When Trauma Means a Stoma

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J Wound Ostomy Continence Nurs. 2006;33(5):491-500. Published by Lippincott Williams & Wilkins

O OSTOMY CARE When Trauma Means a Stoma

Susan E. Steele

Trauma is a leading cause of death and disability. When trau- injuries were sustained can assist the nurse in planning care matic injuries require ostomy surgery, the wound, ostomy, and and identifying the potential for complications during the continence nurse acts as a crucial part of the trauma team. This recovery period. Traumatic injuries occur when the human literature review describes mechanisms of injury associated body is exposed to physical forces causing tissue destruc- with creation of a stoma, key aspects of wound, ostomy, and tion. In most trauma situations, the physical forces are continence nursing care in trauma populations and presents kinetic in nature, and injury occurs when the energy of suggestions for future research. movement is transformed into other forms of energy, such as compression, shearing, and cavitation.4 Trauma nurses categorize mechanisms of injury into two broad cate- rauma affects all ages, races, and socio-economic classes gories: blunt injuries in which the skin surface is unbroken Tand ranks globally as a leading cause of morbidity and and penetrating injuries, which include a break in the skin mortality for all age groups except for persons aged 60 years integrity.5,6 In both mechanisms of injury, the mass of the or older.1 In 2003, more than 105,000 deaths in the United object striking the body and the velocity of the strike de- States were attributed to unintentional injuries.2 In that termine the amount of kinetic energy to which the body is same year, nearly half a million U.S. hospital discharges subjected and therefore the amount of damage. were attributed to injury treatment, with an estimated ag- gregate cost of over $8 billion.3 When an injured individual Blunt requires ostomy surgery, the wound, ostomy, and conti- Blunt trauma comprises the largest majority of nonmilitary nence (WOC) nurse becomes an integral part of the trauma injuries. The most common sources of blunt trauma in the team. United States are motor vehicle crashes (MVC) and falls. Working with trauma patients provides many unique These two categories comprised nearly 70% of all traumas challenges. Often, adaptation of both pouching techniques reported to the National Trauma Data Bank till 2003.7 and educational strategies is necessary to effect successful rehabilitation. During the recovery period, the trauma patient is dependent upon a number of different professionals to meet his or her needs, and the WOC nurse must The most common sources of blunt trauma collaborate with a team of specialist physicians, nurses, re- in the United States are motor vehicle habilitation therapists, social workers, and mental health crashes and falls. professionals. Although family involvement may occur to some degree with all ostomy patients, the family of a trauma patient may become overwhelmed with fear, grief, Blunt trauma may result in tearing, crushing, or rupture and anger, impairing ability to support the rehabilitation of internal abdominal organs.5 When an individual in mo- process. Trauma recidivism, the phenomenon of patients tion suddenly stops, deceleration causes shearing and tear- who repeatedly sustain trauma, may provoke feelings of ing of internal organs. The abdominal wall and the spine or anger and frustration in the WOC nurse, and repeated ex- posure to the stories and affect of trauma survivors can im- pose tremendous stress upon the nurse. Susan E. Steele, MS, RN, CWOCN, is WOC Clinical Nurse Specialist, Bayfront Medical Center, St. Petersburg, Florida, and a Doctoral Student, University of South Florida College of Nursing, ■ Mechanisms of Injury Tampa, Florida. Correspondence: Susan E. Steele, MS, RN, CWOCN, 376 18th Avenue Knowledge of the mechanism is critical to the care of a Northeast, St. Petersburg, FL 33704 (e-mail: susan.steele@bayfront. trauma patient with an ostomy. An understanding of how org).

