the heart of the city and adjacent to a World Heritage site. Views along the river are unsurpassed from the upper echelons and there is a wealth of amenities within 15 minutes’ walk. These include the Grade I listed Albert Dock, Liverpool One shopping centre, hundreds of bars, restaurants and cafés, the famous Mersey Ferry and excellent hotels. ACC Liverpool is a unique facility, the only interlinking arena and convention centre complex under one roof in Europe. ACC Liverpool is one of the centrepieces of Liverpool’s year as European Capital of Culture in 2008 and the new jewel in Liverpool’s cultural crown. Liverpool is home to the world-famous Beatles and the gala dinner celebrated their 50 years. Delegates were invited to dress in 60s dress and some of the costumes were absolutely wonderful. Mr Philip Salt, Chief executive of Salts Healthcare, very generously offered a prize for the best costume. This was awarded to the Hollister ladies who looked truly resplendent in their black and white outfits and beehive hairstyles (Figure

of nurses are company-employed and provide a contracted service to health care providers. NHS and company nurses can work in both the hospital and community or one or the other. Whether company-employed, sponsored or NHS-employed, the nurses will have undergone further training to obtain their stoma care qualifications as well as being registered with the Nursing and Midwifery Council (NMC). There is an array of products available to those with a stoma in the UK. Products are obtained through a fully reimbursable system known as FP10 prescription. The WCET UK committee welcomes two new honorary officers: Rebecca Davenport takes over from Carol Katte as Treasurer and Julia Williams steps down as the Education Officer handing the role over to Wendy Osborne.

Figure 1. The winning costumes at the WCET Gala dinner surround Mr Salt. www.wcetn.org 15

1). Philip Salt very generously donated £100 per winning costume to the Help for Heroes, a charity that continues to help those who have suffered extensive, debilitating injuries in the current Afghanistan conflict. Patrick Joyce, Hollister UK sales and marketing director, matched Philip Salt’s donation. The WCET raffle monies were also donated to this charity that is so close to our hearts right now. There were an impressive number of posters and the best poster is voted for by the members with the winners receiving a £100 book voucher prize. This year, the prize was won by Rebecca Davenport and Lindsay Fleming. Their poster was entitled "Understanding Evidence Based Practice". You can read their award-winning abstract in Figure 2. Figure 2. Rebecca Davenport and Lindsay Fleming award-winning poster abstract.

Understanding Evidence Based Practice by Rebecca Davenport and Lindsay Fleming. Within nursing, there is a requirement to provide a high standard of practice and care at all times and this involved delivering care that is based on the best available evidence. However, there is not always evidence within the specialty of stoma on which to base our practice, instead interventions are based upon anecdotal evidence, others expert opinion and our own individual experiences.

reversal, cancer secondaries and using a stoma skin barrier versus a person’s skin type. WCET UK and clinical nurse specialists enjoy a close working relationship with industry and this is clearly evident at occasions such as the conference. As well as a stunning exhibition, there were a number of presentations and awards that are company initiatives. Some of those awards are described below. WCET New Presenter's Award In partnership with Coloplast Ltd The WCET Coloplast New Presenter's Award (Figure 3) is a tailored programme designed to prepare a new presenter to deliver a professional presentation during the annual WCET Congress. The collaboration between WCET and Coloplast provides potential presenters with a unique and fully funded opportunity to develop skills in presenting a topic to an interested and enthusiastic audience of peers. The winner of the award will then have the opportunity to publish their

This poster outlines the sources of scientific evidence and levels of reliability and validity associated with each level. The hierarchy of evidence will be further demonstrated with examples of each level that may be available within the specialty of stoma care nursing. The poster will also provide suggestions on how to evaluate and critically appraise available evidence and reach conclusions and recommendations for best practice. It also highlights the importance of regular audit of current clinical practice and the value of steering groups that can provide a forum for discussing problems, findings and solutions for improvement.

WCET UK has an agreement with the Mark Allen Publishing Group that publishes the British Journal of Gastrointestinal Nursing. Mark Allen now publishes a stoma care supplement to coincide with the WCET UK meeting. Each delegate received a free of copy of both journals in their conference bag. The supplement should soon be available on www. internurse.com. A password is required for the website; however, individuals with an “Athens” password are able to access it via their institution. The supplement included articles on continence, peristomal skin irritation, stoma WCET Journal 16


Figure 3. The Coloplast New Presenter's Award.

research in the leading speciality journal, Gastrointestinal

Figure 4. WCET UK – winning abstract.

