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Fistula Management

Botham, Phillip

Journal of Wound, Ostomy and Continence Nursing: September/October 2017 - Volume 44 - Issue 5 - p E3–E4
doi: 10.1097/WON.0000000000000365
Getting Ready for Certification
Free

Fistula care is one of the most challenging aspects within the WOCNCB® certified nurse role. Patients with fistulas require coordinated, interdisciplinary care including services of a certified WOC nurse, dietitian, social worker, pharmacist, nurse, surgeon, and physician. Coordination of this care, along with extensive patient/family education, is usually managed by the WOC certified nurse.Preparation for the WOCNCB® Ostomy examination should include a careful review of the content outline. The outline is divided into key tasks with critical knowledge listed for each task. Task 8, Assessment and Management of Fistulas, requires the test-taker to be knowledgeable of: clinical presentation, classification systems, medical and surgical management, as well as WOC certified nurse management concepts and related tasks.

Phillip Botham, MSN, RN, CWON, Medical University of South Carolina, Charleston.

Correspondence: Phillip Botham, MSN, RN, CWON, Medical University of South Carolina, PO Box 21989, Charleston, SC 29413 (phillbotham@gmail.com).

The author declares no conflict of interest.

Fistula care is one of the most challenging aspects within the WOCNCB certified nurse role. Patients with fistulas require coordinated, interdisciplinary care including services of a certified WOC nurse, dietitian, social worker, pharmacist, nurse, surgeon, and physician. Coordination of this care, along with extensive patient/family education, is usually managed by the WOC certified nurse.

Preparation for the WOCNCB Ostomy examination should include a careful review of the content outline. The outline is divided into key tasks, with critical knowledge listed for each task. Task 8, Assessment and Management of Fistulas, requires the test-taker to be knowledgeable of clinical presentation, classification systems, medical and surgical management, as well as WOC certified nurse management concepts and related tasks.

Successful test-takers start by critically examining the question. The first step involves determining important information provided in the stem (body) of the question. An example related to fistulas might be identification of information related to fistula output. Is the fistula output is categorized as low, moderate, or high? Descriptors of volume are often related to the location of the fistula within the gastrointestinal tract. After identifying critical information in the question stem, the test-taker needs to connect the question content to the 4 answer options provided. Eliminate easily excluded item responses and connect the remaining ones to the stem applying the core concepts of fistula care and management in the final selection process.

When answering items related to fistula management, test-takers should have basic understanding of the overall management of the patient with a fistula. Key areas include (1) management of hydration and fluid loss, (2) reduction of output, (3) managing infection and/or sepsis, (4) defining anatomy of the fistula tract, (5) addressing nutritional needs, (6) containing and quantifying output while protecting the skin, and (7) providing care using an interdisciplinary approach. Goals of nursing care for fistula management include (1) skin protection, (2) containment of effluent, (3) odor control, (3) patient comfort, (4) quantification of effluent output volume, (5) patient mobility, (6) ease of care, and (7) cost containment. Remember that WOCNCB certification measures entry-level knowledge. Seasoned CWOCNs often have difficulty separating years of clinical and anecdotal experiences from the knowledge expected of the entry-level practitioner.

Study aids are available from multiple outlets, including the WOCN Education Programs, WOCNCB flashcards, and Self-Assessment Examinations. These study aids can be helpful in sharpening test-taking skills in preparation for certification exams. Familiarize yourself with the content outline for the examination you plan to complete. Content outlines are used extensively by the item writing committees when building test content. Visit the WOCNCB Web site (http://www.wocncb.org) for the examination content outline, sample questions, and information on how to purchase the Self-Assessment Examination and flashcards. Refer to the Box for examples of references containing information about fistula care, along with example questions and helpful test-taking strategies.

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BOX. References When Preparing for Fistula Care Items on the WOCNCB Ostomy Examination Cited Here...

1. Nix D, Bryant RA. Fistula management. In: Doughty DB, McNichol LL, eds. Wound Management Core Curriculum. 1st ed. 2016:704–721.