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posterior ribs exert crushing forces on intrabdominal or- resulting in fecal contamination. A more recent trend in the gans, and if there is a sudden rise in the intrabdominal pres- surgical treatment of abdominal trauma is the use of dam- sure, hollow organs, such as the colon, may rupture.4 There age control or staged laparotomy. This approach requires an is some anecdotal evidence that traumatic intestinal rup- initial laparotomy for the control of contamination and he- ture may be more likely in individuals suffering from in- morrhage, an intensive care unit stay for hemodynamic, flammatory bowel disease.8 Although the ribs, sternum, and thermal, and ventilatory stabilization, and a second surgery pelvis normally serve to protect vital organs, a displaced for definitive abdominal repairs and wound closure.10,11 The fracture incurred from blunt trauma in these bones may re- impact of this approach on the overall survival is not clear. sult in severe organ injury. Johnson and associates12 identified a significant difference in the mortality between a cohort of 24 damage control pa- Penetrating tients and historical controls. Acensio and associates13 re- Penetrating trauma comprises a small percentage of all civ- ported no difference in mortality rates but did identify a ilian traumas. The high incidence in military combat in- decrease in the use of blood products, intensive care unit, juries and the successful treatment of penetrating injury and hospital days, and incidence of abscess and infection with diverting colostomy during World War II were re- with damage control surgery. However, bowel edema and sponsible for its acceptance as the primary treatment for abdominal compartment syndrome pose significant post- 14,15 penetrating colon trauma for the second half of the 20th operative complications with this approach. Various century.9 Penetrating trauma occurs most often as a result techniques for the management of open abdomen and fas- 16 of interpersonal violence such as gunshot, stabbing, or sex- cial closure have been identified in the literature, and there is evidence that the use of vacuum-assisted closure results in ual assault, and impalement from MVC. Perforation of early successful closure of the abdominal defect with less solid organs, such as the liver or spleen, results in bleeding ventral herniation.17,18 Regardless of the management and hypovolemia. If bowel is perforated, peritonitis and in- method chosen, the open abdomen in combination with a fection are potential life-threatening consequences. fecal diversion stoma presents significant challenges to the WOC nurse in attaining and preserving an intact pouch seal. Although previously considered the standard of care for penetrating abdominal trauma, the need for fecal diversion Penetrating trauma occurs most often as a has been repeatedly challenged in the past 2 decades. A sub- result of interpersonal violence. stantial body of evidence supports the use of primary repair over fecal diversion for penetrating colon injuries in both adult9,19-22 and pediatric trauma,23 primarily due to a higher incidence of infection in patients with a stoma.24 Delay Cavitation occurs whenever external kinetic forces dis- in performing primary repair does not preclude this ap- place tissues. In penetrating trauma, the cavitation becomes proach,25 and the approach has been deemed safe and ef- permanent as a hole is formed within the skin and the tis- fective even when studied with subjects sustaining war sues. The extent of cavitation depends upon the velocity injuries26 and in trauma within a developing nation.27 with which the object penetrates into the skin, the size of the object, and the path taken by the object after entering Pelvic Trauma 4 the body. Often, the full extent of injury is impossible to The bladder and the rectum, both well protected by the determine by external visual inspection, and surgical ex- bony pelvic ring, are rarely injured by blunt trauma in the ploration is necessary to assess and control the damage. absence of pelvic fracture. Surgical treatment is not usually necessary. Intraperitoneal bladder rupture caused by a sud- ■ Anatomical Location of Injury den, forceful blow to the lower abdomen or pelvis, results in an increased intravesical pressure and rupture of the weak- To properly educate, counsel, and rehabilitate the patient, est portion, the dome of the bladder. Approximately 15% a WOC nurse must also be aware of the anatomical location of all bladder ruptures in adults occur in this manner,28 of the injury that results in ostomy surgery. Three general although chronic alcohol abuse has been linked to intra- anatomic sites of trauma may result in urgent ostomy sur- peritoneal bladder rupture in minor blunt trauma.29 The gery: abdominal, pelvic, and perineal. In addition, spinal currently accepted standard of care for bladder dome rupture cord injury may be treated on a long-term basis with fecal is the operative repair with absorbable suture and postoper- or urinary diversion for the management of neurogenic ative drainage with urethral and suprapubic catheters;30-32 bowel and/or bladder. Each anatomical region is associated however, successful nonoperative management in children with challenges that complicate pouching and ostomy care. with isolated intraperitoneal bladder rupture has been reported.33 Recent studies have also challenged the need for Abdominal Trauma suprapubic catheter placement in bladder rupture treat- Abdominal trauma is associated with significant morbidity, ment,34-36 and WOC nurses should be aware that the stan- particularly when there is a bowel penetration or rupture, dard of care is in a state of transition. 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 493