Nursing. This is a great opportunity for nurses keen to raise their profile and share their research. The process starts now when individuals, or groups, apply to

A Service Evaluation of a Nurse Led Stoma Care Outpatient Clinic

Coloplast for an opportunity to participate in the WCET UK

Theresa Bowles, Norfolk and Norwich University Hospital

programme. The group undergoes training on how to write

Background

an abstract, present with confidence and write for publication with the goal of presenting at WCET UK. In 2011, this training programme culminated in the award being presented at WCET in Liverpool. Theresa Bowles from Norfolk and Norwich hospital was this year's winner with for her presentation, entitled “A Service Evaluation of a Nurse Led Stoma Care Outpatient Clinic” (Figure 4). Based on the success of the 2011 programme, we are now looking for applications for 2012. Applicants of the award will be offered: • A one-day study day to refine your project and learn how to write an abstract. • A two-day presentation skills course on successful

The current economic climate, government healthcare reform strategies and requirement for governance of health services support the need for evaluation, demonstrating health services provide fit for purpose services meeting the perceived needs of the population. Nurse led services are no exception to this. Measurement of importance and performance of variables, patient experience and outcome of care are essential to ensure evaluative studies provide meaningful assessment of services. Aims To determine whether the stoma care nurse led outpatient clinic service offers high quality care, assessing patient experience and patient perceived improvement using Nursing Sensitive Outcomes Measures (NSOM).

acceptance of your abstract for presentation at WCET

Method

2012.

Adults attending the stoma clinic over a six month period were sent a postal survey seeking importance and performance data based on variables identified from the National Patient Satisfaction Survey. Perceptions of care outcome based on NSOM identified from the literature were included. Additional comments on stoma care experience were invited.

• Full PowerPoint presentation support from Coloplast Ltd. • Present at WCET 2012. Judges – WCET committee panel. • Winners to be announced at WCET Gala Dinner. Following the WCET 2012 conference

Results

Successful winners of the WCET Coloplast New Presenter's

Preliminary results demonstrate domains of care identified as important are well performed. Improvements to NSOM are experienced by the majority of patients attending the stoma clinic, even when the initial problem may not be resolved. Qualitative comments demonstrate a strong positive feeling for the stoma care nurse service with particular reference to the supportive nature of the nurse specialists, telephone access and lifelong support.

Award will receive a one-day study day conducted by Dr Terri Porrett, editor of Gastrointestinal Nursing. Terri will provide coaching on how to write up presentations for publication in Gastrointestinal Nursing. The successful winners will have the opportunity to submit their articles to the WCET Journal for publication. What can be achieved? • Learn how to refine a project and write an abstract. • Acquire presentation skills and confidence. • Present an oral paper at the national WCET conference. • Have an opportunity to win an award. • Learn how to write a publication. • Become a published author.

Discussion The problems faced by people with a stoma continue throughout their lifetime. The ability to access a specialist nurse service to assist in the management of these problems is held in high regard by users. Conclusion The nurse led stoma care clinic service at this NHS Trust provides high quality care, improving patients experience and patient perceived outcomes.

www.wcetn.org 17

Who will this appeal to? Stoma care nurses who: • have never presented at a national or international conference • have an interesting case history or management of clinical practice • wish to increase their teaching and academic skills • want to promote their unit/team • have undertaken a project – such as an audit or change in practice • have completed a degree or masters programme • are ambitious and like a challenge. Salts Healthcare Nurse of the Year Award The award itself started in the early 1990s and it came about following a conversation with WCET about acknowledging/ formalising some of the fantastic work that is done by SCNs. Salts Healthcare has no influence whatsoever on selection of the nurse; they are all nominated and selected by the UK SCNs. Salts Healthcare is extremely proud to be associated with the award and has been impressed over the years by the nurses selected. The award for 2011 went to Gail Fitzpatrick, paediatric SCN in Birmingham. Philip Salt paid honour to Gail saying that she puts 100% into supporting her patients and families (Figure 5). Gail was one of the first paediatric SCNs in the UK and developed the first paediatric stoma care course in conjunction with the University of Central England in Birmingham. She is a great supporter of BREAKAWAY, a charity that supports residential breaks for children with bowel and bladder disorders and their families.

Figure 6. Up all night poster.

