General Patient Care Policy and Procedure Statement

MENDOCINO COAST DISTRICT HOSPITAL GENERAL PATIENT CARE POLICY AND PROCEDURE STATEMENT

NUMBER: 205.1820 PAGE: 1 OF 3

TITLE: WOUND CARE; APPLICATION OF OSTOMY POUCH OR WOUND DRAINAGE POUCH TO FISTULAS, DRAINS OR WOUNDS

PURPOSE: To contain drainage for measurement, visual evaluation and/or laboratory analysis. To prevent/reduce skin maceration and exfoliation. To promote patient comfort by simplifying management of drainage containment.

EQUIPMENT:  NS  Tape  Skin barrier wipes  Disposable gloves  Scissors  Measuring tool  Soap and water  Wash cloths or prescribed wound cleaners  Barrier paste  Stoma powder  Wafers (i.e.: Hollister Premium barrier)  Collecting pouch or appliance appropriate to situation (i.e.: colostomy bag; Convatec Wound Manager)  Hairdryer or folding fan.

PROCEDURE: *Note: Prior to pouching, the Nurse must consider: 1. Location of area needing pouch. 2. Skin condition and patient preference. 3. Type of products, ease of availability and cost. 4. Cognitive ability of learner. a) Obtain MD order. b) Assemble equipment. c) Explain procedure to patient or caregiver. d) Wash hands, don gloves. e) Cleanse skin surrounding area prn with soap and/or water. f) Cleanse open areas with NS, pat dry with gauze. g) Lightly paint unbroken skin area surrounding wound/drain/fistula with skin barrier wipe if needed. MENDOCINO COAST DISTRICT HOSPITAL GENERAL PATIENT CARE POLICY AND PROCEDURE STATEMENT

h) Allow to dry. i) Affix pouch – SEE NOTE. Note: If skin trauma is significant; if location presents problems with uneven fit or seal (skin folds, crevices, bony prominence, mucous membranes) stoma powder, paste, and/or barrier wafer, singly or in combination may need to be utilized

FOR WEEPING TISSUE: POWDER 1. Sprinkle stoma powder onto moist areas. 2. Using folding fan, blow or fan any excess powder away from area to be covered with pouch. 3. Apply skin barrier wipe to “seal in” powder. 4. Affix pouch or appliance.

APPLICATION OF BARRIER WAFER 1. Prepare wafer ahead by sizing the wafer’s center to fit over the wound/fistula/drain. 2. Cut-out the sized area on the wafer. Keep the cut-out as the pattern for future wafers to be sized. 3. Note: It is suggested to re-measure each time, even if the previous pattern was saved. In the course of the healing process, the size of the area to be pouched may change. 4. Remove paper backing from wafer and apply 5. Affix pouch to wafer. (See “Application of Paste” lines 2-4 below)

APPLICATION OF PASTE Note: Paste can be utilized to build a smooth surface when folds, crevices, or craters prevent a smooth seal for application of a pouch. The paste is frequently used in conjunction with a wafer. 1. Fill the crevices/fold adjacent to fistula opening with paste, until level with surface. 2. Center and affix the pre-measured wafer over the area to be pouched. Secure the wafer’s seal by applying light pressure to wafer edges for a few moments. 3. Center and affix pouch onto wafer. 4. Secure edges of wafer by framing with tape.

5. Seal open end of pouch as per package directions. MENDOCINO COAST DISTRICT HOSPITAL GENERAL PATIENT CARE POLICY AND PROCEDURE STATEMENT

6. Frequency of change will depend upon quantity of output; fit of drainable pouch; patient’s skin integrity. Some circumstances may demand daily changes, others could safely remain up to 5 – 7 days. If problems persist, solicit a Wound Ostomy Continence Nurse referral from the physician. 7. Document in patient chart:  Type and size of products used  Description of skin integrity  Wound assessment (where applicable)  Patient’s tolerance of procedure 8. Teach patient/caregiver, as appropriate. 9. Follow infection control and OSHA bloodborne pathogen guidelines, as appropriate.

New: Revised: 03/09

Approval Signatures:

Signature on File Nurse Manager Date

Signature on File Chief Clinical Officer Date

Signature on File Medical Chief of Staff Date

Signature on File Chief Executive Officer Date

Signature on File President, Board of Directors Date