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Open pelvic fractures have a high incidence of associ- dictor of stoma complications.56 Ostomy complications re- ated abdominal and urogenital injuries in both pediatric sult in increased morbidity, impaired quality of life, and and adult trauma.37 Not surprisingly, the severity of the may be associated with dissatisfaction with the WOC nurs- fracture is the primary predictor of injury, due to the ing care.57-60 amount of force required to fracture this normally strong Common complications of ostomy surgery include poor bony structure.38 Urogenital injury has been reported in stoma site selection, stomal necrosis, retraction, stenosis, 24%-57% of adults with open pelvic fractures,39 and 17% mucocutaneous separation, peristomal hernia, and peris- in pediatric patients.40 Delays and difficulties in diagno- tomal skin damage. Although surgical technique may con- sis, particularly in the distinction between intraperitoneal tribute to these problems in a general patient population, and extraperitoneal bladder rupture, have been identified trauma patients often have anatomical and physiological as problematic in the treatment of pelvic fractures.41 Open derangements that compromise stoma construction and pelvic fractures communicating with perineal, rectal, or viability. Ordinary stoma sites may be unavailable due to vaginal wounds require urgent irrigation, debridement, and penetrating abdominal injuries, the orthopedic hardware diverting colostomy to decrease the risk of infection and placement, multiple surgical drains, or the presence of an sepsis.42 The frequent use of external fixation devices to sta- open abdomen. The emergent nature of the surgery pre- bilize the pelvic fracture and control hemorrhage in these cludes the ability to examine the patient’s abdomen in any cases limits stoma site placement by the trauma surgeon position other than supine. Skin folds or creases apparent and complicates postoperative pouching of the stoma. in sitting and standing positions cannot be identified and rarely, if ever, does the surgeon have the knowledge of the Perineal Trauma patient’s habits, lifestyle, or other factors that might influ- The majority of trauma patients requiring fecal diversion ence stoma placement. Shock, abdominal compartment surgery have perineal injuries. Common modes of injury syndrome, and mesenteric artery thrombosis may affect are gunshot or stab wounds, impalement, rectal foreign the stomal blood supply, causing stomal necrosis or steno- bodies, and rectal tears associated with vaginal or anal sis. Extreme tension on the mucocutaneous junction due sexual penetration. Low velocity gunshot wounds may be to massive abdominal edema may cause separation and treated with rectal washout, laparoscopic exam followed by sloughing of skin and subcutaneous tissue. Repeated laparo- loop colostomy through an abdominal wall trephine or via tomy incisions for staged surgeries increase the risk of conventional laparotomy incision.43-45 Impalement injury ventral and peristomal hernias. Table 1 summarizes com- usually involves a fall onto the object of impalement,46,47 mon complications and their related etiology in the trauma and may involve bladder trauma and rectal trauma. Rectal population. foreign body injuries may result from an insertion of ob- 48 jects for erotic purposes or by sexual assault. Delay in ■ Psychosocial Aspects of Trauma Care seeking medical attention is common,49 as is the denial of the insertion or circumstances surrounding the injury.50 The ideal outcome of WOC nursing care for the ostomate is Forced anal intercourse and anorectal trauma are known to a return to maximal physical, social, and emotional func- occur in approximately 15% of female rape victims,51,52 and tioning following surgery. Instilling confidence and hope anal tear injuries are believed to be a marker for marital have been historical strengths of the specialty.61 In inflam- rape.53 Although data are not available regarding the inci- matory bowel or cancer populations, the WOC nurse may dence of anorectal trauma in adult male or child sexual as- indeed support the hope that an ostomy represents the abil- sault, this mode of injury should be considered in all ity to survive, or to live free of painful disease. The trauma persons with anorectal trauma and a history of family or patient, in contrast, experiences ostomy surgery as a part interpersonal violence. of a defining moment that divides life into “before” and “after” and forces confrontation with vulnerability and mortality.62 An understanding of some issues specific to trauma populations can assist the WOC nurse in altering the ap- The majority of trauma patients requiring proach to the patient for more therapeutic interactions. fecal diversion surgery have perineal injuries. These issues include adjustment to trauma, posttraumatic stress disorder, and trauma recidivism.