The Dansac Roadshow Play Up all night (Figure 6) is Dansac’s new play taking a unique approach to sex and relationships for ostomists. Following from their previously successful play and concept of Still me waving, which has been touring the country for the last two years as part of the Dansac Voice Lifestyle Roadshows, both plays have received rave reviews from ostomists, family members and carers, and stoma care nurses. To continue this method of learning through theatre, Pete Lawson, the writer of Up all night and Still me waving, in collaboration with Julia Williams, has now taken this idea to the next level. This new play addresses an important issue to ostomists "when do I tell my partner I have a stoma?" The play has a beginning and a middle, but the audience decides on the ending! The world premiere performance of this inspiring new play was performed at the 2011 WCET UK conference in Liverpool in front of 350 stoma care nurses and professionals. All of whom had no option but to become involved and have a leading role in the play as the stoma care nurse. They voted for what they believed was the best option to help their patient reach their goal.

Figure 5. Salts presenting Nurse of the Year Award. WCET Journal 18


This is a completely new approach on the subject of sex and relationships for both ostomists and their stoma care nurses. The play helps take a heart-warming and honest look at what can still be a ‘taboo’ subject to put both parties at ease and ultimately by doing the best thing for the patient to help improve their life and wellbeing.

An update on the Department of Health and the provision of stoma care in England, Scotland and Wales Jonathan Scott, from Hollister UK, delivered a very interesting presentation on the Healthcare Reforms and how this may impact stoma care services. The Health and Social Care Bill which, at the time of writing, is currently being debated in The House of Lords, will see the NHS facing its biggest change since its inception in 1948. If implemented, the main changes will involve decision making being transferred to local commissioning groups and will also facilitate a move towards ‘Any Qualified Provider’, which the government hopes will foster competition in the provider market. In the face of change through these reforms and the current economic pressures driving cost savings within the NHS, industry continues to be fully supportive of the need for clinical freedom of stoma care nurses and patient choice regarding products and services. Industry also considers that the continuation of the full Drug Tariff for stoma care products will be most important element in maintaining this

• secured meetings for WCET UK with Government officials and MPs • arranged for a Parliamentary Motion to be tabled in the House of Commons recognising the important role of the stoma care nurse and supported by 23 MPs • delivered a toolkit to support members to highlight their concerns with MPs • provided 10 detailed reports to keep members informed of developments effecting their practice • secured and wrote an article to promote the work of WCET UK in Gastrointestinal Nursing. WCET UK would like to build on this success with a future campaign. Judy Hanley holds the position of Vice-Chair, and plans to lead an audit on “Demonstrating the value of stoma care nurses”. The action plan includes: • Producing a research report to publish the first-ever UK-focused assessment of the value of SCNs. • Quantifying savings generated for Trusts and the NHS.

freedom in order to provide clinical solutions for patient care.

The audit will look at:

Raising the profile of the stoma care

• preventing prolonged length of hospital stay

specialist in the UK In 2010, WCET UK employed the company FleishmanHillard to support the organisation in raising its profile with members, in Parliament and among key decision makers. Fleishman-Hillard is a fully integrated health care communications consultancy, providing strategic and tactical support across public relations (PR), medical education and

• preventing readmission to hospital • reducing workload on other HCPs (general practitioners, accident & emergency, district nurses and consultants). • provision of nurse-led services. The objectives are as follows:

public affairs.

• To produce a report to be utilised for further lobbying.

The WCET/Fleishman-Hillard campaign involved the

• Editorial control will remain with WCET UK.

development of key messages using input from WCET UK members, and identifying and engaging with Members of Parliament (MPs), the Department of Health and Royal College of Nursing (RCN) officials. The aims of the WCET UK public affairs campaign were to increase the profile and influence of WCET UK and its members with policymakers and influencers. WCET UK desires to inform policy to ensure it reflects stoma care nurses’ priorities.

