Evidence ofinnovation
Contents_4 2020 – Year of the Nurse and Midwife_6 Ostomy Challenges – Peristomal skin complications_8 Study: Balancing stoma complexities with pouch convexity _12 Case Study: A challenging patient_14 Case Study: Stoma education_18 Case Study: Combining Aurum® 2 urostomy and colostomy pouches_22 Case Study: Using Aurum® 2 for peristomal skin complications_24 Case Study: Pyoderma gangrenosum and Manuka honey _28 From nature to nurture – The lifecycle and properties of Manuka honey_34 Maori Manuka story_36 Colostomy UK rugby match UltraFrame® interview_39 References
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WELLAND MEDICAL EVIDENCE OF INNOVATION
“SKIN HAS NOT BEEN SORE SINCE USING THE AURA® POUCH.”Mrs R, UKUses Aura® urostomy pouches
WELLAND MEDICAL EVIDENCE OF INNOVATION
2020isourtimetoreflectontheseskills,thecommitmentandexpertclinicalcaretheybring,andtheimpacttheymakeonthelivesofsomany1.
FlorenceNightingale2said“themoreexperiencewegain,themoreprogresswecanmake”.ThecommonclinicalthemethroughoutthiseditionistheimprovementmadetoperistomalskincomplicationsfollowingtheintroductionofmedicalgradeManukahoneyinthestomaflangeadhesive.
Togetherwecanreviewexamplesofnursingcarewhichhavemadeapositiveimpactuponpatients'qualityoflife,aswetakeatriparoundtheglobetoreadpatientcasestudiesandpublishedarticlesfromAustralia,Holland,Italy,NewZealandandtheUK.
Throughpatientscenarios,weareabletofollowspecialistnursesastheysupporttheirpatients'journeythroughperistomalskincomplications.KatyMartin-Skurrreviewstheimpactofpyodermagangrenosum,MoiraEvans,PamelaWhiteandLynnRidley
sharetheimpactofdementiauponstomacare,whilstDannielleBarrintroducescomplexsocialsituationsandmentalhealthissues,forNellekeVandeVliertandLeilaFatemifarthefocusisuponproblematicabdominalcontours.
ThedynamicofchangeisdiscussedinRebeccaHowson’sreviewofpatienteducationmodelsandthereviewofpatients'clinicalneedsbyPamelaWhiteandMoiraEvans.
Peate(2019)statedthat:‘Theproverbpreventionisbetterthancuremeansthatitiseasiertostopsomethinghappeninginthefirstplacethantohavetorepairthedamageafterithashappened’.3
Thiseditionrecognisesstomatherapynursesintheirnever-endingquesttoenhancethelivesofpatientswithstomas.FlorenceNightingalesaidthatweshould“livelifewhenyouhaveit.Lifeisasplendidgift-thereisnothingsmallaboutit”.4
Dataheldonfile.
Florence Nightingale (1820-1910), photograph ca. 1880
AswecelebrateFlorenceNightingale’sbicentennialyear,designatedbytheWorldHealthOrganisationasthefirsteverglobalYear of the Nurse and Midwife.
WELLAND MEDICAL EVIDENCE OF INNOVATION
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“THE MORE EXPERIENCE WE GAIN, THE MORE PROGRESS WE CAN MAKE.”Florence Nightingale
A VERY SPECIAL YEAR FOR NURSES.
MoiraEvans,ClinicalMarketingManager,WellandMedical
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WELLAND MEDICAL EVIDENCE OF INNOVATION
PERISTOMAL PYODERMA GANGRENOSUM (PPG)Pyodermagangrenosum(PG)isadebilitatingskindiseasemostoftenassociatedwithinflammatoryboweldiseaseandisareportedlyrarecauseofperistomalulceration.ThelesionsofPGrapidlyevolvefromsmall,erythematouspustulestodeep,painful,pyogeniculcerswithinhourstodaysofonset.AlthoughthebehaviourandtheappearanceofthelesionsofperistomalPGarediagnostic,alackoffamiliaritywithPGoftenleadstomisdiagnosisandinappropriatetherapy.1
Asanuncommonsubtype,peristomalpyodermagangrenosum(PPG),whichoccursclosetoabdominalstomas,comprisesabout15%ofallcasesofPG.Thelesionsarepainfulandofteninterferewiththestomabagadheringtotheabdominalwall,whichcancausethecontentsofthebagtoirritatetheskinmorethanusual.2
Wallace(2017)suggeststhattherarityofpyodermagangrenosummeansthatthere is a need for clinicians to share their treatment experiences to act as a guide for future best practice.3
Thereisnouniversallyacceptedguidelinefortreatmentofpyodermagangrenosum,andnodisease-specifictherapieshavebeensubjectedtocontrolledclinicaltrial.4Instead,amultidisciplinaryapproachtotreatmentisrequired,andisbasedoncasereports,randomisedcontrolledtrialsintovariousdrugtherapies,andpreviousclinicalexperience.