■ Ostomy Complications in Trauma Adjustment to Trauma and Ostomy Adjustment to life with an ostomy, whether temporary or Stoma-related complications occur in a portion of all fecal permanent, is influenced by many factors, but a current lack diversion surgeries. Emergency surgery has been identified of sufficient research with adequate methodological rigor as a significant risk factor for stomal complications for data limits the understanding of these variables.63 Piwonka and subjected to repeated univariate testing,54,55 but multivari- Merino64 identified the level of ostomy self-care, psycholog- ate analysis did not identify emergency surgery as a pre- ical support, and social support from family/significant 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 494

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TABLE 1. Ostomy Complications in Trauma

Problem Unique Trauma Issues Poor stoma site • Preoperative stoma site marking usually not possible • May require extensive incisions for exploration • Re-exploration common • External fixation devices may be needed for pelvic fractures • Multiple surgical specialists working simultaneously Stomal necrosis • Hypovolemic shock may compromise blood flow • Mesentary may be damaged in either blunt or penetrating trauma Stomal retraction or prolapse • Abdominal compartment syndrome may result in extensive abdominal edema • Transverse loop stomas more likely to prolapse Excess stomal bleeding • Heparin induced thrombocytopenia or disseminated intravascular coagulopathy may cause stomal bleeding Mucocutaneous separation • Critical illness with catabolism decreases healing • Fecal spillage in penetrating trauma increases likelihood of infection Peristomal herniation • Repeated laparotomy weakens abdominal wall and makes herniation more likely • Stoma siting not possible and location may be outside the rectus muscle due to incisions, hardware Stomal laceration or irritation • Pouching system placed intraoperatively may be too small to accommodate severe postoperative stomal edema Peristomal skin irritation • Frequent pouch changes due to leakage may cause peristomal skin irritation • Fistula formation common in penetrating abdominal trauma and may result in skin irritation from effluent

other as predictors for positive adjustment to ostomy. Post- cial support have been identified as important factors in operative psychological problems have been associated with continued progress, whereas a lack of appropriate anticipa- prior psychiatric history, dissatisfaction with preoperative tory guidance by the healthcare team often serves as an preparation, stoma-related morbidity, loss of bodily control, impediment.62 Frequent and continuing contact with the and lack of self-efficacy in ostomy care.65 The lack of pre- trauma patients throughout the hospital stay and after their operative preparation, and in some life-threatening situa- return to the community may be helpful in mobilizing the tions, the lack of informed consent, magnifies the trauma internal and external sources needed for coping and help- patient’s sense of loss of control. Orthopedic and neuro- ing the patients anticipate specific ostomy-related situa- logic injuries that prevent or delay the achievement of os- tions such as stoma concealment, odor and noise control, tomy self-care can further erode the patient’s progress dealing with pouch leakage, return to sexual intimacy, and toward adjustment. Family and social support may be com- return to social activity. promised or absent when the injury was caused by engag- ing in socially deviant behavior such as criminal activity, Posttraumatic Stress or risk-taking behavior. Posttraumatic stress disorder (PTSD) is a serious psycholog- In the trauma population, health status, health-related ical disorder that develops in some individuals following quality of life and functional abilities are significantly im- physical or emotional trauma. First identified in Vietnam paired following trauma, and impairments may persist for War veterans, similar patterns of psychosocial functioning months or years despite a return to independent living or and symptoms have been validated in civilian trauma sam- work.66-69 As the injured person begins to move through the ples.71 PTSD is associated with depression and anxiety, as recovery process, a stage called “fallout” occurs in which an well as with the decrease in quality of life.72 White65 recom- individual becomes increasingly aware of the way in which mends routine screening of all ostomy patients for PTSD, the injury will affect daily living,62 and typically includes and early screening in trauma patients might identify those the return to work for the employed adult. The severity of for whom learning ostomy self-care is likely to be impaired. injury has not been found to significantly affect the return A 7-item screening scale has been developed to identify to work, but the patient’s belief about the severity of the in- patients in primary care with PTSD symptoms without an jury and its job-related consequences are closely associ- excess use of clinician time.73 Hallmarks of PTSD include ated.70 There is no clear linear path to trauma adjustment anxiety and heightened arousal, which make concentration and no clear end point for recovery. Inner resilience and so- and new learning difficult. Anger, irritability, and avoid- 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 495