2. Nix D, Bryant RA. Fistula management. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. 1st ed. 2016:201–219.

3. Bryant RA, Best M. Management of draining wounds and fistulas. In: Bryant RA, Rolstad BS, eds. Acute and Chronic Wounds; Current Management Concepts. 5th ed. 2016:509–530.

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PRACTICE QUESTIONS

  • 1. Which of the following is the appropriate classification for a spontaneous tract between the bladder and the vagina?
  • Colovaginal fistulaRectovaginal fistulaVesicovaginal fistulaVesicocutaneous fistula
  • Content outline: COCN Task 8 020801, CWCN Task 7 010702
  • Cognitive level: Knowledge

ANSWER C: Rationale: The taxonomy for naming a fistula is based on characterization of its origin and termination points. The stem provides the key anatomical information needed to answer the question; specifically, the bladder and vagina are the locations involved. Vesico (defined as a fluid-filled cavity) describes the origin of the fistula and describes the urinary bladder, and vaginal pertains to the termination (the vagina). In understanding these 2 anatomical designations, the test-taker is able to identify the single option that includes both anatomical locations referred to in the stem. Spontaneous is an important characteristic, but it is not pertinent to the question asked.

1. Nix D, Bryant RA. Fistula management. In: Doughty DB, McNichol LL, eds. Wound Management Core Curriculum. 1st ed. 2016:705.

2. Nix D, Bryant RA. Fistula management. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. 1st ed. 2016:201–219.

  • 2. Which of the following is MOST likely to require surgical intervention?
    1. Complex type 2 fistula
    2. Simple type 1 fistula
    3. Postoperative fistula
    4. Low-output fistula
  • Content outline: COCN Task 8 020803, CWCN Task 7 010705
  • Cognitive level: Knowledge

ANSWER A: Rationale: A complex, type 2 fistula (also known as an enteroatmospheric fistula or EAF) opens into the base of a wound. These often have eversion of the mucosa or form a pseudo stoma. An EAF is not likely to close spontaneously and predominantly requires surgical intervention for closure. In examining the stem, the test-taker is able to exclude fistulas prone to spontaneous closure, as they would not require the identified surgical intervention. Postoperative, simple, type 1, and low-output fistulas have higher spontaneous closure rates. The test-taker is required to have an understanding of fistulas managed with medical management and those requiring surgical intervention.

1. Bryant RA, Best M. Management of draining wounds and fistulas. In: Bryant RA, Rolstad BS, eds. Acute and Chronic Wounds; Current management Concepts. 5th ed. 2016:509–530.

2. Nix D, Bryant RA. Fistula management. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. 1st ed. 2016:201–219.

  • 3. In which of the following would a moisture barrier product and absorbent dressings MOST likely be considered?
    1. Enteroatmospheric fistulas
    2. Colovesicular fistulas
    3. Rectocutaneous fistula
    4. Enterocutaneous fistulas
  • Content outline: COCN Task 8 020803, CWCN Task 7 010705
  • Cognitive level: Application

ANSWER C: Rationale: Close to 8 to 10 L of fluid pass through the jejunum daily, of which 98% is reabsorbed, primarily in the small intestine and the colon. A fistula connecting the rectum to skin level would most likely be low output and located in an anatomically difficult area to pouch. In examining the stem, the test-taker is required to understand when the application of topical skin treatment is preferred over pouching, troughing, or negative pressure wound therapy (NPWT). Enterocutaneous fistulas are characteristically moderate to high output, requiring containment with pouching. Colovesicular fistulas are internal and do not connect to the skin—thus not present cutaneous issues. Enteroatmospheric fistulas are openings within a wound bed, requiring pouching, troughing, or utilization of NPWT where appropriate.

1. Nix D, Bryant RA. Fistula management. In: Doughty DB, McNichol LL, eds. Wound Management Core Curriculum. 1st ed. Alphen aan den Rijn, The Netherlands: Wolters Kluwer. 2016:704–721.

2. Nix D, Bryant RA. Fistula management. In: Carmel JE, Colwell JC, Goldberg MT, eds. Ostomy Management Core Curriculum. 1st ed. St. Louis, Missouri: Elsevier, Mosby. 2016:201–219.

© 2017 by the Wound, Ostomy and Continence Nurses Society.