Evidence of innovation€¦ · compound unique to Manuka honey and is reflected through the MGO...

Evidence ofinnovation

Contents_4 2020 – Year of the Nurse and Midwife_6 Ostomy Challenges – Peristomal skin complications_8 Study: Balancing stoma complexities with pouch convexity _12 Case Study: A challenging patient_14 Case Study: Stoma education_18 Case Study: Combining Aurum® 2 urostomy and colostomy pouches_22 Case Study: Using Aurum® 2 for peristomal skin complications_24 Case Study: Pyoderma gangrenosum and Manuka honey _28 From nature to nurture – The lifecycle and properties of Manuka honey_34 Maori Manuka story_36 Colostomy UK rugby match UltraFrame® interview_39 References

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WELLAND MEDICAL EVIDENCE OF INNOVATION

“SKIN HAS NOT BEEN SORE SINCE USING THE AURA® POUCH.”Mrs R, UKUses Aura® urostomy pouches


2020isourtimetoreflectontheseskills,thecommitmentandexpertclinicalcaretheybring,andtheimpacttheymakeonthelivesofsomany1.

FlorenceNightingale2said“themoreexperiencewegain,themoreprogresswecanmake”.ThecommonclinicalthemethroughoutthiseditionistheimprovementmadetoperistomalskincomplicationsfollowingtheintroductionofmedicalgradeManukahoneyinthestomaflangeadhesive.

Togetherwecanreviewexamplesofnursingcarewhichhavemadeapositiveimpactuponpatients'qualityoflife,aswetakeatriparoundtheglobetoreadpatientcasestudiesandpublishedarticlesfromAustralia,Holland,Italy,NewZealandandtheUK.

Throughpatientscenarios,weareabletofollowspecialistnursesastheysupporttheirpatients'journeythroughperistomalskincomplications.KatyMartin-Skurrreviewstheimpactofpyodermagangrenosum,MoiraEvans,PamelaWhiteandLynnRidley

sharetheimpactofdementiauponstomacare,whilstDannielleBarrintroducescomplexsocialsituationsandmentalhealthissues,forNellekeVandeVliertandLeilaFatemifarthefocusisuponproblematicabdominalcontours.

ThedynamicofchangeisdiscussedinRebeccaHowson’sreviewofpatienteducationmodelsandthereviewofpatients'clinicalneedsbyPamelaWhiteandMoiraEvans.

Peate(2019)statedthat:‘Theproverbpreventionisbetterthancuremeansthatitiseasiertostopsomethinghappeninginthefirstplacethantohavetorepairthedamageafterithashappened’.3

Thiseditionrecognisesstomatherapynursesintheirnever-endingquesttoenhancethelivesofpatientswithstomas.FlorenceNightingalesaidthatweshould“livelifewhenyouhaveit.Lifeisasplendidgift-thereisnothingsmallaboutit”.4

Dataheldonfile.

Florence Nightingale (1820-1910), photograph ca. 1880

AswecelebrateFlorenceNightingale’sbicentennialyear,designatedbytheWorldHealthOrganisationasthefirsteverglobalYear of the Nurse and Midwife.


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“THE MORE EXPERIENCE WE GAIN, THE MORE PROGRESS WE CAN MAKE.”Florence Nightingale

A VERY SPECIAL YEAR FOR NURSES.

MoiraEvans,ClinicalMarketingManager,WellandMedical

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PERISTOMAL PYODERMA GANGRENOSUM (PPG)Pyodermagangrenosum(PG)isadebilitatingskindiseasemostoftenassociatedwithinflammatoryboweldiseaseandisareportedlyrarecauseofperistomalulceration.ThelesionsofPGrapidlyevolvefromsmall,erythematouspustulestodeep,painful,pyogeniculcerswithinhourstodaysofonset.AlthoughthebehaviourandtheappearanceofthelesionsofperistomalPGarediagnostic,alackoffamiliaritywithPGoftenleadstomisdiagnosisandinappropriatetherapy.1

Asanuncommonsubtype,peristomalpyodermagangrenosum(PPG),whichoccursclosetoabdominalstomas,comprisesabout15%ofallcasesofPG.Thelesionsarepainfulandofteninterferewiththestomabagadheringtotheabdominalwall,whichcancausethecontentsofthebagtoirritatetheskinmorethanusual.2

Wallace(2017)suggeststhattherarityofpyodermagangrenosummeansthatthere is a need for clinicians to share their treatment experiences to act as a guide for future best practice.3

Thereisnouniversallyacceptedguidelinefortreatmentofpyodermagangrenosum,andnodisease-specifictherapieshavebeensubjectedtocontrolledclinicaltrial.4Instead,amultidisciplinaryapproachtotreatmentisrequired,andisbasedoncasereports,randomisedcontrolledtrialsintovariousdrugtherapies,andpreviousclinicalexperience.

PERISTOMAL SKIN COMPLICATIONSPeristomalskincomplicationsarethemostcommonissuefollowingcreationofastoma,Martinsetal(2013),andrangefrommilddermatitistoseverecomplicationssuchasulcerationornecrosis.

15%Peristomalpyodermagangrenosum(PPG)comprisesabout

ofallcasesofPyodermagangrenosum(PG).2

OSTOMYCHALLENGES

“THERE IS A NEED FOR CLINICIANS TO SHARE THEIR TREATMENT EXPERIENCES TO ACT AS A GUIDE FOR FUTURE BEST PRACTICE.”WallaceA(2017)

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BALANCING STOMA COMPLEXITIES WITH POUCH CONVEXITYMoiraEvans,ClinicalMarketingManager,WellandMedicalLtd.PamelaWhite,ClinicalGovernanceManager,CliniMedLtdandSecuriCare(Medical)Ltd.LynnRidley,SecuriCareNurseManager(North),SecuriCare(Medical)Ltd.

Areviewofonepatient’sjourneythroughperistomalskincomplicationmanagement. OUR PATIENT

An82-year-oldladywithdementia,whowascaredforinherownhomebyherfamily,thisincludedherdailyileostomycare.

Thepatientwasusingaonepiececonvexpouch.

Thefamilynoticedadeteriorationintheperistomalskincondition.TheyhadbeenadvisedtogetintouchwiththeirStomaCareNurse(SCN)iftheyhadanyconcernsrelatingtothestoma.