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ance of all reminders of the trauma, also frequent symp- tional and physical therapists, if manual dexterity and other toms, may lead to the rejection of the WOC nurse’s at- functional deficits are present from trauma. Some situations tempts at ostomy education and care. Although the practice may even require the WOC nurse to instruct and direct of critical incident “debriefing” is no longer advocated,74 other professionals in providing the actual technical proce- trauma-focused cognitive behavioral therapy with a mental dures, so that ostomy care instruction can be provided with health professional may be effective in helping prevent and other activities of daily living training. Concurrent trau- treat PTSD symptoms.75 The approaches for reviewing and matic brain injury, anoxic encephalopathy, or preexisting responding to negative thinking as detailed by White65 also mental impairment drastically alters the teaching strate- represent a cognitive behavioral approach that can be im- gies used by the WOC nurse. In such cases, consultation plemented by the WOC nurse. with a neurobehavioral psychologist or speech and language pathologist can clarify the extent of cognitive deficits, the Trauma Recidivism potential for independent ostomy self-care, and compen- Recurrent trauma affects a small but challenging portion satory techniques. When trauma has occurred because of of the trauma population. Many of these patients present an MVC or a work-related injury, insurance and worker’s with penetrating gunshot and knife injury likely to result compensation Case Managers may need to interact with in ostomy surgery. Although trauma recidivism has been the WOC nurse to ensure supply access and proper com- documented among older people,76 most studies have iden- munity re-entry. Table 2 summarizes how the roles and re- tified young men with a history of alcohol and controlled lationships of WOC nursing care with other professional substance abuse as the major recidivists.77-81 Screening for disciplines change during various phases of trauma recov- alcohol and other substance abuse and making referral ery. The individuals with whom the WOC nurse commu- for early intervention should become a part of the WOC nicate, the nature of the contributions, and needs of WOC nurse’s advocacy role within the trauma care setting. The nursing evolves as the patient moves through the contin- CAGE screening test for alcohol dependence has a sensi- uum of care. Often, in large urban settings with trauma tivity of 84%, a specificity of 90%, and a positive predic- facilities, the WOC nursing roles will be performed by dif- tive value of 82%82 and can be easily implemented by the ferent individuals within the acute, extended and commu- WOC nurse during ostomy education. For patients with a nity care settings, requiring yet another layer of interaction dependence upon alcohol or other mood altering chemi- and communication. cals, referrals to community resources, including Alcoholics Anonymous (AA), should be made. In some communities, AA may offer in-hospital visitation or other services to support the health professional. Local AA groups may be Collaborative practice is essential for care identified via the organizational Web site: http://www. of the trauma patient with an abdominal alcoholics-anonymous.org. stoma. ■ Ostomy Education and Rehabilitation: Team Collaboration This type of intensive collaboration often requires a Collaborative practice is essential for care of the trauma greater time commitment on the part of the WOC nurse, patient with an abdominal stoma. Trauma patients have and often challenges communication, time management, complex problems that often require expertise beyond the and organizational skills. Failure to share timely, accurate, scope of WOC nursing practice, requiring a dependence and complete information may occur when the WOC nurse upon other professional’s help in providing ostomy edu- or other team members perceive a threat to their profes- cation and rehabilitation. Likewise, the WOC nurse has a sional knowledge and authority. Unfortunately, this same unique contribution to make to the rehabilitation process. failure ultimately erodes trust in the relationship and makes Rehabilitation nursing role functions often include assess- future collaboration more difficult.84 ment, coordination and communication, physical care, emotional support, interaction with family members, and ■ 83 Future Research Needs Regarding integration and carryover of the rehabilitation therapies. Trauma and Ostomy The extent to which the WOC nurse performs each of these role functions changes throughout the trauma care episode. The preceding review elucidates a number of issues that re- Communications with the trauma surgeon during the crit- quire additional study and research summarized in Table 3. ical and acute care phases regarding the need for future Validation is urgently needed for assessment tools that surgical procedures enables the WOC nurse to provide the will enable WOC nurses to diagnose stomal and peris- most accurate anticipatory guidance to the patient and tomal complications in all ostomy populations. A large, family. Mastery of ostomy self-care skills may require the multicenter case-control study is needed to better iden- assistance of rehabilitation professionals, such as occupa- tify the predictors for early postoperative complications, 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 496

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TABLE 2. Roles and Relationships of the WOC Nurse in Interdisciplinary Trauma Care

Inpatient Community- Setting Critical Care Acute Care Rehabilitation Based Care Focus of care • Physiologic • Prevent complications • Return to physical • Adapt to disabilities in stabilization functioning home or long-term care environment • Prevent further injury • Assessment of full • Learn methods of • Continue perfecting extent of injuries compensating for self-care skills ongoing deficits • Identify potential obstacles to return to community WOC nurse contributions to trauma team Assessment • Stoma viability and • Stoma function • Stoma function • Stoma function function • Stomal and peristomal • Stomal and peristomal • Stomal and peristomal • Stomal and peristomal complications complications complications complications • Pouching system • Pouching system • Patient and family skill Activities of daily living integrity needs in pouch hygiene and care • Functional limitations • Pouching system • Return to work, school to ostomy self-care modifications or other social situations • Educational readiness • Financial resources for • Return to intimacy and barriers to supply access learning • Screen for pre-existing • Satisfaction with psychological pouching system disorders • Supply access Coordination • Special supply needs • Patient and family • Pouch emptying in • Obtain supply samples teaching schedule of daily and “welcome” kits activities from manufacturers • Supply access at • Rehabilitation • Referrals to community bedside specialists aware of support groups and functional skills needed web sites for ostomy self-care • Confer with • Primary Care physician rehabilitation access to information specialists regarding about pouching needs most therapeutic (for insurance approach to attain specific skills Communication • Patient • Patient • Patient • Patient Ostomy care • Family • Family • Family • Nurse • Nurse • Nurse • Nurse • Primary care physician • Trauma surgeon • Trauma surgeon Physiatrista • Physical Therapist • Physical Therapist • Occupational Therapist • Occupational Therapist • Cognitive and • Cognitive and Speech/language Speech/language specialist specialist • Dietitian • Dietitian • Social Worker • Social Worker • Case Manager (Continues) 10083-06_WJ3305-Steele.qxd 9/5/06 4:57 PM Page 497