• Launch to the press and make available to key stakeholders (for example, RCN). • Publicise in relevant nursing press. The plan is for the report to be undertaken by FleishmanHillard, along with a working party of SCNs, representatives from industry and patient support groups. The report will answer the question: Does your healthcare provider know who you are and what you do? OPUS Healthcare has

The campaign has been highly successful and Fleishman-

kindly given £3000 to assist WCET UK with funding for this

Hillard has:

research. www.wcetn.org 19

Product options for faecal incontinence management in acute care Jan Powers PhD, RN, CCRN, CCNS, CNRN, FCCM Director of Clinical Nurse Specialists, Director of Nursing Research, Trauma Critical Care Clinical Nurse Specialist, St Vincent, Indianapolis Tel (317) 338-7163 Fax (317) 338-3388

Donna Zimmaro Bliss PhD, RN, FAAN, FGSA University of Minnesota School of Nursing Foundation Research Professor, University of Minnesota School of Nursing, 5-140 WeaverDensford Hall, 308 Harvard Street, Minneapolis, MN 55419 Tel 612-624-1425 Email bliss@umn. ABSTRACT The prevalence of incontinence-associated dermatitis (IAD) and pressure ulcers associated with faecal incontinence is increasingly recognised as a significant issue among hospitalised patients. The problem is noteworthy in terms of patient discomfort and health as well as cost to the healthcare system. In a previous article published in WCET, the authors described the problem and the importance of finding management options In this article, bowel management systems as a way to better manage IAD are discussed.

Introduction We described in a previous article published in the WCET Journal that faecal incontinence is common among hospitalised patients and is a major contributor to incontinence-associated dermatitis (IAD) and pressure ulcers1. In addition to other sequelae, faecal incontinence consumes substantial care giver time, increasing health care costs, and affects patient comfort and self-image. In addition, the patient, family and others may experience distress due to the odour and stigma associated with lack of bowel control. IAD is one adverse outcome of faecal incontinence. Other adverse effects include the development of pressure ulcers and possible contamination leading to nosocomial infections. Poor diarrhoea management increases the use of absorbent and containment products, strains already limited resources in our healthcare institutions and decreases the performance WCET Journal 20


indicators that can affect state and federal funding. Increased costs are associated with overuse of ineffective products as well as associated skin breakdown as a result of faecal incontinence. Managing diarrhoea is imperative for creating the best outcomes not only for patients but also our health care institutions. To avoid or minimise complications from faecal incontinence, nursing care must address faecal leakage, stool containment and skin integrity. The purpose of faecal containment is to prevent skin breakdown, dermatitis, fungal infections and protect healing wounds in the perineal area. Wounds in the perineal areas include pressure ulcers, necrotising fasciitis and Fournier’s gangrene. Faecal containment also reduces the possibility of contaminating vascular lines, urinary catheters, and the patient care environment, thus reducing the risk of cross-contamination. While preventing skin problems, it is important to concurrently evaluate and treat diarrhoea with medication, diet and tests to correctly diagnose the cause. The focus of this article, however, is solely on faecal containment among immobile patients in the acute care hospital setting. Faecal Containment Devices Absorbent products There are several options for managing faecal incontinence, including absorbents (diapers and pads), skin care regimens, faecal collectors and indwelling devices. One systematic review to assess the effectiveness of different absorbent products showed that while diapers and pads absorb drainage, they are more effective in containing urine than stool2. In fact, diapers can be a causative factor in promoting IAD. Additionally, absorbents do not help with odour and must be used with a skin care regime (frequent changes, use of appropriate cleansers and protective creams) because they can trap irritating faecal output against the skin2. Perineal skin cleansers and skin products provide excellent protection when used with baby diapers. However, research is lacking for the use of these products with disposables. Depending on the amount of moisture present, ointments and creams that contain dimethicone, petrolatum and zinc oxide, may actually interfere with the absorbent properties of these products. One study demonstrated petrolatum-based products transfer to the absorbent product and decrease the absorbency, thus leading to increase skin exposure to moisture and development of IAD 3. In this study, a nonalcohol, polymer-based barrier film did not affect the absorbent properties of these products3.

Faecal collectors Faecal collectors are external, closed systems that collect stool to help minimise the spread of infection or prevent incontinence-related skin damage. There are several external faecal collectors currently available from different manufacturers. External collection systems consist of a self-adhering skin barrier and attached pouch which can be emptied or connected to a bedside drainage bag. They collect stool and gas while containing environmental exposure and minimising the spread of infectious organisms. Faecal collectors are user-friendly, cost-effective and efficient in confining and containing patient stool in inactive, bedridden patients (Figure 1). They help prevent skin breakdown, control odour, and are less costly and time-consuming than absorbents and more comfortable for patients. They may be used indefinitely as long as they are changed as needed when no longer sealed or leaking. Faecal collectors, when used appropriately, decrease the use of supplies and caregiver time to clean incontinent patients.