PERISTOMAL SKIN COMPLICATIONSPeristomalskincomplicationsarethemostcommonissuefollowingcreationofastoma,Martinsetal(2013),andrangefrommilddermatitistoseverecomplicationssuchasulcerationornecrosis.
15%Peristomalpyodermagangrenosum(PPG)comprisesabout
ofallcasesofPyodermagangrenosum(PG).2
OSTOMYCHALLENGES
“THERE IS A NEED FOR CLINICIANS TO SHARE THEIR TREATMENT EXPERIENCES TO ACT AS A GUIDE FOR FUTURE BEST PRACTICE.”WallaceA(2017)
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BALANCING STOMA COMPLEXITIES WITH POUCH CONVEXITYMoiraEvans,ClinicalMarketingManager,WellandMedicalLtd.PamelaWhite,ClinicalGovernanceManager,CliniMedLtdandSecuriCare(Medical)Ltd.LynnRidley,SecuriCareNurseManager(North),SecuriCare(Medical)Ltd.
Areviewofonepatient’sjourneythroughperistomalskincomplicationmanagement. OUR PATIENT
An82-year-oldladywithdementia,whowascaredforinherownhomebyherfamily,thisincludedherdailyileostomycare.
Thepatientwasusingaonepiececonvexpouch.
Thefamilynoticedadeteriorationintheperistomalskincondition.TheyhadbeenadvisedtogetintouchwiththeirStomaCareNurse(SCN)iftheyhadanyconcernsrelatingtothestoma.
ThefamilycontactedtheirSCNfollowingthedeteriorationoftheperistomalskincondition.
STUDY AIMTopresentapatientscenariotodemonstratethepositiveimpactsuponperistomalskinintegrity,followingtheintroductionofmedicalgradeManukahoneywithintheconvexflangeadhesive.
WELLAND MEDICAL EVIDENCE OF INNOVATION
WHICH PROBLEM STARTED FIRST?• Patientattemptedtophysically
removethepouchduringthenight
• Theimpactofdementiauponherstomaawareness
• Reducedadherenceoftheflangeupontheskin
• Discomfortexperienced
• PeristomalMoistureAssociatedSkinDamage:ContactDermatitis
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THE IMPACT OF DEMENTIA UPON HER STOMA AWARENESS
NURSE ASSESSMENT 02-NOVEMBERTheSCN’sholisticassessment,promptedachangeofpouchadhesivetoaManukahoneyconvexflangeto:
1. Improvepouchtoskinadhesion
2. Supporttheimprovementofskinintegrity
3. Providecomforttothepatientduringwear-time
NURSE REVIEW 09-NOVEMBER (7 DAYS)Thereviewofthechangeofpouch7dayslater,showedperistomalskinimprovementandthesamepouchwasuseduntilthenextplannedreviewdate.
TREATMENT CONTINUATION 12-NOVEMBER (10 DAYS)TheholisticnursingcareandthechangetoaManukahoneyadhesiveconvexpouchhadresolvedthepatient’speristomalskinproblemsandtheuseofaconvexManukahoneypouchcontinued.
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WELLAND MEDICAL EVIDENCE OF INNOVATION
*Consentonfiletosharephotos PosterpresentedtotheASCN2019Conference,ICCWales.
METHODOD ?TheSCNsutilisedSecuriCareMedicalLtd.'sClinicalStomaScoringThermometertooltoacknowledgeandmanagecumulativeriskfactorstoenableprioritisingandproactivityofcareinput,asthepatient’sscorewasrankedas8,asamedayvisitwasarranged.
THE PATIENT’S JOURNEY LED TO:1.Thevigilanceofthepatient’sfamilycarers2.TheSCNpromptintervention3.ThechangetoaconvexManukahoneyadhesiveflange
Allofthesehavecontributedtotheresolutionoftheperistomalmoistureassociatedskindamageexperiencedbythepatient.
