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• W4316174548 abstract "An estimated 100,000 lifesaving ostomy surgeries are performed annually in the United States, and people living with an ostomy in the United States are estimated to be about 725,000 to 1 million.1 However, the ostomy community remains to be underserved, as mentioned by the United Ostomy Associations of America, Inc (UOAA).1 The Wound, Ostomy, and Continence Nursing Certification Board (WOCNCB®) provides both traditional and experiential pathways for bachelor's prepared nurses to obtain the Certified Ostomy Care Nurse (COCN®) certification and for advanced practice nurses to obtain the Advanced Practice Certified Ostomy Care Nurse (COCN-AP®) credential that validates their specialized knowledge, skills, and competencies to efficiently serve patients living with ostomies including those who are about to undergo ostomy creation surgeries. Patients with fecal or urinary diversions are prone to both peristomal and stoma complications. Moreover, the exact incidence and etiology of these postoperative complications remain uncertain and may be attributed to a variety of factors such as higher body mass index, advanced age, emergent surgery, presence of inflammatory bowel disease (IBD), having an ileostomy versus a colostomy, impact of a diverting or loop procedure, poor bowel quality, and ischemic colitis.2 Stoma complications are usually classified in reference to their usual occurrence after surgery, with early complications such as mucocutaneous separation, stomal necrosis, and stomal retraction occurring within 30 days after surgery and late complications such as stomal stenosis, stomal prolapse, stomal trauma, and parastomal herniation occurring more than 30 days following surgery.2 After ostomy surgery, the peristomal skin may be exposed to both physical and chemical trauma. The most toxic chemical trauma is usually attributed to effluent draining from the stoma, which may lead to inflammation, pressure injuries, and lesions.3,4 It is essential for the COCN® and the COCN-AP® to conduct early assessment and recognition of stoma and peristomal skin complications in addition to routine stomal assessment of the patient with a fecal and urinary diversion to ensure that appropriate preventive and management modalities are being provided to patients. The COCN® and the COCN-AP® also specialize in both fistula and percutaneous tube management. A fistula is an abnormal passage between 2 or more epithelialized surfaces, resulting in a communication between either a body cavity and a hollow organ or between a hollow organ and the skin.5 Fistula management requires a comprehensive understanding of the pathophysiology underlying fistula occurrence in addition to specialized assessment skills and broad knowledge of management options that is often delegated to the COCN® and the COCN-AP®.5 Assessment of the patient with a fistula should include the characteristics and volume of the effluent, abdominal contours, and fistula opening.5 The COCN® and the COCN-AP® play an important role in evaluating the progress of the fistula as well as identifying any factors that may impair healing. Containment of effluent and skin protection are key in managing a fistula. When developing a strategy to manage a fistula, the COCN® and the COCN-AP® know the importance of starting with the simplest approach and understand when modifications are needed. The COCN® and the COCN-AP® will often be consulted for the management of percutaneous tubes such as gastrostomy and jejunostomy tubes. Specialized knowledge of the purpose and desired outcome of tube placement is vital for successful patient care outcomes.6 Skin breakdown around the tube site is a common complication and is most often caused by the leakage of gastric or intestinal contents on the skin.6 Tube migration and movement can enlarge the opening in the skin around the tube, leading to leakage. Tube stabilization will help mitigate the tube's movement and protect the surrounding skin.6 PRACTICE QUESTIONS COCN Questions 1. The COCN® is teaching a patient with a new gastrostomy tube regarding clog prevention and safe management of a clogged tube secondary to continuous feedings and medication administration. The COCN® understands that additional teaching is needed if the patient states which of the following: “I will flush the tube with lukewarm water using a 60-mL catheter-tipped syringe and a push-pull motion to loosen the obstruction. “I will flush the tube with lukewarm cranberry juice using a 60-mL catheter-tipped syringe and a push-pull motion to loosen the obstruction. “I will flush the tube with 15 mL of water before and after medication administration.” “I will flush the tube with 30 mL of water before and after each feeding and every 4 to 6 hours.” Outline location: 010206 Cognitive level: Analysis ANSWER: B Rationale: The correct answer is B. Patient teaching is an important step in preventing complications. The patients should be given clear written instructions with educational materials that are at an appropriate reading level about the care of their gastrostomy tube.1 Use of photographs and diagrams should also be considered to enhance the education provided.1 Patients should be taught to flush their percutaneous gastric tube with 30 mL of water before and after each feeding and every 4 to 6 hours as part of routine tube care.1,2 Each medication should be given separately, and 15 mL of water should be used to flush the tube before and after medication administration to prevent clogs. In the case of clogged tubes, the nurse should ensure that the tube is not kinked.1,2 The tube may be flushed with lukewarm water using a 60-mL catheter-tipped syringe and a push-pull motion to loosen the obstruction. The use of cranberry juice is not recommended as it may cause further obstruction of the gastrostomy tube.2 2. A 62-year-old male patient presents at the outpatient stoma clinic for follow-up 60 days after surgery. The patient reports hearing loud noises when passing gas and also reports pain with stoma evacuation accompanied by small, ribbon-like stools on his pouching system. The COCN® prepares to conduct further assessment and management plan knowing which of the following conditions may be present: stomal retraction stomal stenosis stomal necrosis stomal trauma Outline location: 010203 Cognitive level: Application ANSWER: B Rationale: The correct answer is B. Stoma complications affect many individuals living with an ostomy, and due to the growing number of ostomies created annually, the prevalence of stoma-related complications is expected to increase.1 While stoma complications may occur any time following ostomy creation, most complications develop within the first 5 years following stoma surgery.1 Gathering a thorough patient history, including