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TABLE 2. Roles and Relationships of the WOC Nurse in Interdisciplinary Trauma Care (Continued)

Inpatient Community- Setting Critical Care Acute Care Rehabilitation Based Care • Home Health coordinator Facilitation of • Complex pouching • Complex pouching • Problem solving • Problem solving rehabilitation • Educate and coach • Initiate ostomy • Coach and supervise ICU nurses as needed education developing ostomy to ensure consistency skills of pouch care and family information regarding ostomy • Coach and supervise • Incorporate exercise developing ostomy and other new abilities skills into ostomy teaching sessions • Monitor nurses tech- • Monitor nursing to niques to ensure ensure that patient consistency independence is fos- tered and encouraged • Incorporate exercise and other new abilities into ostomy Provide teaching sessions emotional • Family • Patient • Patient • Patient support to • Nurse • Family • Family • Family • Nurse • Nurse • Home health nurse • Rehabilitation WOC nurse needs Professionals from trauma • Information about • Reinforcement of • Reinforcement of • Consultation for team extent of injury and stoma teaching stoma teaching solving speciﬁc type of ostomy surgery problems • Physiologic status and • Results of cognitive • Results of cognitive • Community resource contraindications to evaluations and evaluations and referrals for issues performing stoma care therapy therapy beyond the scope of WOC nursing practice • Knowledge about • Results of Physical and • Results of Physical and family dynamics and Occupational Therapy Occupational Therapy support evaluations and evaluations and treatment treatment • Adaptive techniques • Adaptive techniques to to facilitate ostomy facilitate ostomy education and self- education and self-care care • Diet information and anticipated effect on stoma output • Need for future surgery • Financial and insurance status for supply access

aPhysician specialist in Physical Medicine and Rehabilitation.

followed by design and testing of prevention and treat- Although we may embrace the concept of the WOC nurse- ment protocols. Interventional research regarding novel led interdisciplinary care for ostomy patients, there is a teaching strategies must be conducted with samples from need to design and test the outcomes of such a model. physically and cognitively challenged individuals to iden- Are commonly used scoring systems, such as the Injury tify best practices for working with the trauma population. Severity Scale and the Revised Trauma Score, predictive of 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 498

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TABLE 3. such as the WOCN Center for Clinical Investigation will Nursing Research Needs Concerning Trauma become increasingly more important in the effort to build and Ostomy Care evidence to guide practice.

Category Research Needs ■ References Assessment • Predictors of stomal and peristomal complications 1. Peden M, McGee K, Krug E, eds. Injury: A Leading Cause of the • Assessment tools for diagnosis of stomal Global Burden of Disease, 2000. Geneva: World Health Orga- and peristomal complications nization; 2002. Available at: http://www.who.int/en/index. html. Accessed October 12, 2005. • Utility of trauma scoring systems in 2. Hoyert DL, Hsiang-Ching K, Smith BL. Deaths: preliminary predicting ostomy self-care ability data for 2003. National Vital Statistics Reports [serial online]. • Comorbid chronic health problems and 2005;53(15):3-4. Available from National Center for Health ostomy rehabilitation Statistics, Hyattsville, Md. Accessed October 12, 2005. Ostomy • Novel teaching strategies for physically 3. HCUPnet, Healthcare Cost and Utilization Project. Agency for management and cognitively challenged Healthcare Research and Quality, Rockville, MD. Available at: • Prevention and treatment of stomal and http://www.ahrq.gov/HCUPnet. Accessed October 17, 2005. peristomal complications 4. Dickinson M. Understanding the mechanism of injury and • Relationship between type of pouching kinetic forces involved in traumatic injuries. Emergency Nurse. system and self-care ability 2004;12:30-34. • Cost of ostomy supplies and methods of 5. Jacobs BB, Hoyt KS, eds. Trauma Nursing Core Course. 5th ed. management Bedford Park, Il: Emergency Nurses Association; 2000. 6. McQuillan KA, VonRuedn KT, Hartsock RL, Flynn MB, • WOC nurse-led interdisciplinary models Whalen E, eds. Trauma Nursing: From Resuscitation Through of stoma management Rehabilitation. 3rd ed. Philadelphia: W. B. Saunders; 2002. Psychosocial • Type of pouching system and perceived 7. Fantus RJ, Fildes J. The blunt majority? Bull Am Coll Surg. 2003; adjustment ostomy burden 88:42. • Health related quality of life with ostomy 8. Gur E, Michowitz M, Abu-Abeid S, Klausner Y, Yossiphov Y, in trauma Lelcuk S. Traumatic rupture of the intestine in patients with • Impact of PTSD on ostomy self-care inflammatory bowel disease. Am J Surg. 1995;61:539-542. • Family coping and perceived burden of 9. Nelson R, Singer M. Primary repair for penetrating colon injury injuries. Cochrane Database Syst Rev [database online]. • Impact of culture on perceived ostomy 2005;3. Available at: http://www.mrw.interscience.wiley.com/ burden cochrane/clsysrev/articles/CD002247/frame.html. Accessed September 10, 2005. • Subjective experience of trauma and 10. Sugrue M, D’Amours SK, Joshipura M. Damage control surgery ostomy surgery and the abdomen. Injury Int J Care Injured. 2004;35:642-648. 11. Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg. 2004;91:1095-1101. 12. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma-Injury Infect Crit Care. 2001;51:261-271. ability to perform ostomy self-care? What effect does the 13. Asensio JA, Petrone P, Roldan G, Kuncir E, Ramicone E, Chan type of pouching system have on the length of time to L. Has evolution of awareness of guidelines for institution of master ostomy self-care and the perceived burden of hav- damage control improved outcome in the management of the ing a stoma? Is there a difference in the health-related qual- posttraumatic open abdomen? Arch Surg. 2004;139:209-214. ity of life of ostomates who have suffered trauma and those 14. Offner PJ, de Souza AL, Moore EE, et al. Avoidance of abdominal compartment syndrome in damage control laparotomy whose stoma was prompted by cancer or inflammatory after trauma. Arch Surg. 2001;136:676-681. bowel disease? How do culture, family coping, and PTSD af- 15. Raeburn CD, Moore EE, Biffl WL, et al. The abdominal com- fect ostomy education and rehabilitation following trauma? partment syndrome is a morbid complication of postinjury What factors affect the cost of ostomy care supplies and the damage control surgery. Am J Surg. 2001;182:542-546. method of stoma management? Finally, qualitative research 16. Rutherford EJ, Skeete DA, Brasel KJ. Management of the pa- can yield a greater understanding of the experiential path tient with an open abdomen: techniques in temporary and definitive closure. Curr Probl Surg. 2004;41:821-876. one walks when trauma means a stoma. Is having a stoma a 17. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective final insult, minor inconvenience, or badge of courage? evaluation of vacuum-assisted fascial closure after open ab- The complexity of caring for the trauma patient with a domen: planned ventral hernia rate is substantially reduced. stoma demands the use of more scientific inquiry to direct Ann Surg. 2004;239:608-616. the care of this special population. As the number of per- 18. Garner GB, Ware DN, Cocanour CS, et al. Vacuum-assisted sons requiring fecal or urinary diversion because of injury wound closure provides early fascial reapproximation in trauma patients with open abdomens. Am J Surg. 2001;182: declines, the ability to obtain sufficiently large samples for 630-638. such research will become more challenging. Collaboration 19. Chavarria-Aguilar M, Cockerham WT, Barker DE, Ciraulo DL, between WOC nurses in multiple settings and resources Richart CM, Maxwell RA. Management of destructive bowel 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 499