Patient attempted to physically remove the pouch
during the night
Discomfort experienced
Reduced adherence of the flange upon
the skin
Peristomal Moisture Associated Skin Damage: Contact
Dermatitis
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HomelessnessandemergencystomalsurgeryCASE STUDY: A CHALLENGING PATIENT
THE PERSON / THE STORYMrCpresentedasanemergencypatientviaambulancewithsevereabdominalpainandhaematemesis.Shortlyafteradmissionhewastakentotheatreandunderwentanemergencylaparotomy/totalcolectomyandwashout.Hislargebowelwasnecroticfromthedistalileumtotheproximalrectumwithnoobviouscause.Atthisstagethewoundwasleftopen(laparostomy)andatopicalnegativepressuredressingwasputinplace.ThepatientwasadmittedtoICU.Thefollowingdayhereturnedtotheatreagainforare-looklaparotomy/proctectomyandsmallbowelresection.Anendileostomywasformedatthisstage.Thepatientwascriticallyunwellanditwasunknownwhetherhewouldsurvivetheseprocedures.Stomaltherapywascontactedonday2postoperatively.Surprisingeveryone,MrCdidrecoverfromhissurgerybuthisstomaprovedtobechallenging.
SOCIAL, MEDICAL AND SURGICAL HISTORY / DIAGNOSISMrCisanex-IVdruguserandhasHepC.Atthetimeofadmissionhewasofficiallyhomeless;althoughhehadbeensleepinginemergencyhousinghehadlosthisbedwhenhedidnotpresent.HehasnonextofkinandsuffersfromPTSD1duetochildhoodabusefromwhenhespenthisyouthinaboys’orphanage.Hewascurrentlyonahighdoseanti-depressantandonamethadoneprogramme.Hehadnorelevantsurgicalhistory.
Thesurgicaldiagnosiswasischaemicbowelofunknowncause.MrChadnorecollectionofwhateventmayhavetriggeredtheischaemicbowel.Althoughhewasanex-IVdruguser,hecouldnotrecallusingintheperiodpriortoadmission.
POSTOPERATIVE ASSESSMENT AND DISCHARGEMrC’sileostomywasfoundtobeflat,non-spouted,initiallysloughy,withhealthytissuebecomingvisibleafterusingstomapowderforseveraldays.Hisstomarequiredaconvexapplianceandasealwasalsoused.However,norealissueswiththispresentedduringhishospitalstay.
StomaltherapyworkedcloselywithsocialworktoemphasisetheimportanceofMrCreturningtoemergencyhousingasweweregravelyconcernedabouthimreturningtothestreetswithhisnewstomaandcomplicatedsocialhistory.Thankfully,thesocialworkerwasabletosecureaccommodationbackattheplacehewaspreviouslysohewasdischargedthere.
However,themealsprovidedhadlittlevariationandwerenotidealforsomeonewithanileostomy.Inaddition,hisstomacausedembarrassmenttoMrCwhenitproducednoisyflatus.Thefacilitynotonlyhadasharedkitchenandlivingareasbutsharedbathroomcubicleswhichleftlittleprivacyforchangingastomaappliance.
MrCbecamedepressedandadmittedtobeing“really,reallylow”.Hewasstrugglingwithbodyimageassociatedwiththestoma,compoundedbyongoingleakswhichheattributedtotheexcessflatus.Healsostruggled,andcontinuestostruggle,withnotknowingwhyhe'dbecomesounwellinthefirstplacesincehehasnomemoryofthattime.Cognitively,wethoughtMrCmayhavesomeshort-termmemorylossassociatedwithbeingsocriticallyunwell.Inaddition,hisperistomalskinwaserythematouswithabrasionsandwaspainful,althoughthestomasizehaddecreased.
THE PLAN FOR MR CItwasabsolutelycriticalforustouseaproductthatwouldhavehealingproperties.Inaddition,theappliancewouldneedconvexity.Itwasclearabeltwouldbebeneficialalsoto‘pop’thestomaoutasmuchaspossibleduetoitsflatprofile.Theproductusedpriortodischargehadabelt,butMrCfounditdifficulttomanage.ThestomaltherapyteamthereforechosetousetheWellandAurumConvex(Figure1)withabelt2.Weneededtobeconfidentthattheproductwouldnotleakandwouldhealthesoreskin.Anotherreasonwechosethisproductisthatthebeltiseasytomanagewiththevelcrothateasilyslidesthroughthebelthole.AsMrCisoftenforgetful,itneededtobesimpletoensureself-efficacy3.Wealsofacilitatedareferraltothepsychiatricteamforongoingmanagementofhisdepression.