ThefamilycontactedtheirSCNfollowingthedeteriorationoftheperistomalskincondition.

STUDY AIMTopresentapatientscenariotodemonstratethepositiveimpactsuponperistomalskinintegrity,followingtheintroductionofmedicalgradeManukahoneywithintheconvexflangeadhesive.


WHICH PROBLEM STARTED FIRST?• Patientattemptedtophysically

removethepouchduringthenight

• Theimpactofdementiauponherstomaawareness

• Reducedadherenceoftheflangeupontheskin

• Discomfortexperienced

• PeristomalMoistureAssociatedSkinDamage:ContactDermatitis

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THE IMPACT OF DEMENTIA UPON HER STOMA AWARENESS

NURSE ASSESSMENT 02-NOVEMBERTheSCN’sholisticassessment,promptedachangeofpouchadhesivetoaManukahoneyconvexflangeto:

1. Improvepouchtoskinadhesion

2. Supporttheimprovementofskinintegrity

3. Providecomforttothepatientduringwear-time

NURSE REVIEW 09-NOVEMBER (7 DAYS)Thereviewofthechangeofpouch7dayslater,showedperistomalskinimprovementandthesamepouchwasuseduntilthenextplannedreviewdate.

TREATMENT CONTINUATION 12-NOVEMBER (10 DAYS)TheholisticnursingcareandthechangetoaManukahoneyadhesiveconvexpouchhadresolvedthepatient’speristomalskinproblemsandtheuseofaconvexManukahoneypouchcontinued.

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*Consentonfiletosharephotos PosterpresentedtotheASCN2019Conference,ICCWales.

METHODOD ?TheSCNsutilisedSecuriCareMedicalLtd.'sClinicalStomaScoringThermometertooltoacknowledgeandmanagecumulativeriskfactorstoenableprioritisingandproactivityofcareinput,asthepatient’sscorewasrankedas8,asamedayvisitwasarranged.

THE PATIENT’S JOURNEY LED TO:1.Thevigilanceofthepatient’sfamilycarers2.TheSCNpromptintervention3.ThechangetoaconvexManukahoneyadhesiveflange

Allofthesehavecontributedtotheresolutionoftheperistomalmoistureassociatedskindamageexperiencedbythepatient.

Patient attempted to physically remove the pouch

during the night

Discomfort experienced

Reduced adherence of the flange upon

the skin

Peristomal Moisture Associated Skin Damage: Contact

Dermatitis

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HomelessnessandemergencystomalsurgeryCASE STUDY: A CHALLENGING PATIENT

THE PERSON / THE STORYMrCpresentedasanemergencypatientviaambulancewithsevereabdominalpainandhaematemesis.Shortlyafteradmissionhewastakentotheatreandunderwentanemergencylaparotomy/totalcolectomyandwashout.Hislargebowelwasnecroticfromthedistalileumtotheproximalrectumwithnoobviouscause.Atthisstagethewoundwasleftopen(laparostomy)andatopicalnegativepressuredressingwasputinplace.ThepatientwasadmittedtoICU.Thefollowingdayhereturnedtotheatreagainforare-looklaparotomy/proctectomyandsmallbowelresection.Anendileostomywasformedatthisstage.Thepatientwascriticallyunwellanditwasunknownwhetherhewouldsurvivetheseprocedures.Stomaltherapywascontactedonday2postoperatively.Surprisingeveryone,MrCdidrecoverfromhissurgerybuthisstomaprovedtobechallenging.

SOCIAL, MEDICAL AND SURGICAL HISTORY / DIAGNOSISMrCisanex-IVdruguserandhasHepC.Atthetimeofadmissionhewasofficiallyhomeless;althoughhehadbeensleepinginemergencyhousinghehadlosthisbedwhenhedidnotpresent.HehasnonextofkinandsuffersfromPTSD1duetochildhoodabusefromwhenhespenthisyouthinaboys’orphanage.Hewascurrentlyonahighdoseanti-depressantandonamethadoneprogramme.Hehadnorelevantsurgicalhistory.

Thesurgicaldiagnosiswasischaemicbowelofunknowncause.MrChadnorecollectionofwhateventmayhavetriggeredtheischaemicbowel.Althoughhewasanex-IVdruguser,hecouldnotrecallusingintheperiodpriortoadmission.

POSTOPERATIVE ASSESSMENT AND DISCHARGEMrC’sileostomywasfoundtobeflat,non-spouted,initiallysloughy,withhealthytissuebecomingvisibleafterusingstomapowderforseveraldays.Hisstomarequiredaconvexapplianceandasealwasalsoused.However,norealissueswiththispresentedduringhishospitalstay.

StomaltherapyworkedcloselywithsocialworktoemphasisetheimportanceofMrCreturningtoemergencyhousingasweweregravelyconcernedabouthimreturningtothestreetswithhisnewstomaandcomplicatedsocialhistory.Thankfully,thesocialworkerwasabletosecureaccommodationbackattheplacehewaspreviouslysohewasdischargedthere.

However,themealsprovidedhadlittlevariationandwerenotidealforsomeonewithanileostomy.Inaddition,hisstomacausedembarrassmenttoMrCwhenitproducednoisyflatus.Thefacilitynotonlyhadasharedkitchenandlivingareasbutsharedbathroomcubicleswhichleftlittleprivacyforchangingastomaappliance.

MrCbecamedepressedandadmittedtobeing“really,reallylow”.Hewasstrugglingwithbodyimageassociatedwiththestoma,compoundedbyongoingleakswhichheattributedtotheexcessflatus.Healsostruggled,andcontinuestostruggle,withnotknowingwhyhe'dbecomesounwellinthefirstplacesincehehasnomemoryofthattime.Cognitively,wethoughtMrCmayhavesomeshort-termmemorylossassociatedwithbeingsocriticallyunwell.Inaddition,hisperistomalskinwaserythematouswithabrasionsandwaspainful,althoughthestomasizehaddecreased.