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injury in the open abdomen. J Trauma-Injury Infect Crit Care. 42. Collinge C, Tornetta P III. Soft tissue injuries associated with 2004;56:560-564. pelvic fractures. Orthop Clin North Am. 2004;35:451-456. 20. Bulgur EM, McMahon K, Jurkovich GJ. The morbidity of pen- 43. Navsaria PH, Shaw JM, Zellweger R, Nicol AJ, Kahn D. Diag- etrating colon injury. Injury. 2003;34:41-46. nostic laparoscopy and diverting sigmoid loop colostomy in 21. Bowley DMG, Boffard KD, Goosen J, Bebington BD, Plani F. the management of civilian extraperitoneal rectal gunshot in- Evolving concepts in the management of colonic injury. Injury. juries. Br J Surg. 2004;91:460-464. 2001;32:435-439. 44. Plummer JM, McDonald AH, Newnham MS, McFarlane ME. 22. Fealk M, Osipov R, Foster K, Caruso D, Kassir A. The conun- Civilian rectal trauma: the surgical challenge [abstract]. West drum of traumatic colon injury. Am J Surg. 2004;188:663-670. Indian Med J. 2004;53:383-386. 23. Haut ER, Nance ML, Keller MS, et al. Management of pene- 45. Demirbas S, Yildiz M, Uluutku AH, et al. Surgical treatment of trating colon and rectal injuries in the pediatric population. ano-rectal gunshot injuries caused by low-velocity bullets [ab- Dis Colon Rectum. 2004;47:1526-1532. stract]. Ulusal Travma Dergisi [Turkish Journal of Trauma and 24. Dente CJ, Tyburski J, Wilson RF, Collinge J, Steffes C, Carlin Emergency Surgery]. 2004;10:17-21. A. Ostomy as a risk factor for posttraumatic infection in pen- 46. Tanuma Y, Horita H, Kadono M. Extraperitoneal bladder rup- etrating colonic injuries: univariate and multivariate analy- ture secondary to rectal impalement. Int J Urol. 2001;8:634-636. ses. J Trauma-Injury Infect Crit Care. 2000;49:628-637. 47. Jang TL, Yap RL, Batler RA, Brannigan RE. Intraperitoneal 25. Kamwendo NY, Modiba MC, Matlala NS, Becker PJ. Ran- bladder rupture and bowel injury from peri-rectal impale- domized clinical trial to determine if delay from time of pen- ment. J Urol. 2003;170:2382-2384. etrating colonic injury precludes primary repair. Br J Surg. 48. Hellinger MD. Anal trauma and foreign bodies. Surg Clin North 2002;89:993-998. Am. 2002;82:1253-1260. 26. Hudolin T, Hudolin I. The role of primary repair for colonic 49. Clarke DL, Buccimazza I, Anderson FA, Thomson SR. Colorectal injuries in wartime. Br J Surg. 2005;92:643-647. foreign bodies. Colorectal Dis. 2005;7:98-103. 27. Adesanya AA, Ekanem EE. A ten-year study of penetrating in- 50. Lo SF, Wong SH, Leung LS, Law IC, Yip AWC. Traumatic rec- juries of the colon. Dis Colon Rectum. 2004;47:2169-2177. tal perforation by an eel. Surgery. 2004;135:110-111. 28. Power N, Ryan S, Hamilton P. Computed tomographic cystog- 51. Riggs N, Houry D, Long G, Markovchick V, Feldhaus KM. raphy in bladder trauma: pictorial essay. Can Assoc Radiol J. Analysis of 1,076 cases of sexual assault. Ann Emerg Med. 2000; 2004;55:304-308. 35:358-362. 29. Lunetta P, Penttila A, Sajantila A. Fatal isolated ruptures of 52. Slaughter L, Brown CRV, Crowley S, Peck R. Patterns of geni- bladder following minor blunt trauma. Int J Legal Med. 2002; tal injury in female sexual assault victims. Am J Obstet Gynecol. 116:282-285. 1997;176:609-616. 30. Gomez RG, Ceballos L, Coburn M, et al. Consensus on geni- 53. Sommers MS, Buschur C. Injury in women who are raped. tourinary trauma. Br J Urol Int. 2004;94:27-32. Dimens Crit Care Nurs. 2004;23:62-68. 31. Chi-Hsun H, Chen RJ, Fang JF, et al. Diagnosis and manage- 54. Arumugam PJ, Bevan L, Macdonald L, et al. A prospective ment of bladder injury by trauma surgeons. Am J Surg. 2002; audit of stomas—analysis of risk factors and complications 184:143-147. and their management. Colorectal Dis. 2003;5:49-52. 32. Corriere JN, Sandler CM. Bladder rupture from external trauma: 55. Robertson I, Leung E, Hughes D, et al. Prospective analysis of diagnosis and management. World J Urol. 1999;17:84-89. stoma-related complications. Colorectal Dis. 2004;7:279-285. 33. Osman Y, El-Tabey N, Mohsen T, El-Sherbiny M. Nonoperative 56. Duchesne JC, Wang YZ, Weintraub SL, Boyle M, Hunt JP. treatment of isolated posttraumatic intraperitoneal bladder Stoma complications: a multivariate analysis. Am Surgeon. rupture in children—is it justified? J Urol. 2005;173:955-957. 2002;68:961-966. 34. Margolin DJ. Gonzalez RP. Retrospective analysis of traumatic 57. Lertsithichai P, Rattanapichart P. Temporary ileostomy versus bladder injury: does suprapubic catheterization alter outcome temporary colostomy: a meta-analysis of complications. of healing? Am Surg. 2004;70:1057-1060. Asian J Surg. 2004;27:202-210. 35. Parry NG, Rozycki GS, Feliciano DV, et al. Traumatic rupture 58. Bakx R, Busch ORC, Bemelman WA, Veldink GJ, Slors JFM. of the urinary bladder: is suprapubic tube necessary? J Trauma- Morbidity of temporary loop ileostomies. Dig Surg. 2004;21: Injury Infect Crit Care. 2003;54:431-436. 277-281. 36. Volpe MA, Pachter EM, Scalea TM, Macchia RJ, Mydlo JH. Is 59. Silva MA, Ratnayake G, Deen KI. Quality of life of stoma pa- there a difference in outcome when treating traumatic in- tients: temporary ileostomy versus colostomy. World J Surg. traperitoneal bladder rupture with or without a suprapubic 2003;27:421-424. tube? J Urol. 1999;161:1103-1105. 60. Persson E, Gustavsson B, Hellstrom AL, Lappas G, Hulten L. 37. Demetriades D, Karaiskakis M, Velmahos GC, Alo K, Murray J, Ostomy patients’ perceptions of quality of care. J Adv Nurs. Chan L. Pelvic fractures in pediatric and adult trauma patients: 2005;49:51-58. are they different injuries? J Trauma. 2003;54:1146-1151. 61. Turnbull RW, Turnbull GB. Enterostomal therapy: personifi- 38. Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos cation of a philosophy of care. In: Erwin-Toth P, Krasner D, G, Chan L. Pelvic fractures: epidemiology and predictors of eds. Enterostomal Therapy Nursing: Growth and Evolution of a associated abdominal injuries and outcomes. J Am Coll Surg. Nursing Specialty Worldwide. Baltimore: Halgo; 1996:181-193. 2002;195:1-10. 62. Richmond TS, Thompson HJ, Deatrick JA, Kauder DR. Journey 39. Grotz MRW, Allami MK, Harwood P, Pape HC, Krettek C, towards recovery following physical trauma. J Adv Nurs. 2000; Giannoudis PV. Open pelvic fractures: epidemiology, current 32:1341-1347. concepts of management, and outcome. Injury. 2005;36:1-13. 63. Brown H, Randle J. Living with a stoma: a review of the liter- 40. Tarman GJ, Kaplan GW, Lerman SL, McAleer IM, Losasso BE. ature. J Clin Nurs. 2005;14:74-81. Lower genitourinary injury and pelvic fractures in pediatric 64. Piwonka MA, Merino JM. A multidimensional modeling of pre- patients. Urology. 2002;59:123-126. dictors influencing the adjustment to a colostomy. J Wound 41. Ziran BH, Chamberlin E, Shuler FD, Shah M. Delays and dif- Ostomy Continence Nurs. 1999;26:298-305. ficulties in the diagnosis of lower urologic injuries in the con- 65. White CA. Ostomy adjustment. In: Colwell JC, Goldberg MT, text of pelvic fractures. J Trauma-Injury Infection Crit Care. Carmel JE, eds. Fecal and Urinary Diversions: Management Prin- 2005;58:533-537. ciples. St. Louis: Mosby; 2004:326-336. 10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 500