OUTCOMEMrCcamebacktoanoutpatientappointmentacoupleofweekslaterforreview.HelovedtheWellandAurumConvexdrainableandhadexperiencednoleakssincewehadseenhimlast.Hefoundthepoucheasytoemptywiththebuilt-intab.Healsolovedtheeaseoftheadjustablevelcrobelt.HisskinwashealedandwasnolongersoreasindicatedinFigure2.
MrCwasalsonowseeingthepsychiatristregularly.Althoughhestillhasalongwaytogopsychologically,havinghadnoleaksforaperiodoftimehasmadeahugeimprovementinhisconfidence,andheisobviouslycopingmuchbetter.ForsomeweeksMrCchosetohaveweeklySTNOPDappointmentswhichhetitrateddownashismentalhealthimproved.ItwasthereforegreatnewstohearthisweekthatMrChadmovedfromemergencyhousingintohisownpublichousingflatwhereheislivingindependently.
Figure2.MrC’sstoma.
Taken from the Journal of Stomal Therapy Australia – Volume 39 Number 3
September 2019. Printed with the kind permission of the AASTN.
WELLAND MEDICAL EVIDENCE OF INNOVATION
Figure1.TheWellandAurumConvexplusbelt.
DannielleBarr,RegisteredNurse,StomalTherapyNurseTheRoyalMelbourneHospital,Parkville,VIC3050
WELLAND MEDICAL EVIDENCE OF INNOVATION
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Fortheolderpersonisaboutkeepingitassimpleas1,2,3
RebeccaHowson,StomalTherapyNurse,CaulfieldHospital,CaulfieldVIC3162
CASE STUDY: STOMA EDUCATION
BACKGROUNDTheagingpopulationpresentsanarrayofissueswhentryingtoeducateanindividualonhowtoself-managetheirnewstomaand,withtheworld’spopulationagingrapidly,thisisanareaofparticularimportance.
Between2015and2050,theproportionoftheworld’solderadultsisestimatedtoalmostdoublefromabout12%to22%1.Inabsoluteterms,thisisanexpectedincreasefrom900millionto2billionpeopleovertheageof601.InAustralia,theproportionofthepopulationaged65yearsandoverincreasedfrom12.2%to15.7%between1998and20182.Thisgroupisprojectedtoincreasemorerapidlyoverthenextdecadeasfurthercohortsofbabyboomersreach65years2.Also,overthepast2decadesthenumberofpeopleaged85yearsandoverincreasedby125.1%comparedwithatotalpopulationgrowthof34.3%2overthesameperiod.Typicalissuesrelatedtoagingincludelossindexterity,decreasedsensationinextremities,changestoeyesight,decreasedproblemsolvingabilitiesandslowerrecall.However,theagingbrainisstillabletolearnnewskills3.
Inaddition,theculturalandlinguisticdiversityofAustralia’sresidentpopulationhasbeenreshapedovermanyyearsbymigration.Historically,morepeopleimmigratetothanemigratefrom,Australia.At30June2017,29%oftheestimatedresidentpopulationwasbornoverseas(7.1millionpersons)4.Thiswasanincreasefrom2016of28.6%3.In2007,10yearsearlier,25.1%ofthepopulationwasbornoverseas4.ThesestatisticshighlightthatAustraliahasnotonlyanagingbutalsoamulticulturalpopulation,andwhileinterpretersareinvaluableassetstheyarenotalwaysavailable.
Sohowdoweprovideeffectiveeducationtothiscohortofpatients?Bykeepingitsimple,asthisallowsthepatientstolearnwithouttheneedtoalwayshaveanadditionalpersonduringalleducationsessions.Also,byremovingunnecessaryproductsandstepsinordertosimplifytheprocess,thetaskbecomesachievableandincreasespatients’likelysuccess.
CASE STUDYMrsRisan87-year-oldnon-EnglishspeakingbackgroundGreeklady.Shelivedathomewithherhusband,whohasdementia,andwashisprimarycarer.Sinceheradmission,herhusbandhadbeenplacedintorespitecareand,ifshewereunabletoachieveindependencewithhercolostomycare,herfamilyhaddiscussedpermanentplacementforbothherandherhusband.WhilstMrsRwasabletospeak
English,aninterpreterwasutilisedduringtheinitialeducationsessiontoensurethatshewasabletofullyexpresstheissueswithchangingherapplianceandtohaveanyquestionsanswered.Priortothestomaltherapynursereview,itwasdocumentedthatMrsRwasrequiringassistancewithallaspectsrelatedtohercolostomycare.