Figure 1. Examples of faecal incontinence pouches.

Faecal collectors may not be appropriate for active or agitated patients, who may dislodge the device, or patients with severe skin irritations that interfere with a secure skin seal. In addition, moisture, or residue from soaps, cleansers and products to treat skin breakdown may impair the self-adhering skin barrier. Faecal collectors also do not accommodate delivery of rectal medication4. In situations that involve fungal infections, pressure ulcers, necrotising fasciitis, Fournier’s gangrene, or Stevens-Johnson syndromes, it can be impossible to get the appropriate adherent surface to use an external containment system. It’s important to note that the caregiver must be proficient in applying a faecal incontinence pouch. Faecal collectors work most successfully when the patient’s skin is properly prepared and the device is applied following step-by-step techniques. Faecal collectors perform best if the patient is lying on their side (rather than supine). Medical adhesives are sometimes used to help hold them in place without harming the patient’s skin. Faecal collectors may be applied or remain in place regardless of the patient's location in the hospital (ICU, medical-surgical floors). Most manufacturers strive to achieve a 24-hour wear-time for external pouches; however, it is not recommended to change the pouch unless faecal leakage is noted. Removal of a well-sealed pouch may cause additional damage to the skin.

One study of faecal incontinence pouches performed in Italy with 120 elderly, bedridden patients with pressure ulcers showed that the device effectively prevented contamination from stool, 76% of the patients tolerated the pouch well and 85% reported that it wasn’t painful to apply or to remove4. Nurses and physicians reported that the device was easy to use, prevented contamination and cross-contamination and may have helped improve management of faecal incontinence and associated complications4. Indwelling devices Indwelling drainage devices comprise a group of products that traverse the anal sphincter and dwell in the rectum to manage faecal flow. They are used in situations where faecal collectors have failed or cannot be used because of severe burns, distorted anatomy, or lack of potential adherent surface. Invasive devices must always be used judiciously because of their limitations, contraindications, precautions and unanswered questions about long-term effects. The advantages of using an indwelling device are that it: contains stool and gas; reduces environmental contamination; presumably decreases the risk of cross-contamination and contamination of the patient’s lines and tubes; protects the patient’s skin and enhances the patient’s dignity by preventing bed soiling. Some devices that have been used in early attempts to divert faecal flow included large bore urinary catheters, or tubes such as nasal trumpets placed in the rectum. Stool drained through the lumen of the tube into a bedside drainage bag. Disadvantages to the use of these devices include: the stool must be liquid to drain; the tubes may leak, resulting in odour and skin irritation; and the catheter and balloon can act as a blockade and potentially cause bowel obstruction and perforation. In addition, if a urinary catheter is used in this way, the balloon requires strict periodic deflation to prevent injury to the rectal mucosa. These devices were designed for a different intended purpose, and are not cleared by the Food Drug Administration (FDA) for use in the rectum, which is a concern due to risk of litigation if adverse events occur. In one case series of nine patients, it was found that the patients had barotrauma from rectal balloons and perforations secondary to pressure from the device 5 . Barotrauma is physical damage to body tissues caused by differences in pressure inside the body. A single clinical series that has been published of patients managed with the rectal trumpet after other attempts at containment failed 6 . This study demonstrated 100% improvement in stool containment with the use of a rectal trumpet. The authors reported the technique was easy to use by 84% of the nurses and patients’ skin improved over the course of the study. However, the sample size was small with only 22 patients enrolled, there was no control group and no examination of the internal sphincter via endoscopy for signs www.wcetn.org 21