500 Steele J WOCN ■ September/October 2006

66. Inaba K, Goecke M, Sharkey P, Brenneman F. Long-term out- 75. Bisson J, Andrew M. Psychological treatment of post-traumatic comes after injury in the elderly. J Trauma-Injury Infect Crit stress disorder (PTSD). Cochrane Database Syst Rev [online data- Care. 2003;54:486-491. base]. 2005; Issue 3. Accessed October 25, 2005. 67. Dimopoulou I, Anthi A, Mastora Z, et al. Health-related qual- 76. Gubler KD, Maier RV, Davis R, Koepsell T, Soderberg R, Rivara ity of life and disability in survivors of multiple trauma one FP. Trauma recidivism in the elderly. J Trauma. 1996;41: year after intensive care unit discharge. Am J Phys Med Rehabil. 952-956. 2004;83:171-176. 77. Caufeild J, Singhal A, Moulton R, Brenneman F, Redelmeier 68. DePalma JA, Fedorka P, Simko LC. Quality of life experienced D, Baker AJ. Trauma recidivism in a large urban Canadian by severely injured trauma survivors. AACN Clin Issues. 2003; population. J Trauma. 2004;57:872-876. 14:54-63. 78. Cooper C, Eslinger D, Nash D, al-Zawahri J, Stolley P. Repeat 69. Greenspan AI, Kellerman AL. Physical and psychological out- victims of violence: report of a large concurrent case-control study. Arch Surg. 2000;135:837-843. comes 8 months after serious gunshot injury. J Trauma-Injury 79. Kaufmann CR, Branas CC, Brawley ML. A population-based Infect Crit Care. 2002;53:709-716. study of trauma recidivism. J Trauma. 1998;45:325-331. 70. Schnyder U, Moergeli H, Klaghofer R, Sensky T, Buchi S. Does 80. Hedges BE, Dimsdale JE, Hoyt DB, Berry C, Leitz K. patient cognition predict time off from work after life-threat- Characteristics of repeat trauma patients, San Diego County. ening accidents? Am J Psychiatry. 2003;160:2025-2031. Am J Public Health. 1995;85:1008-1010. 71. Kuhn E, Blanchard EB, Hickling EJ. Posttraumatic stress dis- 81. Rich JA, Grey CM. Pathways to recurrent trauma among order and psychosocial functioning within two samples of young black men: traumatic stress, substance use, and the MVA survivors. Behav Res Ther. 2003;41:1105-1112. “code of the street.” Am J Public Health. 2005;95:816-824. 72. Wang CH, Tsay SL, Bond AE. Post-traumatic stress disorder, 82. Soderstrom CA, Smith GS, Jufera JA, et al. The accuracy of the depression, anxiety and quality of life in patients with trafﬁc- CAGE, the Brief Michigan Alcoholism Screening Test, and related injuries. J Adv Nurs. 2005;52:22-30. the Alcohol Use Disorders Identification Test in screening 73. Kimerling R, Ouimette P, Prins A, et al. BRIEF REPORT: utility of trauma center patients for alcoholism. J Trauma-Injury Infect a short screening scale for DSM-IV PTSD in primary care. J Gen Crit Care. 1997;43:962-969. Intern Med. 2006;21:65-67. 83. Long AF, Kneafsey R, Ryan J, Berry J. The role of the nurse 74. Rose S, Bisson J, Churchill R, Wessely S. Psychological de- within the multi-professional rehabilitation team. J Adv Nurs. brieﬁng for preventing posttraumatic stress disorder (PTSD). 2002;37:70-78. Cochrane Database Syst Rev [online database]. 2002; Issue 2. 84. Birmingham J, Anctil B. Managing the dynamics of collabo- Accessed October 25, 2005. ration. Case Manager. 2002;13:73-77.

CE Test When Trauma Means a Stoma

Instructions: • No Internet access? Call 800-933-6525 ext. 6617 or Alabama #ABNP0114, Florida #FBN2454, and Iowa #75. • Read the article on page 491. 6621 for other rush service options. LWW home study activities are classified for Texas nursing • Take the test, recording your answers in the test answers • Questions? Contact Lippincott Williams & Wilkins: continuing education requirements as Type 1. Your certifi- section (Section B) of the CE enrollment form. Each ques- (646) 674-6617 or (646) 674-6621 cate is valid in all states. tion has only one correct answer. Registration Deadline: October 31, 2008 • Complete registration information (Section A) and course Payment and Discounts: evaluation (Section C). Provider Accreditation: • The registration fee for this test is $24.95. • Mail completed test with registration fee to: Lippincott • If you take two or more tests in any nursing journal pub- Williams & Wilkins, CE Group, 333 7th Avenue, Lippincott Williams & Wilkins (LWW), the publisher of lished by LWW and send in your CE enrollment forms to- 19th Floor, New York, NY 10001 Journal of Wound, Ostomy, and Continence Nursing, will gether, you may deduct $0.95 from the price of each • Within 4-6 weeks after your CE enrollment form is re- award 3.5 contact hours for this continuing nursing educa- test. ceived, you will be notiﬁed of your test results. tion activity. Lippincott Williams & Wilkins is accredited as • We offer special discounts for as few as six tests and in- • If you pass, you will receive a certiﬁcate of earned contact a provider of continuing nursing education by the stitutional bulk discounts for multiple tests. Call (800) hours and answer key. If you fail, you have the option of American Nurses Credentialing Center’s Commission on 787-8985 for more information. taking the test again at no additional cost. Accreditation. This activity is also provider approved by the • A passing score for this test is 13 correct answers. California Board of Registered Nursing, Provider Number • Need CE STAT? Visit www.nursingcenter.com for imme- CEP 11749 for 3.5 contact hours. LWW is also an ap- diate results, other CE activities and your personalized proved provider by the American Association of Critical- CE planner tool. Care Nurses (AACN 00012278, CERP Category A),