What to do if a WOC Nurse is Not Available?Pouching Techniques and More

Linda Coulter, RN, BSN, CWOCNAmber McCourt, RN, BSN

Purpose

This presentation will provide a resource for those nurses caring for clients with fecal and urinary stomas, and fistulas when there is no ET/WOC nurse available.Some institutions may have ET/WOC available only during certain hours (e.g. no ET/WOC at night).Other may have no ET/WOC on site at all.

What is the best suggestion for caring for a surface that has damage from ostomy fluids? I am always afraid I may be intensifying the injury to the skin by putting an adhesive seal on it.

Irritant Dermatitis

Irritant Contact Dermatitis

Erythematous, shallow, moist, painfulEpidermis is eroded by contact with offensive substance (effluent)

Caring for Irritant Dermatitis

PreventionSkin Care with Pouch Change

Adhesive removersNo lotion/oil/fragrancePat dry – don’t rubNo alcohol

Assessment by ET/WOC Nurse

Tips to Prevent Irritant Dermatitis

Assess the pouch for emptying during hourly rounds.Empty the pouch when 1/3 to ½ full.Don’t tape it, change it. Dry skin thoroughly before applying pouch.Don’t cut the aperture too large.

How to apply a pouch

Gather supplies: Adhesive removers, chux, 4x4’s (3 soapy, 3 wet, plenty of 4x4s), new pouch, scissors, measuring guide.Remove old pouch using adhesive removers or soapy 4x4.

How to apply a pouch continued

Measure stoma with measuring guide then cut the back of the pouch 1/8" larger than the stoma size. Wash the skin around the stoma well, then rinse and drywell. Apply pectin-based powder to irritated (open, wet) skin. Remove excess.

How to apply a pouch continued

Peel off the backing paper from the pouch and place the pouch over the stoma. Place your warm hand over the pouch for 30-60 seconds.

But what about the paste?

Just say “No”There are situations when paste is appropriate – use a thin layerToo much of a good thing

What would be the best option for pouching for patient with a new ostomy if they start functioning the night of surgery with a post-op pouch and a rod?

Pouching with a rod

Is the pouch leaking?No?

• Empty it. • Consult the ET/WOC.

Yes? • Remove the pouch very carefully.• Be careful not to dislodge rod• Clean and dry skin • Apply a bead of paste around the aperture• Apply a new, flat pouch – cut the aperture to fit the

size of the stoma (flange will cover rod)• Consult the ET/WOC

What about those LARGEfistula pouches?

Like this?

You might want to know

How to level out a surface that is not uniform?

How to pouch multiple fistulas?

What if there is very little skin surface?

What are some troubleshooting tips for window pouch leaks?

Some things to consider

Most Important: Keep the skin clean and dryIf possible, even out the skin surface, then apply a new pouch Otherwise, protect the skin using skin barrier spray or cream and dressings Fistula pouching is not just a science, but an artConsult the ET/WOC Nurse

How to "even out " the surface to get a good seal?Formulary will dictate what products you will use

Skin barrier sheetsSkin barrier rings and stripsPaste (sparingly)

Level - cut, twist, smear

Multiple Fistulas and Stomas

A freshly applied pouch

Troubleshooting tips for large fistula pouches

Most important: SKIN CARECheck the lid: Clean it, tape it, or replace itIf the leak is large:

Remove the pouchClean and dry skinLevel pouching surface with skin barriersReplace pouch (if comfortable doing so)If not, use skin sealant, moisture barriers, or powder and cover with gauze dressingsConsult the ET/WOC Nurse

If the leak is small:Clean and dry skin at site of leakageReinforce this area with skin barrier and tapeConsult the ET/WOC Nurse

Document

What are your suggestions for odor? A long time ago we used an aspirin.

Managing odor

Pouches are odor-proof.Clean end of pouch at each emptying.Make sure that 2-piece pouches are completely attachedCommercially available “odor eliminators”Some foods can lead to odor: cabbage, eggs, fish, beans, etc.Odor from a urostomy can indicate a UTI

Review

Skin Care and ProtectionKnow your formularyConsult a WOC Nurse

Save the

Skin!

Keep it Clean & Dry!

References

Wound Ostomy and Continence Nurses Society.(2010). Management of the Patient with a Fecal Ostomy: Best Practice Guideline for Clinicians. Mt. Laurel, NJ: author.Colwell, J.C. (2004). Stomal and Peristomal Complications. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal and Urinary Diversions: Management Principles. St. Louis: Mosby Elsevier.Rolstad, B.S. and Ovington, L.G. (2007). Principles of Wound Management. In R.A. Bryant and D.P. Nix (Eds.), Acute & Chronic Wounds: Current Management Concepts. St. Louis: Mosby Elsevier.