10.2 (8.4 Fistula bits) Palliative wound and ostomy care Flashcards
What are three types of skin failure?
Acute, chronic and end stage
Name 3 causes for:
(a) acute skin failure
(b) chronic skin failure
Acute skin failure:
- Peripheral arterial disease*
- Severe sepsis/septic shock*
- Respiratory failure*
- Mechanical ventilation
- Liver failure
Chronic skin failure:
- Peripheral arterial disease*
- Diabetes*
- Nephropathy*
- Neurodegen disorders
V - PAD
I - sepsis
N - cancer
D - liver or kidney failure
I - radiation, chemo
C
A - eczema
T - trauma
E - diabetes
What are 2 examples of end stage skin failures?
Are they avoidable or unavoidable injuries?
Kennedy terminal ulcers (KTUs)
Trombley-Brennan terminal tissue injury (TB-TTI)
Generally unavoidable injuries
2 ways to distinguish KTUs from TB-TTI
KTU:
- Over bony prominences
- Develop < 2 months prior to death
TB-TTI:
- Found in locations with little to no pressure (e.g thighs)
- Median time to death is 36 hours
Name 3 characteristics of KTUs (in terms of appearance)
Sacroccoygeal location*
Sudden onset*
Butterfly or pear shape*
Irregular borders
Purple, blue, black or red color
What are the 11 parts of systematic wound assessment?
How often should this be done?
- Location
- Etiology or type of skin damage
- Dimension
- Base description (e.g. granulation, nerotic, eschar, slough, epithelial, mixed)
- Undermining/tunneling (stage III or IV pressure injuries only)
- Stage
- Drainage
- Odor
- Periwound skin
- Pain
- Infection
Done weekly or with change in condition
LED
BUS
DOPPI
What are 5 common symptoms associate with wound?
Pain, odor, bleeding, exudates, pruritus
FS: DOPPI
Drain (bleeding, exudates)
Odor
Periwound skin - pruritus
Pain
Infection
What can exacerbate wound symptoms? List 2
Infection
Lymphedema
Name wound pain interventions:
- 4 meds
- 4 care methods
4 meds:
- Systemic antibiotics
- Systemic medications (opioids, adjuvants)
- Topical opioids
- Topical anesthetics (2% lidocaine jelly 3-5 min before wound care)
4 interventions:
- Anti-microbial dressings
- Non-adherent dressing (foams, silicone)*
- Soaking dressing before removal with NS or tap water*
- Gentle irrigation/patting/blotting wound bed*
- Decrease number of changes with moisture retentive dressings*
- Use of burn nets or garments to secure dressing and normalize body image
- If adhesives needed, use skin protectants and apply skin tape
Key components to wound bed preparation
Tissue that is nonviable must be debrided
Infection or inflammation must be managed
Moisture imabalance or exudate control must be addressed
Edge margins of wound must be examined for non-adherence
TIME
Common wound debridement methods
Autolytic debridement: hydrogel (Tegaderm) dressings
Biological debridement: larval therapy
Chemical debridement: iodine, medical grade honey
Surgical and sharp (doctor) debridement: scalpel, scissors, forceps by trained tissue viability nurse or surgeon
Enzymatic debridement: collagenase agents
Mechanical debridement: ultrasound and water irrigation devices
FS: ABCDE + M
Name 4 agents to help to control wound odour and drainage
- Flagyl (spray, powder, tablets, gel)*
- Honey*
- Charcoal*
- Silver*
- Foams
- Calcium alginate
- Dakin solution (diluted bleach)*
How to manage wound related bleeding issues as below:
- Prevention (3)
- Minor bleeding (3)
- Major bleeding (2)
- Hemorrhage as a terminal event (3)
Prevention:
- Non-adherent dressing
- Wet dressings before removal
- Gentle cleansing or irrigation
Minor bleeding:
- Pressure
- Silver nitrate sticks
- Epinephrine soaks
- Calcium alginate
Major bleeding:
- Vascular intervention
- Radiation
Terminal bleed:
- Dark towel
- Benzo PRN
- Cover with blankets as blood loss can cause hypothermia
What are 2 peri-wound skin barriers to reduce pruritus and moisture-associated skin damage?