THE PLAN FOR MR CItwasabsolutelycriticalforustouseaproductthatwouldhavehealingproperties.Inaddition,theappliancewouldneedconvexity.Itwasclearabeltwouldbebeneficialalsoto‘pop’thestomaoutasmuchaspossibleduetoitsflatprofile.Theproductusedpriortodischargehadabelt,butMrCfounditdifficulttomanage.ThestomaltherapyteamthereforechosetousetheWellandAurumConvex(Figure1)withabelt2.Weneededtobeconfidentthattheproductwouldnotleakandwouldhealthesoreskin.Anotherreasonwechosethisproductisthatthebeltiseasytomanagewiththevelcrothateasilyslidesthroughthebelthole.AsMrCisoftenforgetful,itneededtobesimpletoensureself-efficacy3.Wealsofacilitatedareferraltothepsychiatricteamforongoingmanagementofhisdepression.

OUTCOMEMrCcamebacktoanoutpatientappointmentacoupleofweekslaterforreview.HelovedtheWellandAurumConvexdrainableandhadexperiencednoleakssincewehadseenhimlast.Hefoundthepoucheasytoemptywiththebuilt-intab.Healsolovedtheeaseoftheadjustablevelcrobelt.HisskinwashealedandwasnolongersoreasindicatedinFigure2.

MrCwasalsonowseeingthepsychiatristregularly.Althoughhestillhasalongwaytogopsychologically,havinghadnoleaksforaperiodoftimehasmadeahugeimprovementinhisconfidence,andheisobviouslycopingmuchbetter.ForsomeweeksMrCchosetohaveweeklySTNOPDappointmentswhichhetitrateddownashismentalhealthimproved.ItwasthereforegreatnewstohearthisweekthatMrChadmovedfromemergencyhousingintohisownpublichousingflatwhereheislivingindependently.

Figure2.MrC’sstoma.

Taken from the Journal of Stomal Therapy Australia – Volume 39 Number 3

September 2019. Printed with the kind permission of the AASTN.


Figure1.TheWellandAurumConvexplusbelt.

DannielleBarr,RegisteredNurse,StomalTherapyNurseTheRoyalMelbourneHospital,Parkville,VIC3050


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Fortheolderpersonisaboutkeepingitassimpleas1,2,3

RebeccaHowson,StomalTherapyNurse,CaulfieldHospital,CaulfieldVIC3162

CASE STUDY: STOMA EDUCATION

BACKGROUNDTheagingpopulationpresentsanarrayofissueswhentryingtoeducateanindividualonhowtoself-managetheirnewstomaand,withtheworld’spopulationagingrapidly,thisisanareaofparticularimportance.

Between2015and2050,theproportionoftheworld’solderadultsisestimatedtoalmostdoublefromabout12%to22%1.Inabsoluteterms,thisisanexpectedincreasefrom900millionto2billionpeopleovertheageof601.InAustralia,theproportionofthepopulationaged65yearsandoverincreasedfrom12.2%to15.7%between1998and20182.Thisgroupisprojectedtoincreasemorerapidlyoverthenextdecadeasfurthercohortsofbabyboomersreach65years2.Also,overthepast2decadesthenumberofpeopleaged85yearsandoverincreasedby125.1%comparedwithatotalpopulationgrowthof34.3%2overthesameperiod.Typicalissuesrelatedtoagingincludelossindexterity,decreasedsensationinextremities,changestoeyesight,decreasedproblemsolvingabilitiesandslowerrecall.However,theagingbrainisstillabletolearnnewskills3.

Inaddition,theculturalandlinguisticdiversityofAustralia’sresidentpopulationhasbeenreshapedovermanyyearsbymigration.Historically,morepeopleimmigratetothanemigratefrom,Australia.At30June2017,29%oftheestimatedresidentpopulationwasbornoverseas(7.1millionpersons)4.Thiswasanincreasefrom2016of28.6%3.In2007,10yearsearlier,25.1%ofthepopulationwasbornoverseas4.ThesestatisticshighlightthatAustraliahasnotonlyanagingbutalsoamulticulturalpopulation,andwhileinterpretersareinvaluableassetstheyarenotalwaysavailable.

Sohowdoweprovideeffectiveeducationtothiscohortofpatients?Bykeepingitsimple,asthisallowsthepatientstolearnwithouttheneedtoalwayshaveanadditionalpersonduringalleducationsessions.Also,byremovingunnecessaryproductsandstepsinordertosimplifytheprocess,thetaskbecomesachievableandincreasespatients’likelysuccess.

CASE STUDYMrsRisan87-year-oldnon-EnglishspeakingbackgroundGreeklady.Shelivedathomewithherhusband,whohasdementia,andwashisprimarycarer.Sinceheradmission,herhusbandhadbeenplacedintorespitecareand,ifshewereunabletoachieveindependencewithhercolostomycare,herfamilyhaddiscussedpermanentplacementforbothherandherhusband.WhilstMrsRwasabletospeak

English,aninterpreterwasutilisedduringtheinitialeducationsessiontoensurethatshewasabletofullyexpresstheissueswithchangingherapplianceandtohaveanyquestionsanswered.Priortothestomaltherapynursereview,itwasdocumentedthatMrsRwasrequiringassistancewithallaspectsrelatedtohercolostomycare.

SURGICAL HISTORYOn20June2018MrsRunderwentanemergencyHartmann’sprocedureforcolonoscopicperforation.Thiswasfollowedbyanextendedstayintheacutesetting.On5July2018shewastransferredtosubacute/rehabilitationforstomaltherapyeducation,assessment

andcomplexdischargeplanning.Atthetimethecolostomymeasured32mm,themucocutaneousjunctionhadhealed,butperistomalskincomplicationswerepresentrelatedtocontactwithoutput.

ABSTRACTAustralia’sagingpopulationpresentsuniquehurdleswhenplanning,providingcareandeducatingnewostomates,andthesevariationstocarediffergreatlydependingontheindividual.