of pressure damage6. Further research is required for this technique before it should be a recommended practice. Indwelling bowel catheter systems Bowel management systems are medical devices designed to direct, collect and contain liquid stool from bed-bound, immobilised patients. The advantage of faecal or bowel management systems is that they are closed systems of stool containment, they decrease exposure of the health care practitioner to possibly infectious body substances and they prevent infection and protect the patient’s perineal skin. Three types of indwelling bowel catheters are currently commercially available on the market (Figure 2). One of these systems provides access for medication, which is convenient in the ICU, especially for administration of lactulose enemas, Kayexalate, antibiotic enema or similar treatments. Three manufacturers currently produce indwelling bowel catheter systems which are FDA cleared for use up to 29 days: Acti-Flo Indwelling Bowel Catheter from Hollister, Flexi-Seal Fecal Management System from ConvaTec and DigniCare Stool Management System from Bard. The ActiFlo Indwelling Bowel Catheter System also is FDA cleared for access for colonic irrigation and rectally administered medications. A thorough literature search was conducted for each of these bowel management systems and manufacturers of these devices were also asked for evidence that may have been missed in the literature review. The retrieved studies covered safety and product effectiveness, product performance and descriptions of product use. Indwelling bowel catheter systems use a soft, latex-free catheter with a collection bag. After a digital rectal exam, and removal of any impacted stool, the tube is inserted and a retention balloon is filled with water. The balloon is thought to conform to the rectal vault, and has a lowpressure retention cuff, helping to reduce the risk of anorectal barotraumas. In three studies, researchers performed a colonoscopy to examine the rectal mucosa integrity and found the product to be safe and effective7-9. The products are not without risk, thus the contraindications and precautions of each device should be reviewed before product insertion and use. Two authors have published single cases of rectal bleeding10,11. User training is required, as with any medical device. Users must be educated about insertion, maintenance and removal of the product. In one study, nurses who used these products reported feeling confident about product use after they had completed three or more device insertions12. Some data exist describing the effectiveness of an indwelling bowel catheter system. Case series design research was used to examine the advantages of a bowel management system in a large south-eastern burn centre 13. The authors compared 140 patients with a bowel management system to a control group and found fewer skin and soft tissue WCET Journal 22


Figure 2. Bowel management systems. Top: ActiFlo Indwelling Bowel Catheter, Hollister Inc., Libertyville, IL. Middle: Flexiseal Bowel Management System, Convatec, Princeton, NJ. Bottom: DigniCareTM Stool Management System, Bard Inc., Covington, GA.

infections (23 v 8), fewer urinary tract infections (10 v 4) and decreased bloodstream infections (9 v 6)13. There also was a cost savings associated with decreased linen soiling13. Long-term outcomes were not addressed and no internal inspection of rectal tissue was performed13. In another study, the authors measured the rate of nosocomial pressure ulcers in a surgical intensive care unit and found advantages in using a bowel management system as a part of their pressure ulcer prevention efforts14. Pressure ulcer prevalence of stage II and above was 43% before implementation of the BMS, 12.5% six months after implementation and zero at nine months after implementation. More recently, authors used an observational study with block design, to compare two indwelling bowel catheters at 12 American hospitals: Catheter A sites used 86 new devices in 76 patients; Catheter B sites used 85 new devices in 70 patients12.

The authors compared the number of leakages, the frequency and reason for removal and insertion and user satisfaction at hospitals that had been using the systems for some time. This design ensured the clinicians were familiar and comfortable with the catheter being studied.

promote optimal patient outcomes. Approaches must be knowledgeably selected, carefully instituted and constantly monitored for the effect on the patient.

The authors reported there was less leakage and fewer devices used at Catheter A sites, with a nearly 30% fewer (1.20 vs 1.71) unplanned bedding/dressing changes (due to leakage) per patient day. This adds up to fewer costs in terms of nursing time and linen cleaning. Leakage also is an important criterion when evaluating bowel management systems from the patient perspective because of the potential skin damage and risk of infection.

The authors based these articles on their presentations made at the National Teaching Institute and the Wound Ostomy and Continence Nurses Society conferences. They appreciate the summary of the audio recording of their presentation at the National Teaching Institute by Theresa J Marousek that was funded by Hollister Inc.

Catheter A was ActiFlo Indwelling Bowel Catheter System and Catheter B was the Flexi-Seal Fecal Management System. No studies were found that included the Bard DigniCare Stool Management System. Conclusion In conclusion, while there are a variety of approaches to managing faecal incontinence in the acute adult patient, there is no 'one-size-fits-all' answer. This is an area where more research is needed. In the meantime, we must judge each situation on a case-by-case basis. As nurses, we need to carefully assess the patient and the caregivers’ needs related to faecal management. We also need to be knowledgeable about the indications and contraindications for each of the available devices and need to stay up-to-date on the latest evidence-based information. Summary Perineal skin damage is a significant problem in hospitalised patients and the goals of nursing are to prevent and manage the problem. Faecal incontinence is an important contributing factor that needs to be addressed in the acute care setting15,16. Traditional management methods (absorbents, barrier creams, faecal collectors) are effective in many clinical situations for management of faecal incontinence. However, these measures may be ineffective in managing perineal skin damage for many acutely ill hospitalised adults. There is increasing evidence that indwelling bowel catheter systems provide an advantage for patient care in terms of skin protection, patient comfort, containment and cost control in the acute care setting. These results may vary depending on the specific product selected for use. In selecting the best way to manage faecal incontinence in the acutely ill, it is important to consider patient risks and needs, staff knowledge and skills, financial impact and available resources. It is also critical to be aware of the advantages, disadvantages, indications and contraindications for the various methods of faecal incontinence. Future research needs to assess which therapies are best in selected care situations and what combinations of methods can