- Liquid polymer acrylates
- Dimethicone
- Zinc-oxide skin barrier* (triad)
- Petroleum skin barrier* (Vaseline)
Name 2 pressure-injury risk assessment tools
Braden Scale
Norton Scale (Norton hears a who…)
Hospice Pressure Ulcer Risk Assessment Scale
Name 4 risk factors for pressure-injury
- Advanced age*
- Protein-calorie malnutrition*
- Immobility*
- Shear*
- Friction
- Moisture*
- Incontinence
- Altered sensory perception
Name 4 ways to reduce/manage pressure-injury
- Maximizing nutrition and hydration*
- Pressure redistribution*
- Skin care (TIME)*
- Managing incontinence*
- Controlling wound related symptoms
- Providing psychosocial support
FS: think of cause -> intervention
Age - psychosocial support
Malnutrition - hydration + nourish
Immobility - pressure redistribution
Shear/friction - skin care
H20/Moisture - manage incontinence
Name 3 ways to facilitate pressure redistribution? What about foam rings or cutouts?
- Regular repositioning*
- Heel suspension devices and protective dressing*
- Support surfaces on beds and chairs (e.g. roho cushion)*
- Minimize or reduce medical device
Don’t use foam rings or cutouts
Describe the 4 stages of NPUAP pressure injury staging system
Stage 1 pressure injury: non-blanchable erythema of intact skin
Stage 2: partial thickness skin loss with exposed dermis
Stage 3: full thickness skin loss (adipose tissue is visible)
Stage 4: full thickness skin and tissue loss (fascia, muscle, tendon, ligament, cartilage or bone visible)
FS:
Epidermis - Dermis - Hypodermis/SC tissue - Muscle
Skin = epidermis, dermis, hypodermis
What are 3 ways to prevent incontinence related dermatitis
- Non-invasive containment products (absorptive products, fecal pouch, condom catheter, etc.)*
- Invasive containment productrs (urine catheter, fecal management system)*
- Incontinence care (pH balanced, non-rinse cleanser; skin moisturizer; skin barrier)*
- Treatment of candidiases
2 types of skin tears
Partial thickness (separation of epidermis from dermis)
Full thickness (separation of both epidermis and dermis from underlying structures - fat)
Name 4 ways to prevent skin tears
- Asssess for risk upon admission and whenever condition change
- Implement systematic prevention protocol
- Have individuals at risk wear long sleeves, long pants, knee high socks*
- Shin guard*
- Safe patient handling techniques*
- Involve patients and families in preventative strategies
- Condult dietician to ensure adequate nutrition and hydration*
- Keep skin moisturized at least 2 times per day*
FS:
Nourish (dietician)
Moisturize (twice a day)
Cover skin (long sleeves, skin guard)
Careful patient handling
How to manage new skin tears (5 steps)
- Cleansing with non-toxic solution (NS)
- Control bleeding and remove clots
- Approximating skin flap when possible
- Apply skin protectant on peri wound area
- Apply hydrogel (tegaderm), alginate, foam or non adherent dressing
Chronic critical limb ischemia:
- What is the etiology?
- How does it manifest? (3)
- What is the possibility of healing?
Arterial occlusive disease
Manifest as rest pain, ulceration or gangrene
Healing is not realistic goal when invasive vascular interventions are not available
What are 2 types of gangrene?
Dry and wet
Wet gangrene:
- What does it signal?
- What organism can be involved?
- What is treatment?
- Bacterial infection
- Clostridium perfringens
- Apply Dakin solution once or twice daily (bactericidal and decrease exudates)
FS: Dakin = diluted bleach
What is malignant fungating wound?
Name 3 cancers affilitated
Non-healing wounds - from aggressive proliferation of malignant cells - with infiltration of skin, blood and lymph
Head and neck*
breast*
lung
GI
skin*
More than 50% of those with malignant fungating wound will die how fast?
Within 6 months
Beside wound symptoms (DOPPI), what are other negative effects of malignant fungating wounds?
- Psych (Depression or anxiety)
- Social (marginalization, isolation)
- Spiritual (cause patients to focus on impending death, loss of hope)
What are marjolin ulcers?
Commonly seen with which cancers?
Malignant degenerations over years or decades (from areas of chronic skin inflammation or injury)
Commonly squamous cell ca - BCC and melanoma have been reported
FS:
Marjolin ulcers are a type of skin cancer that can develop from chronic wounds or scars. Specifically, they arise from long-standing non-healing wounds, scars, or burns, and can occur anywhere on the body.