Whilsttherearemanypredictorstoflagpotentialissues,andwell-planned-outpathwaysforthestoma’sphysicaljourney,thisarticleisaimedathighlightingtheoftenoverlookedandunder-documentedcomplexitiesencounteredaswenavigatepatientsinthetransitiontohome.Thisisanexampleofhownotallcomplicationsandbarrierstodischargeareduetothestoma,theoutput,oranymedicalissue,butratheraboutthepatient’sabilitytoself-manage.Theabilitytoself-manageastomaisoftenthedefiningfactortoanagedperson’sabilitytoeitherreturntotheirlivesathomeorbeplacedintoformalcare.Thisarticlefollowsthejourneyofanon-Englishspeakingbackgroundpatienttransferredfromtheacutesettingtorehabilitation.Shewasstrugglingtomanagehercolostomyappliancewhichcouldputher,andherhusbandwithdementia,intoresidentialcare–hermotivationtopreventthiswasdemonstratedbyherreadinesstolearn.Asstomaltherapynurses,itisourresponsibilitytoidentifythebarrierstoself-care,adaptproductselection,andimplementthemostachievablegoals.Thepatient’sspecificgoalsandtheinterventionsproducedtoachievethesewereindividualisedsothatshewasabletoreturnhometocontinuetoliveherlife,andnotbedictatedbyhernewstoma.Thismeantthattheconceptofself-carehadtobeassimpleas1,2,3.

“AN EDUCATION PLAN WAS SET UP IN ORDER TO REITERATE THAT SELF-CARE IS A 1, 2, 3 PROCESS.”

Imageisindicativeonlyandnotofactualpatient.

Taken from the Journal of Stomal Therapy Australia – Volume 39 Number 3

September 2019. Printed with the kind permission of the AASTN.

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ISSUES IDENTIFIEDMrsRexplainedthatshehaddifficultycuttingtheflangetothecorrectsizeandalsotryingtoattachthebagtotheflange.Shewasunabletovisualisehercolostomywithouttheuseofamirrorandsaidshedidn’thave‘enoughhands’toapplytheflangecorrectly.Theseissueshadcausedhertocutthe

openingforthestomatoolargewhichhadledtothecircumferentialdamage(Figure1).Thereforethemainissueswerelanguagelimitations,atwo-piecemechanicalcoupling,incorrectsizingofproduct,anddifficultieswithfinemotorskillsduetodexterityandsensation.

REHABILITATION PLANAnumberofsuggestionsweremade.Firstly,thatMrsRchangestoaone-pieceproducttosimplifytheprocess.Secondly,thatshebeginstouseapre-cutproductandasshewasnotabletoreadEnglishwell.TheAurumwithManukaHoneywaschosenasthiscameintheappropriatepre-cutsize,wouldaidinhealingthe

damagedperistomalskin,andiseasytoapply.Thirdly,thatshecreatesaphotocareplan(Figure2)torefertowhenchanginghercolostomybag.Inadditiontothis,aneducationplanwassetupinordertoreiteratethatself-careisa1,2,3process.Thisisdefinedastherebeingonlythreethingstocollectpriortochanging.

Eachstepwasdemonstratedbysaying1asthebagisremoved,2whilecleaningtheskinandstoma,and3whileapplyingthenewbag.

REVIEWMrsRreportedatthenextreviewthatitwasmucheasiertochangeherapplianceandlikedhavingthephotocareplantorefertoduringappliancechanges.Herperistomalskinhadimprovedinthe3daysofusingtheAurumwithManukaHoney(Figure7)andMrsRalsocommentedthatshedidn’tfeel“itchy”aroundherstoma.Shewasnolongerrequiringanyassistancefromnursingstaffandwasconfidenttobedischargedhometoresumecaringforherhusband.MrsRwasdischargedhomewithdistrictnursesupport.

CONCLUSIONTheuseofunnecessaryproductsandnumerousstepsintheprocessofchangingbagscreatescomplicatedandconfusingtasksfortheagedorforthosepatientswithlimitedEnglish.Simplifyingtheprocessallowsforallpatientstobepresentedwiththesameeducationprocessandfacilitatescontinuityofcareashandoveroftheprocessforeducationisthenalsosimplified.The1,2,3stepeducationprocessrequiresonlyrepetitionandpractice.STNsprovidehands-onbedsideeducationtoallpatientsand,byusingthisprocess,canminimisethepotentialforvariationandmiscommunicationbetweenSTNsandbedsidenurses.

Note:Consentwasobtainedtousetheseimagesandcasestudyfromthepatientwithintheguidelinesoftheorganisation.

Figure1:MrsR’sstomapriortoeducation.Theperistomalskinisunprotectedduetoamis-fittingstomaappliance.

Figure5:PhotocareplanforthepatientshowingStep3:applyingthebag.

Figure3:PhotocareplanforthepatientshowingStep1:howtoremovethebag.

Figure2:Photocareplanforthepatientshowingthe1,2,3suppliesrequiredforbagchange.

Figure7.Reviewofthestoma–theperistomalskinshowedmuchimprovement.

Figure6:PhotocareplanforthepatientshowingStep3:checkingthepositionofthebag.

Figure4:PhotocareplanforthepatientshowingStep2:cleaningtheskinandthestoma.


1New bag Wet cloth

2Rubbish

bag

3

1Remove Clean

2Apply

3

andthenthattherearethreestepstotake(Figures3–6):

Thisisdefinedastherebeingonlythreethingstocollectpriortochanging.

Aurum® 2urostomyflangeincombinationwithAurum® 2colostomypouch

AclinicalaccountbyNellekevandeVliert,NursingConsultant

PatientMale,75,colostomy

SourceNellekevandeVliert,NursingConsultant,WellandServiceTeam,WellandNederlands

ProblemPeristomalskincomplication

SolutionAurum®2urostomyflangeincombinationwithAurum®2colostomypouchandUltraFrame®flangeextender

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Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.

CASE STUDY

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DIAGNOSIS AND TREATMENTTheWellandServiceTeam(WST)wasapproachedbyahospitalstomanurseforhelp.Theyhadapatientwithacolostomywhohadaseveremoist,redandirritatedperistomalcomplication.

Thehospitalnurseswereunabletodeterminethecauseofhisskinproblemandhadalreadyrecommendedatwopiecepouchingsystem,thisdidnotrelievetheskincomplicationandanAurum1piecewasgiventothepatient.Priortothis,thepatientusedmultiple1pieceflatflangecolostomypouchesfromseveralmanufacturers.

ToclearlyidentifytheproblemIvisitedthepatientathishomeaddress.

WhenImetthepatient,hewasonlyabletoleavethe1piecepouchinplaceforfourhoursastheflangestartedtoliftawayfromhisskin.