Acknowledgements

References 1. Bliss DZ & Powers J. Fecal Incontinence and Its Associated Problems in Hospitalized Patients: The Need for Nursing Management. WCET 2011; 31(2). 2. Brazzelli M, Shirran E & Vale L. Absorbent products for containing urinary and/or fecal incontinence in adults. J Wound Ostomy Continence Nurs 2002; 29(1):45–54. 3. Zehrer CL, Newman DK, Grove GL & Lutz JB. Assessment of diaper-clogging potential of petrolatum moisture barriers. Ostomy Wound Manage 2005; 51(12):54–58. 4. Palmieri B. The anal bag. A modern approach to fecal incontinence management. Ostomy Wound Manage 2005; 51(12):44–52. 5. Nelson JA, Daniels AU & Dodds WJ. Rectal balloons: complications, causes and recommendations. Invest Radiol 1979; 41(1):48–59. 6. Grogan TA & Kramer DJ. The rectal trumpet: Use of a nasopharyngeal airway to contain fecal incontinence in critically ill patients. J WOCN 2002; 29(4):193–201. 7. Keshava A, Renwick A, Stewart P & Pilley A. A nonsurgical means of fecal diversion: The Zassi bowel management system. Dis Colon Rectum 2007; 50(7):1017–1022. 8. Padmanabhan A, Stern M, Wishin J, Mangino M, Richey K, DeSane M & Flexi-Seal Clinical Trial Investigators Group. Clinical evaluation of a flexible fecal incontinence management system. Am J Crit Care 2007; 16(4):384–93. 9. Kim J, Shim MC, Choi BY, Ahn SH, Jang SH & Shin HJ. Clinical application of a continent anal plug in bedridden patients with intractable diarrhea. Dis Colon Rectum 2001; 44(8):1162–1167. 10. Page BP, Boyce SA, Deans C & Cmilleri-Brennan J. Significant rectal bleeding as a complication of a fecal collecting device: Report of a case. Dis Colon Rectum 2008; 51:1427–1429. 11. Bright E, Fishwick G & Berry D, Thomas M. Indwelling bowel management system as a cause of life-threatening rectal bleeding. Case Rep Gastroenterol 2008; 2:351–355. 12. Kowal-Vern A, Poulakidas S, Barnett B et al. Fecal containment in bedridden patients: economic impact of 2 commercial bowel catheter systems. Am J Crit Care 2009; 18(3): S2–S14. 13. Echols J, Friedman BC, Mullins RF et al. Clinical utility and economic impact of introducing a bowel management system. JWOCN 2007; 34(6):664–670. 14. Benoit RA & Watts C. The effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcers in an ICU setting. JWOCN 2007; 34(2):163–177. 15. Rees J & Sharpe A. The use of bowel management systems in the high-dependency setting. Br J Nurs 2009; 18(7):suppl S15–16, 18, 20, 21. 16. Wishin J, Gallagher J & McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs 2008; 35(1):104–110. www.wcetn.org 23

A good hug can prevent a lot of problems.

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& ConvaTec Moldable Technology™ Skin Barriers create a unique, three-layer seal as comfortable and secure as a hug. The active hug helps to prevent leaks and protect the skin.1,2 Clinical experience demonstrates it, and people living with an ostomy confirm it. Patented* tri-laminate construction with Rebounding Memory Technology™: On top: Durahesive® Technology actively moves and turtlenecks around the stoma for a snug fit, even during peristalsis.

}

In the middle: Durable polyethylene film provides an extra barrier against stoma output. On the skin: Choose between Stomahesive® and Durahesive® Technologies to achieve an optimal level of adhesion and skin protection for successful stoma management.

Give your patients a hug.

