Michelle Tilson, BSN, RN, CWOCN, Colleen Vollenwieder, BSN, RN, CWON, Gundersen Lutheran Health System La Crosse, WI
Perhaps one of the most challenging patient care situations that a wound, ostomy, and continence (WOC) nurse can encounter is the management and treatment of an enterocutaneous fistula. Treatment of this catastrophic complication usually involves multifaceted medical and nursing care. Nursing management of fistulas includes: a) protection of perifistular skin integrity, b) containment of effluent, c) control odor, d) allow accurate measurement of effluent, e) allow mobility and comfort for the patient, and f) decrease cost and time spent in care.
Achieving predictable and effective containment of the fistula effluent often proves to be essential for patients to effectively cope with this rare and frustrating complication. Because each individual patient situation has its own complexities, management requires developing creative and individual plans of care. Utilization of basic pouching concepts, previously reported customized techniques, and networking with WOC nurses are invaluable tools to achieving the goals for management of enterocutaneous fistulas.PATIENT HISTORY
The patient is a 66-year-old Caucasian female with a past medical history of chronic abdominal pain and recurrent small bowel obstructions. Her medical history includes diabetes, anemia,
hypertension, hypothyroidism, osteoporosis, Raynaud’s phenomenon, recurrent pancreatitis, renal
lithiasis, mild renal insufficiency and renal tubular acidosis.
Surgical history includes numerous abdominal surgeries, including multiple laparotomies and lysis of adhesions, as well as sigmoidectomy with loop colostomy and subsequent colostomy takedown, total abdominal hysterectomy with left salpingo-oophorectomy, open cholecystectomy, and small bowel resection. With the last small bowel obstruction she underwent exploratory laparotomy and four-hour lysis of adhesions. She experienced complications including a deep vein thrombosis, and postoperative wound infection with methacillin-resistant staph aureus, and an enterocutaneous fistula at the most proximal aspect of her incision.Picture A: Enterocutaneous fistula prior to pouch applicationPicture A: Enterocutaneous fistula prior to pouching system application
Uneven abdominal contour with thick scar tissue related to multiple surgeries, wound infection, and closure by secondary intention with an enterocutaneous fistula matured into a well-formed stoma
After a CT scan, the fistula was determined to be mid-jejunal. The output was a thin yellow-green liquid with faint fecal odour, rich in digestive enzymes. With the assistance of negative pressure wound therapy, the incision distal to the fistula eventually healed, and the fistula matured into a well formed stoma.
Picture 1Picture 1: Perifistular skin protected by creating a pseudo scab
Yaunker suction catheter used to collect effluent during dressing changes to keep perifistular skin dry. Stomahesive powder applied to the denuded areas of skin with the excess blown off, and protective skin barrier wipe dabbed over the powder
Picture 2Picture 2: Perifistular skin prepared with skin cement
Skin cement applied to fill in the creases on the abdomen and left for several minutes to allow the solvents to evaporate.
Picture 3Picture 3: Hydrocolloid molded to fit crevices
Cohesive hydrocolloid material molded to fit the deep defect distal to the fistula.
Picture 4Picture 4: Layering hydrocolloid material to build an even surface
Four-inch hydrocolloid seals cut in five wedge shaped pieces and molded together with a tongue blade around the distal aspect of the stoma.
Picture 5Picture 5: Hydrocolloid molded together with a tongue blade
Two-inch hydrocolloid seal, divided in half and layered to create a double thickness, placed above the stoma. Peristomal plane was now even.
Picture 6Picture 6: Pouching system applied and reinforced
A convex skin barrier and drainable pouch were applied as a unit, an ostomy belt was secured, and additional pieces of soft cloth tape were placed around the tape collar to further enhance the seal.
Picture 7Picture 7: Pouching system allowing containment of fistula effluent
The patient rested for 15 to 20 minutes to allow her body heat to enhance product adherence.
This new application technique was able to provide a comfortable pouching system with a wear time of five to seven days. The products used were comparable in cost, accessible, and easily customized for the patient. The application time was reduced by minutes compared with other pouching techniques performed. Patient return visits required for applications were reduced to twice week in an outpatient clinic setting. The patient was able to regain a productive and active lifestyle including resumption of her exercise routine of walking up to two miles a day.
The products used with this technique have been further utilized to customize other pouching systems for patients with enterocutaneous fistula(s) as well as less than ideal ostomy stomas to achieve adequate wear time. WOC nurses can contribute to providing efficient and effective patient care by sharing their experiences using the properties and functions of common products and/or equipment to customize treatments and achieve patient-centered goals.
Stomahesive powder & Allkare protective barrier wipes (ConvaTec)
Eakin cohesive seals, four-inch & two-inch (ConvaTec)
SUR-FIT Natura Durahesive Convex skin barrier with flange (ConvaTec)
Nu-Hope skin cement
Medipore soft cloth surgical tape (3 M Health Care)