DuringthehomevisitIobservedthatthepatienthadmoistandredskinaroundhisstoma(Figure1).Inaddition,thepatienthadsomeproblemswithleakage,probablycausedbyhisverymoistskin.

Figure1.Patientbefore22-05-2019.

>>>

Thenextstepwastospeaktothepatientaboutwhatoneofthecausesoftheproblemcouldbe,namelythemoistskinwhichcausedmostoftheleakage.Idecidedtousea2piecesystemwithanAurum2urostomyflangeduetoitsabsorptioncapacity(Figure2).Iselectedatwopieceurostomyflangeasithasathickerflange,adeeperhydrocolloidbase.

Astheskinproducedsomuchmoisture,itwasdecidedtoinitiallychangethe2piecesystemdaily,wethen

extendedthepouchweartimeto48hoursduringthesecondweekandprogressedtoa72hourweartimefromthethreeweekperiodonwards.InthefirstweekUltraFrameflangeextenderwasusedtoensurethattheflangeremainedinplace.Theoutcomewasthattheurostomyflangeappearedtohaveabsorbedmostofthemoisturefromtheskinsurface.

Figure2.Aurum2urostomyflangeincombinationwithAurum2colostomypouch.

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HOME VISIT 06-06-2019Skinisstillredbutdry.Themoisturehasdisappeared.NoleakagehasoccurredsincetheuseofanAurum2urostomyflange(Figure4).ThepatientbrieflytriedanAurum1piececolostomypouch,butthisresultedinmoistandredskinagain.ThedecisionwasmadetopermanentlyuseanAurum2urostomyflangeincombinationwithanAurum2colostomypouchandthepatientisveryhappywiththissolution.

HOME VISIT 27-05-2019Situationafter5daysusinganAurum2urostomyflange.Skinisnotasmoistandtheleakageisresolved.WellandAurumwasspecificallychosentoenabletheskintohealandrecover(Figure3).

Figure3.Situationafter5daysusinganAurum2urostomyflange.

Figure4.Homevisit06-06-2019.

OUTCOME AND FOLLOW UPThepatientiscomfortablewiththeuseoftheAurum2pouchsystem.Aurumhashadapositivehealinginfluenceonthemoistandredskin(Figure5).Heisabletostarthishobbiesagain,suchasgardening.

Figure5.Homevisit23-08-2019.

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DIAGNOSIS AND TREATMENTThegentleman,presentedtotheSanPietroHospitalinRome,Italyasanemergencypatient.Followingdiagnosisofapelvicabscess,thepatientunderwentemergencysurgeryresultingintheformationofaterminalcolostomyfollowingaHartmann’sprocedure.Thepatientcomplainedofitchingandburningacrosstheperistomalareaalongwithcontinuousdetachmentofthepreviousconvexpouch.

UponinitialassessmentbytheStomatherapistnurse,thestomawasassessedasflushtotheabdominalcontourwiththreeareasofperistomalulceration.ThesecanbeseeninFigure1.Itisassumedthatthesehavebeencausedbythepreviousstomaflange.

Thedecisiontochangethestomaflangetypefrom

flattoaconvexflangewastakenandtheperistomalareawascleanedandaprotectivepowderandpasteappliedpriortotheflangeapplication.

TheAurum2piecewasselectedasitprovidedasoftandflexibleconvexity,whilsttheManukahoneymayimprovetheperistomallesions.

TheperistomalskinintegrityimprovementcanbeseenfollowingtwoapplicationsoftheAurum2piececonvexpouch(Figure2).Thesameskinpreparationwasundertakenasdiscussedabove.

ThethreeulceratedareashavesignificantlyimprovedalongwiththegeneralperistomalskinareafollowingtheintroductionofManukahoneyintheflangeandthesoftconvexity.

PatientA75-year-oldgentleman,whoisdiabeticandhasaterminalendcolostomy

SourceLeilaFatemifar,StomaTherapistNurse,SanPietroHospital,Rome,Italy

ProblemItchingandburningacrosstheperistomalareaalongwithcontinuousdetachmentofthepreviousconvexpouch

SolutionAurum®2ConvexwithManukahoneycolostomypouch

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Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.Printed with the kind permission of Teleflex.

23

ProvidingconvexityforapatientwithperistomalskincomplicationsusingAurum® 2piececonvex

AclinicalaccountbyLeilaFatemifar,StomaTherapistNurse

CASE STUDY

CONCLUSIONThedesiredoutcomewastoenablethestomaeffluenttodrainintothepouchfollowingtheinsertionofsoftpressurearoundthestomaviatheconvexflange,enablingthestomatoberaisedratherthancontinuingtorestsoclosetotheskin.

Figure1. Figure2.AftertwoweeksofusingAurum®2piececonvex.

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PatientMrs.D,Female,38,ulceratedcolitis.Underwentanelectivetotalcolectomywithendileostomy

SourceKaty-MartinSkurr,StomalTherapyNurseSpecialist,Omnigon,NewZealand

ProblemUlceratedlesionscausedbypyodermagangrenosum(Pg)

SolutionAurum®ConvexwithManukahoneyIleostomypouchandHyperSeal®WasherswithManukahoney

Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.Printed with the kind permission of Omnigon.

TheuseofManukahoneyinthetreatmentofPyodermaGangrenosumrevisited

AclinicalaccountbyKatyMartin-Skurr,StomalTherapyNurseSpecialist

CASE STUDY

Thiscasestudyidentifieshow,asnurses,wearechallengedbyourpatientsinoureverydaypracticewhichtestouringenuityandresourcefulnessandhowweneedtoconstantlyrefreshourclinicalknowledgebank.IhopethatthroughthisclinicalreflectionwecancontinuetoshareclinicalpracticeandpatientoutcomesasWalls(2016)statedthisimprovesourpracticeandhelpstoaddtoourarmoury.

MoiraEvans,ClinicalMarketingManager,WellandMedical.

PRESENTATION AND HISTORYMrs.Dhashadsevereulcerativecolitiswhichwasdiagnosedin2012.Herbowelsmoveupto10timesadaypassingbloodandmucouswithassociatedurgency,incontinenceandcrampingabdominalpain.

Becauseherconditionhasbeenresistantandnon-responsivetomedicaltreatmentMrs.Dunderwentanelectivetotalcolectomywithendileostomy.Sherecoveredwellfromsurgery,discharginghomeafter4daysinhospital.

