Newly paced ileostomy with wound dehiscence

[Doll Head]

Please help! I work for a rehab and we had this pt with us about a month ago who had a colostomy. He went for a reversal and they had some complications so they created an ileostomy. He was fine when he was d/c'd from the hospital and about the first or second day he came to us he dehisced in both places. One where the colostomy reversal attempt took place, and the other RIGHT next to his new ileostomy.

So, I get into work last night to take care of him for the first time this visit, and I hear in report this awful wound, with this plan to treat his dehiscence that is anything but a solution. We're packing it with Aquacel AG, covering with gauze, and covering that with duoderm, we have to do these things first because his appliance literally goes into the wound bed vicinity. Mind you his ileostomy is leaking into his wound! Pretty much all of the time. So, we're changing the dressing, appliance, etc 4+ times a day and night therefore his skin is breaking down, his wound has BM in it most of the time and when the dehisce happened the facility sent him to the wound clinic in the hospital and they sent him back that day with this "plan" in place.

I'm stressed out not only because this doesn't seem like a solution, but also because we have never gotten any formal training regarding brand new ostomy's not to mention how to manage a wound that seems like a set up for disaster. Any suggestions?

I'm concerned this guy is going to go septic soon. What is the solution?

[OhioCCRN, MSN, NP]

You need to send the patient out to the ED ASAP!!!!

They need surgery and/or better wound management- that wound will never heal otherwise and you (and the facility) are opening yourselves up to some serious (and founded) litigation...

[RainMom]

Is the surgeon aware of the complication? He/she needs to be involved & should be dictating this pt's care.

[ixchel]

I had a patient this week with an ileostomy and a dehiscence right next to it as well. Stool doesn't stay on the wound, but does soak the dressing. Then this morning, out portable x Ray lady was absolutely awful, sat this poor patient up forcefully, jammed her board behind him. He was in so much pain. When I realized what she was doing, I told her - STOP! When she was done, I assessed for damage and the movement basically burst that bag open all over him, the gown, the bed, the wound. It was awful. And I'm sure the one predictable part of the story was this happened right before shift change.

Anyway, I was thinking this patient had it bad, but after reading your story, WOW. Your patient needs to go back to the hospital BEFORE infection develops.

[Davidaugustyn]

Man I'm gonna need a picture for this one. Too bad...

I can help you with the skin. the miracle cure that's worth a try is cyanoacrylate marathon liquid skin protectant. The only thing I could find that stuck and let an appliance stick to denuded skin.

I don't know what the dehisced wound looks like, but we would use an Eakins wafer around the stoma and down into the wound bed. Than go over with the appliance. Duoderms are nothing as good for sticking as an eakins.

I find these things take trial and error.

-David

[CherryB85]

I had a patient with the same thing.... We actually used a wound vac. My wound care nurse is awesome. But usually when a sutured wound opens they want it to heal from the inside out

[Davidaugustyn]

That is a thought. A wound vac. If nothing else, for on and off periods to give the ostomy area a period of rest. Though it will increase the risk for infection.

[CherryB85]

The wound vac worked perfectly. It was a tunneling stage 4. The tegaderm kept the stool out of the wound when changed appropriately. It's been about 4 weeks believe it or not that wound is 90% healed. I really wish I had a before and photo.