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

fragile skin (5.5). After addressing the issue of the inappropriate
bandaging, (13.2), my preceptor and I collaborated in the
dressing of the wounds (5.1). It was clear that additional support
was required to ensure adequate treatment was provided for
our patient. Her carer was contacted to emphasise her needs
and ensure future appointments were kept, she was provided
with a meal and a taxi was organised to take her home (6.5, 6.6).
The next appointment was kept and our patient was admitted
for intravenous antibiotics after extensive collaboration on the
part of my preceptor (5.4). This provided me with an example
of advocacy in action. Beyea 11 states that, practising registered
nurses (RNs) have the authority and the responsibility to act in
their patients’ best interest.
My primary mentor also provided me with examples of advocacy
during the extensive hours I spent working with her equipping
me with the knowledge to become an advocate myself. Recently
a male patient had undergone an extensive debridement of a
necrotic perineal lesion, including debridement of part of the
anal sphincter. After consultation with the infectious diseases
consultant (ID) and the surgeon (5.1) I attempted to apply a
suction dressing to the area. However, due to the proximity
of the wound to the anus, it was impossible to obtain a seal
without covering the anus. The patient was ventilated in
intensive care and neutropaenic as a result of treatment for
lymphoma; therefore the friability of the rectum prevented the
use of rectal tubes to control faecal output. Containment devices
were also inappropriate as they would not stick. This man was
also receiving alimental feeding through a nasojejunal tube.
This was causing diarrhoea so the wound was being constantly
contaminated. After considering many dressing options,
discussion with my mentor and ostomy and wound care
suppliers and reference to The Journal of Stomal Therapy Australia,
World Council of Enterostomal Therapists Journal and online
literature search (6.1) I approached the ID consultant regarding
the possibility of a temporary stoma to facilitate wound healing.
This took some courage as up till now I have played a minor role,
always deferring to my mentor. I also realised that if I made a
recommendation that was inappropriate, the patient could suffer
(3.2). Vaartio, Leino-Kilpi, Saantera and Suominen 12 believe
that the question of appropriateness of an action can only be
answered by the patients who are supposed to benefit from it. I
chose the ID consultant with whom to discuss this issue because
he had the best overall knowledge of the patient’s condition and
would not be biased towards surgical options (5.3). Meanwhile
I prescribed dressings with a hypertonic saline-impregnated
gauze twice daily and as required after bowel motions (4.7).
This type of dressing promotes a cleansing effect on exuding,
malodorous wounds, absorbs exudate and bacteria, promotes
autolysis of slough and maintains a moist environment 13 . The
ID consultant initially rejected the stoma idea, stating that he
would be reluctant to recommend this action since the bowel
was not a major factor in the patient’s current condition.
However, as the patient’s general condition improved and it
became evident that he was going to recover, this consultant
and the surgeon agreed. He now has a temporary ileostomy
and a negative pressure dressing, which is rapidly contracting
his wound and maintaining a base of clean granulation tissue,
expected outcomes as described by Dyson 14 . As the debridement
surgery involved part of the anal sphincter, the next issue will
24 Journal of Stomal therapy australia – Volume 30 Number 4
be continence (4.1). Intact sphincter function is essential to
maintenance of continence 15 . I was concerned that the stoma
might be reversed before investigations of sphincter control had
been performed. The consultant involved is a general surgeon.
I discussed this issue with him after careful consideration of the
correct approach to use (5.4). He assured me that he is planning
to refer to a colorectal surgeon for investigations.
My involvement in the care of this patient has also required
stoma education. His mental status has improved from
unconsciousness to full awareness and participation in his
daily care. He is now independently caring for his stoma,
including the cutting out of the hole to accommodate the stoma
because it is a “double-barrel”, oval shape. This single case has
encompassed multiple dimensions of stomal therapy practice,
including patient teaching, wound management, stoma care,
continence management and the professional responsibilities of
being a patient advocate and practising within one’s scope of
competence. Through the support of my mentor I have been able
to play an influential role (5.5). “Effective clinical supervision
can help to maintain the practitioner’s balance, and effectively
facilitated reflective practice will stimulate self-awareness and
personal growth, thus transforming the life and practice of the
individual ” 16
Treatment of a female patient who underwent a pelvic
exenteration has allowed me to follow through multiple levels
of care. I was asked to provide her pre-admission education for
ileal conduit and colostomy (1.1, 1.3). Her husband was present
during this education and on the day of admission when I
answered their questions and sited her for both stomas. The
surgery was performed on a Saturday. She spent two days in
intensive care. I visited her next with the STN. Her colostomy
was dusky. The surgeon was informed (7.2). Blackley 17 states
that this is appropriate. The stents were visible in the urostomy,
which was pink and had a satisfactory spout (1.5). Due to the loss
of vascularity of the colostomy, the stoma became sloughy and
the spout was no longer effective, which resulted in leaks when
the colostomy was active. Both the urologist and gynaecologist
were made aware of the situation (5.5). Both were reluctant to
consider refashioning due to the complexity of the previous
surgery. The problem of colostomy management had developed.
The output was liquid so at an appropriate postoperative
recovery stage when bowel function was confirmed, steps were
taken to facilitate thickening of the stool (8.1). Benefibre and
Loperamide were introduced. The fluid thickened but there
were still leaks. My mentor and I tried several methods of
approach, including the use of seals, paste and convexity with
a belt (13.1) until we reached a successful outcome. Although
thicker, the output remained liquid. The concern was that after
discharge when a firm stool developed, stenosis of the stoma
might result in inability of the faeces to be expelled 17 . It was
decided to introduce Codeine Phosphate to further thicken
the faecal output, with the surgeon’s cooperation (6.4), to test
the ability of the stoma to pass a thicker motion. I performed a
digital examination of the stoma tract to identify any stenosis.
None was identified. Digital dilatation may be helpful for stomal
stenosis 18 . Codeine Phosphate was introduced, and as this can
be used to control mild to moderate pain, the Endone which
the patient had been taking was ceased. Codeine Phosphate