Mrs.Dmanagedherstomawellaftersurgerywithnoconcerns.Herstomawashealthy,32mmindiameterandwellspouted.

Shewasfollowedupinthecommunitybyboththelocaldistrictnursesandthestomaltherapynurse.

PARASTOMAL ABSCESS OR PYODERMA GANGRENOSUM?OnemonthfollowingsurgeryMrs.DwasseenintheDistrictNursingclinic.Shewastroubledbyaremainingsutureandhypergranulationtissueatthe6o’clockposition(Fig1).Thesuturewasremoved,andthegranulomawastreatedwithsilvernitrate.

Overthefollowingmonththeareabecameinflamedwithwhatlookedlikeasutureabscessappearing.Mrs.Dreportedslightdiscomfortfromthisarea.Theareaappearedtoresolveusingstomapowder.

AmonthlaterMrs.Dattendedsurgicalclinicwithwhatappearedtobeareformationoftheabscess.TheStomalTherapyNurse(STN)suggestedtheuseoftopicalbetadine.Aweeklater,withlittleimprovementMrs.DwasprescribedantibioticsbyherGP.Thisresultedinsomeslightimprovement.

Aweeklateranewareaofconcernat11o’clockwasalsonotedbytheSTNandaphotographwastakenandsenttohersurgeon.

>>>

Figure1.Firstappearanceofpainfulareaat6o’clockpositioninferiortostoma.

26 27

3monthspostherinitialsurgeryMrs.Dattendedclinic.Hersurgeonarrangedheradmissiontohospitalforincisionanddrainageoftheapparentparastomalabscess(2.5mmx0.8mm).Theareawasexcisedandopenedleavingalargerareaoftissuewhichwaspainfulduringpouchchanges(Fig2).AtthispointIbecameinvolvedinMrs.D’scare.IwassuspiciousthatasMrs.DhadulcerativecolitisanautoimmunediseasewewerelikelytobedealingwithPyodermagangrenosum(PG).

CONCLUSIONAnearlierdiagnosisofPGmayhavepreventedthesurgeryandMrs.D’sprolongedrecovery.WiththerepeatedsuccessfuluseofWellandManukahoneyproductsforthetreatmentandpreventionofPGreoccurrence,Iwouldnowconsiderandrecommendusingthisproductrangeasafirstlinechoiceinpatientswithautoimmunediseases.

Figure3.ConfirmeddiagnosisofPyodermagangrenosum.

Figure4.8weeksfromcommencementoftreatment.

Figure5.10weeksfromcommencementoftreatment.

PYODERMA GANGRENOSUM (PG)

PGisarareauto-inflammatorydisorderalsoknownasneutrophilicdermatosis.Itis

associatedwithotherautoimmunedisordersincludingthatofinflammatoryboweldiseases

suchasulcerativecolitisandCrohn'sdisease,rheumatoidarthritisandsomehaematological

conditions.PGmaystartasasmallpustule,redbumporbloodblisteroftenstartingsuddenlyafteraminor

injury.Theskinbreaksdownresultinginextremelypainfululcerswithraggededgesandundermining.Theremaybeabluishcolorationtothewound’sedges.Surgeryiscontraindicatedasittendstoextendtheareaandnotcontributetohealing.

DuetomyprevioussuccessusingtheWellandManukahoneyproductrangeforthetreatmentofPGIcommencedusingtheAurum®ConvexpouchwithWellandHyperSealwasherwithManukahoney.

IaccompaniedMrs.Daweeklatertohernextclinicappointment.ThesurgeonagreedwiththePGdiagnosisandaskedforanurgentDermatologyreview.TheDermatologistattendedclinicandconfirmedoursuspicions(Figure3).ApplicationofLocoid®cream,asteroid,wasrecommended.

WecontinuedtousetheWellandManukahoneyproductsasthePGhadshownsomeimprovementfromthepreviousweeks.

ThepouchwasmaintainingagoodsealhoweverMrs.Dpreferredherpreviousproduct.ToallowMrs.D’schoiceofproductwenegotiatedtocontinuetheuseofManukahoneyandthehealingofherPGbyusingalargeWellandHyperSeal®washerwithManukahoneyunderneaththeproductofherchoice.ThisallowedfullcoverageofthePGandsurroundingperistomalskin.

WiththeabovetreatmentsMrs.Dcontinuedtohaveamarkedimprovementinthepain,inflammationand

healingsothetreatmentplanwascontinued.Thehealingprocesstookapproximately3monthsfromPGdiagnosistocompleteresolution.

ThecurrenttreatmentinusetomaintainhealthyperistomalskinandpreventthereoccurrenceofPGisthesmallerWellandHyperSealwasherwithManukahoney(40mm)andintermittentuseofLocoid®creamwhenMrs.Dsuspectsaflareup(tingling/discomfortandslighterythema).

Figure2.Followingincisionofwhatwaspresumedtobeanabscess.



29

A GU

IDE TO

THE LIFECYCLE AND PROPERTIES OF MANUKA HONEY

Howandwhydoesmedical-grade

Manukahoneypromoteskin

health?What’sthestoryandthe

sciencebehindthisnaturalremedy,

usedforcenturiesinwoundcare.

28

16 ⁺UMFMEDICAL GRADE MANUKA HONEYisusedinAurum®ostomypouchesandaccessories.

30


31

LIFECYCLE AND PROPERTIES OF MANUKA HONEY

THE PLANT

Leptospermum scoparium

isashruborsmalltreenativetoNewZealand,thatbloomsjust2-6weeksperyear.CommonlyknownastheManukaorteatreebush.TeatreearosebecauseCaptainCookusedtheleavestomakea‘tea’drink.1

THE NECTAR

Manuka Power of Three

TherearethreekeynaturalmarkersinManukaHoney(Methylgloxal,Leptosperin,andDihydroxyacetone),whicharetestedinregisteredlaboratoriesandtheresultsmeasurethe“Manuka-ness”ofthehoney.3

THE GRADE

Unique Manuka Factor (UMF)

Thisistheofficialstamponhoneythathasbeenscientificallytestedandgradedappropriately.ThehoneycompaniesthatusethisgoldstandardsgradingsystemareofficiallicenseesoftheUMFHoneyAssociation(UMFHA),whichhasstrictcriteriaandauditsitsmembers’packagingandmarketingmaterial.TestingforMGOlevelsisimportantastheycanvarygreatly–notallManukahoneyisequal!3

LeptosperinAnaturallyoccurringchemical

foundonlyinthenectarofManukaplants.Itstaysstable

overtime,whichmakestestingforLeptosperininhoneyagoodwayof

identifyingifitcontainsManuka,andifitisconcentratedenough

tobelabelledasManukahoney.