Name 3 skin conditions (beside cancer) that can give rise to marjolin ulcers
Burns*
Frostbites*
Traumatic wounds*
Venous ulcers
Pressure injuries
Osteomyelitis
FS: VINDICATE
V - venous ulcer
I - osteomyelitis
N - SCC > BCC / melanoma
T - burns, frostbites, trauma
How to treat marjolin ulcer?
- Surgical excision +/- skin graft
- Treat symptoms
Calcinosis cutis VERSUS Calciphylaxis:
- What are they?
- What is the cause?
- Where are they found?
Calcinosis cutis:
- abnormal deposition of calcium in skin and fat tissue (((extravascular)))
- idiopathic or malignant hypercalcemia - met ca, CKD, hyperparathryroidism
- commonly in lower extremeties
Calcyphylaxis:
- calcification of small vessels of skin and fat tissues resulting in localized ischemia and tissue damage (((intravascular)))
- usually due to ESRD
- can be anywhere on body and may affect multiple areas
What are general principles for treating calcinosis cutis and calciphylaxis?
- Treat underlying cause
- Correct electrolytes
- Plan for wound care
What are 2 types of radiation dermatitis?
How do they manifest?
Acute rad dermatitis - manifest as erythema or dry/moist desquamation
Delayed rad dermatitis (months or years) - manifest as chronic dermatitis and/or skin fibrosis
Describe general skin care during radiation therapy (3 ways)
Mild soaps and deodorants*
Loose fitted clothing over irradiated site
Avoid sun exposure*
Avoid scratching*
Adequate nutrition
Moisturize
What 2 prophylactic treatments have shown promise in reducing radiation dermatitis
Topicals:
- Steroids
- Silver sulfadiazine (silver + sulfa = antimicrobial)
Name if the following stomas are for stool or urine:
Ileostomy
Colostomy
Urostomy (ileal conduit)
Ureterstomy
Indiana pouch
Neobladder
table 10.2.12
Stool:
Ileostomy
Colostomy
Besides DOPPI*, name 3 unique skin complications of stoma (and their treatments)
(1) Mucocutaneous separation: complete or partial detachment of stoma from surrounding skin (not correctable)
(2) Peristomal varices: dilatation of mucocutaneous vessels surrounding stoma (treat bleeding with pressure, silver nitrate, epinephrine gauze, suture ligation)
(3) Peristomal moisture-associated dermatitis: inflammation and erosion of skin related to moisture that begins at the stoma/skin junctin and extends outward (choosing pouching system that fits closely around stoma and prevent leakage)
*Drainage, odor, pain, peri wound skin, infection
Name 4 etiologies of fistula
V - vascular deficiency
I - infection
N - advanced cancer
D - malnutrition
I - steroid, radiation
C
A
T - post op, dehiscence of interstitial anastomosis
E - endocrine abnormalities
2 most common organ systems affiliated with fistula
GU and GI
How to classify fistulas by output volume?
Low output - < 200ml/day
Mod output - 200-467 ml/day
High output - >467 ml/day
Name 6 complications of fistulas
Pain*
Bleeding*
Infection*
Tissue destruction
Delirium*
Malnutrition*
Fluid and lyte imbalance*
Acid base imbalance
DOPPI
Name 6 conditions which are barriers to closure of fistulas
A - Abcess
B - IBD
C - Cancer
D - Distal obstruction
E - Epithelialization of tract
F - Foreign body
What investigations can be ordered to assess fistulas
- 2 general
- 2 GI
- 2 GU
CT scan
Fistulogram (injection of water soluable contrast directly into fistula followed by radiograph)
—
Barium swallow - Upper GI series (pt swallows barium and then have fluoroscopy of upper GI tract)
Barium enema (barium enema and then have fluoroscopy of colon)
—
IV pyelogram (xray of urinary tract with IV contrast)
Cystoscopy
Name 4 main components of fistula management
Skin cleansing and protection*
Uneven skin surface management
Dressing or pouch selection
Containment of output *
Odor management*
Nutrition management*
FS:
DOPPI management including intake (nutrition)
Name 3 meds that can slow GI fistula output
Anticholinergic (loperamide, atropine)
Opioids
Octreotide
what are two types of bladder fistulae? What are three risk factors for this?
vesicovaginal
vesicoenteric
Risk factors:
advanced malignancy
prior pelvic floor sx
XRT
poor nutrition
poor wound healing
infection
FS: VINDICATE causes of fistula
List 3 complications of vesicoenteric fistula and vesicovaginal fistula
rash
skin breakdown
ulcer
chronic infection
sepsis
