My Scope of Practice: No Small Potatoes: Managing a Complex Wound with a Stoma

   Jetta Tressel, RN, BS, CWOCN, of Idaho, faced a challenge - a 22-cm midline abdominal incision started out as a wound, then presented as a transverse loop stoma. How could healing be achieved and feces be kept separated from the wound?

   Ostomy care is but one part of Jetta's responsibilities at Eastern Idaho Regional Medical Center, Idaho Falls, Idaho. With 300 beds, it is the largest acute-care hospital in the state and services 200,000 primarily rural clients in an area that runs from Jackson, Wyoming to West Yellowstone, Mont., and includes metropolitan Salmon, Idaho. In fact, when the President was in Jackson, the facility was on call. "We are the resource center for all of southeastern Idaho," Jetta says. "I am the only ET. I do many telephone consultations."

   A 1976 graduate of the University of Colorado's nurse training program, Jetta worked in various clinical and management positions related to geriatrics. She earned her bachelor's degree from Idaho State. Jetta has spent 4 years in the rehabilitation unit of her hospital, working with spinal cord injuries and orthopedic cases. She also works in what she calls the "very active" outpatient wound clinic in addition to seeing inpatients with complex wounds and ostomies. She recently completed her 5-year, ET recertification requirements.

   Jetta has shared her knowledge through part-time teaching positions at Western Idaho Technical College and through her involvement in the educational programs at her facility. She is a strong advocate for patient/family/ caregiver education.

   Like other facilities, the importance of having an ET nurse on board wasn't always appreciated at Jetta's hospital. "We had an ET nurse about 10 years ago, but new management at the time let her go," Jetta explains. "The physicians, realizing the difficulties of not having an ET nurse, requested that someone be sent to ET school. I had always been interested in the field and I made my interests known. I volunteered to be trained. As I already was a clinical educator in long-term care and rehab, it made sense for me to obtain additional training. For 2 months, I participated in a program at MD Anderson in Houston. I have utilized every single thing they taught me and added to that body of knowledge. I've been doing ET ever since and I love it."

   For a time after her ET training, Jetta continued to work in long-term care and rehab, doing ET part time. Eventually, she moved into ET full-time. She says it was "slow going, but the physicians were supportive." Outpatient wound care has quadrupled in the last 3 years and is supported by three physical therapists who perform home care. Because of the high demand for her services, Jetta has requested an in-house assistant to work on prevention - checking on high-risk patients to ensure protocols are followed. "I don't know if or when this will happen," she says, "but it never hurts to ask."

   As part of her already busy schedule, Jetta organized a skin care team to standardize products and rework protocols by instituting use of the Braden scale. She enjoys instructing floor nurses on how to use products with competency, finding great satisfaction when positive outcomes are achieved. She says, "It's so rewarding when you see, for example, a vascular ulcer that a patient has had for years suddenly heal in a short time with the proper product and care. I also enjoy teaching patients how to self care."

   When asked about the challenges she faces, she laughs and says, "They haven't learned how to clone me. Time is always a challenge - how to get everyone seen." She also is frustrated when she treats a complex, complicated wound in a patient with many comorbidities and healing remains elusive. She says that some administrative changes have been a mixed blessing. "The hospital added physicians and specialists," she explains. "We had only one plastic surgeon and now we have three. But this increase in physicians also means an increase in wound care and ostomy care, heightening the demand on our practice."

   Jetta anticipates that her role will continue to evolve as more specialists are added to the staff. She also would like to get more involved in another facet of her practice: incontinence. For now, she says the work is "always fascinating, always challenging." She counsels, "It often takes several tries to get [healing] done. You have to be creative and innovative. No two patients are alike. No two patients respond the same. You can't sit back. With all the new products, you need to keep training and learning - reading, doing and following research, and talking to vendors. They are a great resource for what you need to know about products."

   But what of the transverse loop stoma? "To keep the feces away from the wound, we ultimately used suction," Jetta explained. "A flat, multifenestrated drain tube was placed into the undermined portion of the wound. Hydrocolloidal dressings were used to line the wound. A 6-inch wafer with a 4-inch flange was placed over the stoma and a pouch was applied. The drain tube was attached to medium, constant wall suction. This method provides a secure vacuum seal by using suction to evacuate the wound exudate while simultaneously bringing the stoma prominently into the pouch for collection of fecal material. We were able to reduce dressing changes to once every 48 hours. We taught the family how to do this complex dressing change and they became capable enough to get the patient home." This "Rube Goldberg" approach elicited numerous inquiries from others who, like Jetta, seek to nurture creativity and innovation in their scope of practice.

My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.