JSTA December 2010 - Australian Association of Stomal Therapy ...

specialist nurses, other health professionals and secured further
opportunities for clinical placements.
I cannot state what my supervisor’s views were about changes
they noticed in me but they felt that my skills were at the very
least developed. For me it was about the specific knowledge
required to become a competent STN. I have noticed that with
the increased understanding of continence, wound management
and stomal therapy I have a more complete perception of issues
and am able to confidently and aptly work through the process
and address care of these clients with more competence. This
knowledge has also enabled me to educate and assist nursing
staff at ward level to resolve some unusual issues.
cASe STudy
Throughout this case study the Australian Nursing Federation
Competency Standards for the Advanced Registered Nurse 4 will be
applied with the competency standard identified in bold and in brackets
following the related action.
A female was admitted on Friday afternoon from her nursing
home with a history of fracturing her left clavicle two weeks ago.
She had been treated at the local regional hospital and transferred
to the medical ward of a metropolitan private hospital as they
could not care for her because she had a fistula and they had
no STN; neither did we! Upon arrival she was found to be in
great discomfort and of limited manoeuvrability because of
the fracture and her large size. Her pain was managed and she
was orientated then settled into the ward. Over the course of
the afternoon the surgical nurse unit manager (NUM) assessed
the fistula, establishing it was an enterocutaneous fistula, and
devised a dressing but did not record any management plan in
the notes except under no circumstances remove the dressing,
and measure then record all output carefully (5.1). Over the
course of the evening, the dressing started to leak and the
nursing staff dutifully reinforced the dressing with whatever
would soak up the effluent. I (student STN) was contacted for
advice at the commencement of my shift around 23.00 hours
about the management of a fistula with a continuous flow (11.2).
A check of the patient’s chart (5.1) did not mention wound
management but alerted me to the fact that the patient had
had extensive abdominal surgery over many years and that an
intestinal fistula had spontaneously developed two weeks ago.
The patient had a history of Crohns disease and surgical review
(at another hospital) stated that nothing could be done for at
least four months.
When I arrived at the patient’s bedside with the night nurse I
noted an obvious malodour and that the patient was in some
distress, her abdomen was stained with excrement as were her
hands and fingernails, with the fistula freely draining under
the dressing down into her body folds and groin (1.4, 1.10). I
introduced myself, donned some gloves, held her good hand,
looked directly at her (1.6) and explained that I had come to
see if we could devise an improved dressing for the fistula, and
make her comfortable (4.1). Privacy was maintained. I continued
to interact and involve the patient in what was happening and
gain some insight into her history, but she was a terrible historian
(1.8). Together the night nurse and I carefully removed the entire
dressing, using principles of skin care to preserve skin integrity
and assess the wound (4.2). The skin below the fistula was badly
excoriated and had a small ulcer, but it was also noted that the
16 Journal of Stomal therapy australia – Volume 30 Number 4
fistula was on the right, lower corner of a square-shaped, healed
wound that had the appearance of a window with wound mesh
exposed in the healed suture line, giving it the appearance of
badly sewn, frilled lace on the upper and lower sill. Fortunately
the integrity of these suture lines were fine and not inflamed,
though the appearance was most unusual (1.10); the mesh was
caked with a dry film. Using the principles of stomal therapy
and wound care 1 , I devised a dressing plan that used protective
care products (2.1), explaining my rationale to the night nurse
as I went. (1.11, 14.2) The plan included protective film (Cavilon
wipe), protective paste (Stomahesive Paste), protective powder
(Stomahesive powder), adhesive barrier (Eakin Rings) and
adhesive removal wipes to create minimal skin damage on
removal of hydrocolloids. A hydrocolloid was used to protect
the healed suture line (Comfeel plus) and finally the application
of a cut-to-fit, drainable ostomy management appliance to
contain exudate and odour. The patient was washed, her wet
clothing and linen were changed, and she was repositioned for
comfort of the left clavicle. I left the buzzer in the client’s reach
and reinforced that she should use it if she had any concerns,
wound leakage or further discomfort she should contact the
nursing staff.
I recorded my actions in the patient’s progress notes, making
careful record of my wound assessment and dressing plan
and discussed the patient’s care with the nursing staff. I also
discussed measures (4.7) with nursing staff that they should be
aware of, such as hydration, electrolyte imbalances, thickening
agents (but these may be of doubtful use) and the use of low
suction connected to the pouching system if the drainage
continues to defeat the appliance seal 3 . Nursing staff expressed
that they would like further in-service (13.2) relating to troubleshooting
stomal therapy dressings and the risks associated with
Crohns disease. I agreed to organise this with the nurse educator
as soon as possible. A courtesy email was made to the surgical
NUM as I would be off duty when she returned to duty. I
reminded staff to contact me if they had any further issues; they
had my pager number. I checked in with the patient later in the
shift (3.5) to find her settled and dozing.
This experience left me most troubled because I had so many
unanswered questions about my patient’s management such
as wound healing, foreign objects in healed wounds, further
management options, ethical and social issues which I have
explored further (1.9) by discussing with medical personnel (6.3)
and peers (8.1), reading journal articles (1.7), using the internet
(relevant articles I have given to ward to refer to [14.1]) and look
forward to discussing with my preceptor and STNs at the next
AASTN Q meeting. Of course patient confidentiality will be
maintained at all times.
refereNceS
1. Carville K. Wound care manual, 5th edn. Osborne Park, WA: Silver
Chain Foundation, 2005.
2. Davenport J. Establishment of a stomal therapy practice: A
retrospective. Journal of Stomal Therapy Australia 2002; 22(2)33–36.
3. Toth P, Hocevar B & Landis-Erdman J. Fistula Management. In:
Colwell J, Goldberg M & Carmel J. Fecal & Urinary Diversions
Management Principles. Missouri: Mosby Inc, 2004.
4. Australian Nursing Federation. Competency standards for nurses in
general practice. Advanced registered nurses. Melbourne: ANF, 2005.