the date of the surgical creation of the stoma in relation to the onset of the complication, provides the COCN® key information on the type of complication the patient is experiencing. Stomal stenosis is generally considered a late stomal complication occurring more than 30 days after surgery.2 Stomal stenosis occurs as a narrowing and contraction of the stomal tissue at the skin or fascial level and is frequently manifested by a smaller than the usual appearance of the stoma accompanied by pain on stomal evacuation, small ribbon-like stool, and constipation, followed by loud, large explosive evacuations with gas.2 Stomal retraction and stomal necrosis are early complications. Stomal necrosis is the most common early complication that results from impaired blood flow resulting in ischemia of the stomal tissue, while stoma retraction is the disappearance of the stomal tissue protrusion in line with or below skin level.2 Stomal trauma is an injury to the stomal mucus due to pressure or physical force exerted on the stomal tissue.2 3. The COCN® is assessing a 47-year-old patient with a diverting loop ileostomy 1 day after surgery and notes a plastic support bridge on the stoma. Which of the following statements about a support bridge is not true? Support bridges are made either of soft silicone or firm, rigid plastic. Support bridges are used to prevent stomal retraction. Support bridges are placed under and around the stoma during surgery. Support bridges are left in place until ileostomy reversal. Outline location: 010201 Cognitive level: Application ANSWER: D Rationale: The correct answer is D. Support bridges may be placed under and around the stoma during surgery to temporarily support the loop of the bowel on the abdominal wall, preventing stomal retraction, and are often made of soft silicone or firm, rigid plastic.1,2 Removal of support bridges typically occurs between 1 day to a month and results from a joint decision between the surgeon and the COCN®; it should not be left for long periods as it may cause intestinal necrosis, increased pain, peristomal skin complications, and difficulty obtaining pouching system seal.1 COCN-AP Question 4. A 42-year-old female patient with a history of Crohn's disease and a diverting loop ileostomy is seen in the outpatient ostomy clinic with complaints of a painful peristomal ulcer over the last 2 weeks. The patient describes the ulcer starting out as a cluster of pustules and quickly progressing to an edematous, full-thickness ulcer with purple borders, within 2 days. The patient also reports pain with appliance changes and difficulty with her convex pouching system adhering to skin, even with the use of powder. Upon assessment, the advanced practice ostomy nurse (COCN-AP®) finds a peristomal lesion at the 12 o'clock stoma border, measuring 2.2 × 1.7 × 0.4 cm, with a red wound base, erythematous, purple borders, and seropurulent drainage. After a thorough history and physical exam, including ruling out all other potential causes, the COCN-AP® performs a tissue biopsy that shows neutrophilic infiltrates. The COCN-AP® diagnoses peristomal pyoderma gangrenosum (PPG). What is the most appropriate initial treatment plan? Start the patient on a course of corticosteroids (oral prednisone therapy at a dose of 0.5-1 mg/kg/d) and treat the ulcer topically with a polyvinyl alcohol (PVA) foam–impregnated ring dressing, designed for use under ostomy skin barriers, and a soft, flat skin barrier for pouching. Consult dermatology for further recommendations and a medical workup. Perform an intralesional injection of triamcinolone acetonide (Kenalog) 40 mg and instruct the patient to call if no improvement, while continuing to use a moisture-absorbing ostomy powder on the ulcer with each pouch change. Refer back to colorectal surgery to ensure systemic conditions and underlying diseases are being well-controlled prior to initiating a new treatment plan. Outline location: 010201, 010202 Cognitive level: Analysis ANSWER: A Rationale: The correct answer is A. Peristomal pyoderma gangrenosum is somewhat uncommon and a challenging condition to diagnose and treat, as no evidence-based guidelines or standard treatments exist.1 Using corticosteroids, removing convexity, and applying an absorptive dressing, which may stay on for an extended period beneath a pouching system, are important initial steps in an evidence-based treatment plan for PPG.2 Peristomal pyoderma gangrenosum is a neutrophilic dermatosis characterized by painful ulcers that can be recurrent and is often associated with systemic diseases such as IBD, arthritis, or hematologic disorders. Peristomal pyoderma gangrenosum initially presents as pustules or blisters and quickly enlarges into partial- or full-thickness wounds, sometimes with erythematous or purple, irregular borders, and purulent exudate. These ulcers are typically painful, fail to heal with usual treatment, and are often associated with pouching difficulties, specifically difficulty with pouches adhering to the skin due to wound drainage. Convex pouching systems may also be a precipitating factor to PPG ulcerations.2 Peristomal pyoderma gangrenosum is a diagnosis of exclusion, which means all other causes of the ulcer should first be ruled out. A tissue biopsy may assist with ruling out other conditions along with clinical presentation and assessment findings. Referral to dermatology is indicated and an important part of the plan of care, as a medical workup, should be completed with evaluation for underlying pathology. Additionally, lab work, ruling out or treating other autoimmune processes, drug-induced vasculitis, coagulopathies, and malignances are an important piece of the dermatology workup. However, a treatment plan should first be initiated by the COCN-AP® prior to this referral.2 Intralesional injections with Kenalog not only will help reduce inflammation and pain but are also a more invasive approach, and oral prednisone therapy has been shown to be effective in controlling PPG in literature.2 Also, this patient has already tried using a moisture-absorbing powder without improvement as there is still difficulty with her pouching adherence, indicating that alternative treatments should be explored. Although referral back to colorectal surgery may eventually be needed to help with an interprofessional approach, the immediate concerns should first be addressed, which include managing pain, pouching difficulties, and initial attempts at healing the ulcer. Involving an interdisciplinary team is a critical element of the treatment plan when managing complex comorbidities and systemic processes." @default.
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• W4316174548 title "The Patient With Fecal and Urinary Diversion" @default.
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