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

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case studies Hollister Adapt Barrier Seals (7805) used in conjunction with negative pressure therapy dressing to maintain moisture control in complex wounds Jennifer Daniels • CNC/STN Wound Management/Stomal Therapy, Redcliffe Hospital Metro North Health Service District, QLD INTroducTIoN Since becoming exposed to stomal therapy nursing whilst working as a wound consultant in 2005 and subsequently becoming an STN in 2008, being able to use wound and stoma therapies concurrently has enhanced my overall practice. Confronted often with difficult to manage or highly exudating wounds, adapting principles from stoma care through pouching systems, powders, belts, wafers, seals and pastes has enabled reduced dressing costs, extended wear time of dressing products, reduced dressing application time, enabling enhanced quality of life for wound suffers and peace of mind for nursing staff. The following case studies look at using Hollister Adapt Barrier Seals (7805) to assist with wound care management. The first case study of three focuses on a patient admitted with multiple Stage 4 pressure injuries in some exceptionally challenging sites with the addition of high exudate. Although it is noted Hollister Adapt Barrier Seals are not considered sterile in nature (they do not come in sterile packaging) all other products previously used (Eakin seals, pastes, hydrocolloids, pouches and drapes) failed to maintain peri skin integrity and negative therapy seal. The Adapt seals did not compromise the wound as their placement was adjacent to the wound and not in direct contact with the actual wound bed. cASe STudy 1 Patient history • Fifty-two-year-old male classified as C6, a complete tetraplegic using the ASIA (American Spinal Injury Association – ASIA– standard neurological classification of spinal cord injury) post-diving incident at age 19. • Chronic constipation requiring self-administration of aperients. • Multiple admissions for previous pressure injuries requiring extensive wound care/surgery: • In 2006: rectus femoris flap to L) trochanter: incision and drainage of gluteal abscess. Debridement of R) trochanteric bursa and direct closure: sacral pressure injury repair with local flap. • In 2008: admitted infected pressure injuries for wound care, discharged four months later. 6 Journal of Stomal therapy australia – Volume 30 Number 4 current • Admitted June 2010: septic from Stage 4 pressure injury to sacrum with osteomyelitis of pelvis. • Multiple pressure injuries to lower limbs, hips and elbows, all requiring sharp surgical debridement 6 June 2010. Medications Intravenous antibiotic (IVAB) vancomycin, multivitamins, coloxyl and senna. Iron transfusion and red blood cell transfusion. This case study will focus on the Stage 4 pressure injury to the sacrum including perineum. On admission, the patient had necrotic friable bone at ischium and fragmented ischium with possibly obliterated necrotic tissue. The patient was also noted to have osteomyeltis of the pelvis. Figure 1. Stage 4 pressure ulcer with fragmented bone on view. Extensive surgical debridement was carried out, which left fragmented bone on view and extensive structural injury. There was over 600ml of haemopurulent exudate in a 24-hour period, with periwound excoriation. The skin was fragile and the patient had excessive diarrhoea.
Management Vacuum assisted closure (VAC ® ) negative pressure therapy (NPT) was used, despite recommended precautions on use with fragmented bone on view; however, conservative dressings were not able to cope with the high exudate requiring changing 1/241 . High exudate predisposed the patient to further wound deterioration and breakdown2 . Additional issues were faecal incontinence constantly contaminating the wound bed due to close proximity to and involving the perineum. Therefore, NPT was primarily used for exudate management and wound containment3 . Note: The area was not suitable for a wound pouching system due to the patient requiring positioning on his back (extensive, multiple, Stage 4 pressure injuries) and not able to draw away exudate. Issues • Excessive diarrhoea with subsequent faecal contamination of wound. • Fragile periwound skin ++. • Wound adjacent to perineum: difficulty to get a seal using negative therapy, causing further skin maceration and increased wound breakdown. Eakin seals were previously tried, but these did not adhere or conform to periwound skin or around the perineum, resulting in leakage of VAC ® negative therapy seal. Trials using pastes required more time to apply and were not found to be stable enough around the perineum with normal rectus movement. The advantages of the Adapt seal: • No warming is required, which, in this case of extremely high exudate, enabled fast application. • Mouldable. • High absorbency, which reduced non-adhesion while applying negative therapy. • Easy application for staff. dressing technique • 3m Barrier Wipe applied to periwound skin. • Coloplast Stomahesive ® Powder was applied to heavily excoriated areas of periwound skin prior to application of Adapt seals. • After first dressing change 48 hours later, periwound excoriation had healed and stoma adhesive powder no longer required. • Adapt seals were applied to the entire periwound skin single layer, distal wound close to rectum Adapt seal applied triple layers to build up wound edge for even surface and cope with normal motility of rectal muscles without losing negative therapy seal. Adapt Barrier Seals were able to be moulded and shaped as required. Figure 2. Adapt seals to protect periwound skin. • Application VAC ® dressing as per direction using WhiteFoam to exposed bone with Granufoam to remainder of the wound bed 3 . Figure 3. VAC ® dressing in situ. • Success was immediate with the Adapt seal and negative therapy dressing remaining intact between dressing changes. • Periwound skin healed and the patient eventually was able to transfer to conservative dressings earlier than expected and is currently awaiting discharge to rehab for final mobility clearance. Journal of Stomal therapy australia – Volume 30 Number 4 7
Page 1 and 2: Print Post Approved PP 642521/00041
Page 3 and 4: aaStN Code of Ethics The Journal of
Page 5 and 6: President’s report Sharmaine Pete
Page 7: ConvaTec (Australia) Pty Limited. A
Page 11 and 12: Try the NEW Moderma Flex 1 piece po
Page 13 and 14: FD10175 alginate gel with enzymes t
Page 15 and 16: ALL THINGS UROSTOMY! Flexima Urosil
Page 17 and 18: not the vagueness of nursing know-h
Page 19 and 20: Reflective essay Katie Jane Bird IN
Page 21 and 22: could approach for this. I spoke wi
Page 23 and 24: SenSura 1-piece system Recommend Se
Page 25 and 26: *HOS-GON - NO-SMELLS! Nursing Homes
Page 27 and 28: causes a decrease in gastrointestin
Page 29 and 30: Iran, an experience Carmen George I
Page 31 and 32: What was often challenging for me w
Page 33 and 34: Stomal Therapy Nurses of Newcastle
Page 35 and 36: aCSa report Australian council of S
Page 37 and 38: Ray Garske presented with certifica
Page 39 and 40: familiar to us and it was great to
Page 41 and 42: • CS: Management of a complex fae
Page 43 and 44: • Diversity of a Stomal Therapy N

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

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