Contact your local ConvaTec sales representative to learn more. www.convatec.com

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Scott V, Raasch D, Kennedy G, Heise C. Prospective assessment and classification of stoma related skin disorders. Poster presented at: 41st Annual Wound Ostomy and Continence Nurses Society Conference; June 6-10, 2009; Orlando, Florida. Hoeflok J, Guy D, Allen S, St-Cry D. A prospective multicenter evaluation of a moldable stoma skin barrier. Ostomy Wound Manage. 2009;55(5):62-69. * U.S. Patent No. 6,840,924 B2

1

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®/™ indicates trademarks of ConvaTec Inc. ©2011 ConvaTec Inc.

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Our adhesives have found their match. So will your patients. Pair the ConvaTec adhesives you’ve always loved with the new ConvaTec Pouches: more comfort, less odor, better security.

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Contact your sales representative to learn what Pouches can do for your patients. ConvaTec Available in a range of sizes, shapes and features.

Visit us at WCET at Booth #8 Product comparisons are internal product comparisons to existing ConvaTec product. ®/™ Indicates trademarks of ConvaTec Inc.

©2011 ConvaTec Inc. AP-011097_MM

Stories from the bedside

Nursing management of a viscerocutaneous fistula

Mario Antonini Enterostomal Therapy Nurse Ospedale San Giuseppe – ASL11 Empoli, Florence, Italy [email protected]

Gaetano Militello Enterostomal Therapy Nurse Ospedale Misericordia e Dolce Prato, Italy [email protected]

ABSTRACT Enterocutaneous fistulas present as serious, important complications following abdominal surgery or as a secondary manifestation of other organic diseases. The management of a fistula poses many immediate physical problems including possible malnutrition, and water-electrolyte imbalances (with associated need for fluid replenishment), abdominal wall injuries, skin wounds and septic manifestations. Fistulas can have either a congenital or acquired aetiology. Acquired enteric fistulas arising after surgery range from 75% to 85%, whereas spontaneous fistulas account for 15%–25% of all fistulas1 with high-output enterocutaneous fistulas having a 37% postoperative mortality rate. This case study reports on a 50-year-old male who developed a colonic viscerocutaneous colonic following anterior rectum resection for the treatment of cancer.

injuries, skin wounds and septic manifestations. In light of these issues, the best strategy may be initiation of total parenteral nutrition (TPN). TPN would keep the involved intestinal tract at rest by minimising the presence of the faecal mass, and avails itself of the use of supportive antibiotic therapy2. It is also important to protect the perifistular skin by both allowing complete fistula drainage and, at the same time, avoiding skin contact with intestinal matter3. The surgical approach to the resolution of a fistula should be considered as a last resort. Incidence and Aetiology The word “fistula” comes from the Latin term fistola which means canal, tube or duct. Enteric fistulas generally connect one hollow organ to another hollow organ or to the skin. Fistulas can have either a congenital or acquired aetiology. Acquired enteric fistulas arising after surgery range from 75% to 85%, whereas spontaneous fistulas account for 15%–25% of all fistulas1. In a paper on high-output enterocutaneous fistulas, Schein and Decker report a 37% postoperative mortality rate 4. The majority of these deaths should be attributed to electrolyte imbalance, malnutrition and sepsis. Fistulas may develop immediately after surgery or years later in concomitance with other events such as diabetes mellitus, pelvic inflammatory diseases, pelvic surgery, hypertension and atherosclerosis5. Classification Anatomically, enteric fistulas are classified according to the site of origin. Therefore, fistulas are divided as follows: - oesophageal fistulas - gastric fistulas - duodenal fistulas - jejunal fistulas

Enterocutaneous fistulas present as serious complication following abdominal surgery or as a secondary manifestation of other organic diseases. The management of a fistula poses many immediate physical problems. There is a psycho/social aspect as well. This should not be underestimated as the medical issue affects both the patient and his/her relatives. The management aspects include the patient’s possible malnutrition, and water-electrolyte imbalances (with associated need for fluid replenishment), abdominal wall WCET Journal 26


- biliary fistulas - pancreatic fistulas - ileal or colonic fistulas. The site of origin of a fistula and the characteristics of the matter discharged (in terms of both quantity and quality) provide important information since the specific clinical picture and the relevant therapeutic approach are established on the basis of this data. From a quantitative viewpoint,

fistulas are divided into high-output fistulas (volume >200 ml/24 hours) and low-output fistulas (volume

WCET Journal

WCET Journal

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