DHADihydroxyacetone

TheManukaflowernectarcontainsDHAwhichbeesconvert(thanks

toenzymesintheirsaliva)tomethylglyoxal(MGO).

MGOMethylglyoxal

AnaturallyoccurringcompoundwithantibacterialandantimicrobialpropertiesthatmakesManuka

honeysospecial.

THE PRODUCT

From Hive to Harvest

Beekeepersgatherthehoneyattheendofthesummerseason.ThisharvestedhoneyistestedbyTheNewZealandMinistryforPrimaryIndustries(MPI)standardsandcertifiedusingtheUMF-approvedgradingsystem.

32 33


SKIN FRIENDLY PROPERTIES

SKIN HEALTH IN STOMA CARE

Anti-inflammatory

•Reducesoedema,whichreducespainfrompressureontissues

Provides a moist wound healing environment

•Hygroscopicthereforedrawsmoisturefromenvironmenttowound

•ClinicalevidencehasbeenpublishedtosupporttheantibacterialpropertiesofManukahoneytospeedupgrowthofnewtissuetohealwounds

Antimicrobial activity

•LowpH:Inhibitsbacterialgrowth

•Highsugarcontent:Reduceswateravailableforbacterialgrowth

•Methyglyoxal(MGO):non-enzymaticantibacterialcompounduniquetoManukahoneyandisreflectedthroughtheMGOcontent.Onewaytolookatthisisthat'traditional'honeyandManukahoneycanbothexhibitantibacterialproperties,butManukahoneyhasauniqueadditionalcomponent(MGO)whichreliesonnon-hydrogenperoxideactivity

•Highviscosity:Formsprotectivebarrieragainstbacteria

The importance of skin health in stoma care

•Thewasteoutputfromthestomacandisruptthenormalskinbarrierfunction

•TheskinpHisusuallybetween4.1-5.8,butthewastematterfromthestomaisalkalinewhichdisruptsthisbalanceandcancauseirritation,breakdownandinfectionoftheskin

•Somestudiesreportupto75percentofpeoplewithanostomyexperienceaperistomalskincondition* withManuka Honey

MANUKA HONEY

Acidic Alkaline

SkinpH

Neutral

THE PH SCALE

34


35

'Manuka' MeaningMaoriaretheindigenouspeopleofAotearoaNewZealandandhaveaculturalconnectiontoitstaonga(treasure)Manuka.Maoriaretangatawhenua(peopleoftheland)whoareresponsibleforprotectingourtaongaforcurrentandfuturegenerations.

“Manukahasawhakapapa(genealogy)fromaMaoriworldview.TaneMahuta–thegodoftheforests–wasresponsibleforseparatinghisparentsRanginui(skyfather)andPapatuanuku(earthmother).Aftertheseparation,PapatuanukuwasnakedandvulnerablesoTaneMahutacoveredherintrees.TaneMahutamarriedTawake-toroandtheyhadManuka.Therefore,fromaMaoriperspective,Manukaisnotjustanameonalabelbuthasawhakapapa.ThisisourMaoristoryandonlywecantellthis.”

The story of Manuka“Ranginui(skyfather)andPapatūanuku(earthmother)werelockedinaneternalembrace.Theirchildrenbecamefrustratedwiththecrampedconditionsanddecidedtoseparatetheirparents–TaneMahuta(godoftheforests)layonhisbackandforcedhisparentsapart.HeadornedRanginuiwiththesun,moonandthestars.Healsocloakedhismotherwithtrees.TaneMahutahadaunionwithTawake-torowhichgaverisetoManuka.TaneMahutaalsointroducedallournativetreespecies,ournativebirdsandinsects.TaneMahutaalsobreathedlifeintothefirstfemalegivingrisetohumankind.”

Victor Goldsmith, Ngati Porou Miere Limited Partnership Managing Director

MAORI

MANUKA STORY

TaneMahuta=

Tawake-toro

Manuka

36

COLOSTOMY UK RUGBY MATCH ULTRAFRAME® INTERVIEW

So, you are now wearing UltraFrame, how do you feel?

Oliver: Yeah,Icanfeelitextendsthenaturalpartofthepouch

Kav: Ialwaysfeellikethenaturalpartofthebagyouhaveisn’tquitebigenough.So,anythingtosupportroundtheedgeshelps.

Chris: Andtheyfeelinvisibleandyoucan’tfeelit.

Oliver: Andthebestthingis,youjustforgetaboutit.Whichiswhatyouwant.

Have you worn them before, during physical activity?

All three:Ihave,yeah.

Chris: Tothegym.Theybendandmovewithallyourmovementsandreallywellshaped.

Kav: Youdon’treallyfeellikeyou’vegotanythingon.

How easy were they to apply?

Oliver: Prettysimple.Followthenumbers.Aslongasyoucancountto4,you’llbealright!

What does it mean to you to represent Team Colostomy UK?

Kav: Itmeansanawfullot.It’sgoodtoshowwhatispossible.Especiallythistimeround,withthepublicity,thisonehasbeenimmense.

Chris: ThereasonIwantedtoplayisjusttoshoweverybodywhohasastomayoucandoallthethingsyoudidbefore.

Oliver: Ididn’tevenplayRugbybeforeIhadastoma.So,I’veonlyjuststartedplayingsinceI’vehadit.Formeitsbeengreattostartanewsportandmeetlotsofpeoplewhoareinasimilarsituation.

How did you find the game today?

All three:Great,reallygood.

Did your stoma bag remain secure throughout the match?

Chris: Absolutelynoworries.Noproblemsatall.

How does UltraFrame compare to other flange extenders?

Kav: It’salotthinnerthanalltheothers.Evenineverydayactivities,youdon’tfeelit.Itmouldstoyourbody.It’sgreat.

Oliver: Youdon’tnoticeit.Youwantittobeasstrongaspossible,butnotactuallynoticeit’sthere.

Does it give you the confidence to play without holding back?

Chris: You’veseenthefilm.Idon’tthinkanyonewasholdingbackatall!

What was the best part about playing for team Colostomy UK today?

Oliver: Ithinkprobablyawareness.Youcanseehowmanypeopleareheretodayandthedifferencethatcanmake.Peoplejustknowingaboutwhatitisliketohaveastomaandit’snotabarriertodoingwhatyouwanttodo.

Chris: IfyouaskedoneoftheChorleyplayerswhoinourteamhadastoma,theyprobablywouldn’tbeabletotellyou.(Allthreeshowtheirstomabags).

Chris: andI’vegottwo!


37

ManythankstoOliver,ChrisandKavforsharingtheirthoughtsonUltraFrame®.

TheviewsandopinionsexpressedbythefeaturedusersonUltraFramearetheirownanddonotnecessarilyreflectthoseofWellandMedicalPID7379


REFERENCES

393938

Page 4-5

1.https://www.england.nhs.uk/year-of-the-nurse-and-midwife-2020/accessed19.02.2020

2.https://www.azquotes.com/quote/614045

3.ClinicalgovernanceforostomatesatriskofperistomalskincomplicationsWhiteP,EvansM(2019)BritishJournalofNursing,2019,Vol28,No16

4.https://everydaypower.com/florence-nightingale-quotes/accessed13.5.19

Page 6-7

1.Cairns,B.A.,Herbst,C.A.,Sartor,B.R.,Briggaman,R.A.andKoruda,M.J.,1994.Peristomalpyodermagangrenosumandinflammatoryboweldisease.ArchivesofSurgery,129(7),pp.769-772.

2.BrooklynT,DunnillGandProbertC.Diagnosisandtreatmentofpyodermagangrenosum.BMJ2006;333:181–84.

3.Wallace,A.,2017.Bestpracticemanagementofperistomalpyodermagangrenosum.JournalofCommunityNursing,31(1),pp.24-32.

4.HeffernanMP,MilanJA,SmithDI(2007)Adalimumabtreatmentforpyodermagangrenosum.ArchDermatol143(3):306–8

Page 12-13

1.ShinJH,HyangSS,KimEA.Influenceofpost-traumaticstressdisordersonqualityoflifeamongpatientswithostomy:focusedonthemediatingeffectofresilience.KoreanJournalofAdultNursing2017Dec;29(6):657–666.

2.EvansM.TheuseofManukaHoneywithinstomacaretomaintainperistomalskinintegrity:theostomatesperspective.WCETJournal2018;38(2):40–40.

3.SimmonsKL,SmithJA,BobbK-A,LilesLL.Adjustmenttocolostomy:stomaacceptance,stomacareself–efficacyandinterpersonalrelationships.JAN;LeadingGlobalResearch2007;60(6):627–635.

Page 14-17

1.WorldHealthOrganization[Internet].Mentalhealthofolderadults;2017[cited2018Oct].Availablefrom:http://www.who.int/en/news-room/fact-sheets/detail/mental-health-of-older-adults

2.AustralianBureauofStatistics[Internet].Australiandemographicstatistics;2018[cited2019Mar].Availablefrom:https://www.abs.gov.au/

3.GoldsteinS.Thebiologyofaging.NewEnglandJournalofMedicine1971;285:1120–1129.

4.AustralianBureauofStatistics[Internet].MigrationAustralia2016–2017;2018[cited2019Mar].Availablefrom:https://www.abs.gov.au/ausstats/

Page 26-27

1.Lyon,C.Etal(2000)ParastomalPyodermaGangrenosum:Clinicalfeaturesandmanagement.JanAcadDermJun42(6)992-1002

2.Cullen,J.PyodermaGangrenosumandRelatedDisorders.BMJ2006;333:181

3.Simon,A.etal.MedicalHoneyforWoundCare-StilltheLatestResort?AdvancedAccessPublication7Jan2008

4.Mandel,M.&Mandal,S.Honey:itsMedicinalPropertyandAntibacterialActivity.AsianPacificJournalofTopicalBiomedicine2011(1)2:154-160

5.Dunford,C.etal.(2000)UsingHoneyasaDressingforInfectedSkinLesions.NursingTimes96(14)7-9

6.WallsP,(2016)Faecalfistulae:fromdespairtohopeusingstomaltherapy'tricksofthetrade'JournalofStomalTherapyAustralia–Volume36Number3September2016

Pages 30-31

SourceJ.T.Salmon,TheNativeTreesofNewZealand,Reed,1973

Source:https://www.botany.one/2018/04/what-is-it-that-gives-Manuka-floral-nectar-its-unique-composition/

https://www.hollandandbarrett.com/the-health-hub/food-drink/food/Manuka-honey/Manuka-honey-facts/

Source:www.kanoaManuka.com/leptosperin

Source:haddrells.co.nz/pages/umf

Source:https://www.umf.org.nz/manuka-honey/

www.temarareo.org/TMR-Manuka.html

Page 32-33

Source:Presentation'AurumasaFirstLineDefenceinMaintainingPeristomalSkinHealth'byArashMoavenian.PID5945

Mandal,M.&Madel,S.(2011)Honey:itsmedicinalpropertyandanti-bacterialactivity.AsianPacificJournalofTropicalBiomedicine.1(2)154-160.

RappCG,LRichbourg,JMThorne.DifficultiesExperiencedbytheOstomateAfterHospitalDischarge.JWOCN.2007;34(1):70-79.

Page 34-35

Source:https://www.umf.org.nz/manuka-honey/

PID9214•07-2020•Volume3

“CREATIVITY IS INTELLIGENCE HAVING FUN.”Albert Einstein

Welland Medical Ltd.,HydehurstLane,Crawley,WestSussexRH109ASUnitedKingdom

Tel: +44(0)1293615455Fax: +44(0)1293615411Email: [email protected]

©WellandMedical2019WellandMedicalLtd.isaCliniMed®GroupCompanyWelland®andtheWellandlogoTMaretrademarksofCliniMed(Holdings)Ltd.

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