SURGICAL HISTORYOn20June2018MrsRunderwentanemergencyHartmann’sprocedureforcolonoscopicperforation.Thiswasfollowedbyanextendedstayintheacutesetting.On5July2018shewastransferredtosubacute/rehabilitationforstomaltherapyeducation,assessment
andcomplexdischargeplanning.Atthetimethecolostomymeasured32mm,themucocutaneousjunctionhadhealed,butperistomalskincomplicationswerepresentrelatedtocontactwithoutput.
ABSTRACTAustralia’sagingpopulationpresentsuniquehurdleswhenplanning,providingcareandeducatingnewostomates,andthesevariationstocarediffergreatlydependingontheindividual.
Whilsttherearemanypredictorstoflagpotentialissues,andwell-planned-outpathwaysforthestoma’sphysicaljourney,thisarticleisaimedathighlightingtheoftenoverlookedandunder-documentedcomplexitiesencounteredaswenavigatepatientsinthetransitiontohome.Thisisanexampleofhownotallcomplicationsandbarrierstodischargeareduetothestoma,theoutput,oranymedicalissue,butratheraboutthepatient’sabilitytoself-manage.Theabilitytoself-manageastomaisoftenthedefiningfactortoanagedperson’sabilitytoeitherreturntotheirlivesathomeorbeplacedintoformalcare.Thisarticlefollowsthejourneyofanon-Englishspeakingbackgroundpatienttransferredfromtheacutesettingtorehabilitation.Shewasstrugglingtomanagehercolostomyappliancewhichcouldputher,andherhusbandwithdementia,intoresidentialcare–hermotivationtopreventthiswasdemonstratedbyherreadinesstolearn.Asstomaltherapynurses,itisourresponsibilitytoidentifythebarrierstoself-care,adaptproductselection,andimplementthemostachievablegoals.Thepatient’sspecificgoalsandtheinterventionsproducedtoachievethesewereindividualisedsothatshewasabletoreturnhometocontinuetoliveherlife,andnotbedictatedbyhernewstoma.Thismeantthattheconceptofself-carehadtobeassimpleas1,2,3.
“AN EDUCATION PLAN WAS SET UP IN ORDER TO REITERATE THAT SELF-CARE IS A 1, 2, 3 PROCESS.”
Imageisindicativeonlyandnotofactualpatient.
Taken from the Journal of Stomal Therapy Australia – Volume 39 Number 3
September 2019. Printed with the kind permission of the AASTN.
16 17
ISSUES IDENTIFIEDMrsRexplainedthatshehaddifficultycuttingtheflangetothecorrectsizeandalsotryingtoattachthebagtotheflange.Shewasunabletovisualisehercolostomywithouttheuseofamirrorandsaidshedidn’thave‘enoughhands’toapplytheflangecorrectly.Theseissueshadcausedhertocutthe
openingforthestomatoolargewhichhadledtothecircumferentialdamage(Figure1).Thereforethemainissueswerelanguagelimitations,atwo-piecemechanicalcoupling,incorrectsizingofproduct,anddifficultieswithfinemotorskillsduetodexterityandsensation.
REHABILITATION PLANAnumberofsuggestionsweremade.Firstly,thatMrsRchangestoaone-pieceproducttosimplifytheprocess.Secondly,thatshebeginstouseapre-cutproductandasshewasnotabletoreadEnglishwell.TheAurumwithManukaHoneywaschosenasthiscameintheappropriatepre-cutsize,wouldaidinhealingthe
damagedperistomalskin,andiseasytoapply.Thirdly,thatshecreatesaphotocareplan(Figure2)torefertowhenchanginghercolostomybag.Inadditiontothis,aneducationplanwassetupinordertoreiteratethatself-careisa1,2,3process.Thisisdefinedastherebeingonlythreethingstocollectpriortochanging.
Eachstepwasdemonstratedbysaying1asthebagisremoved,2whilecleaningtheskinandstoma,and3whileapplyingthenewbag.
REVIEWMrsRreportedatthenextreviewthatitwasmucheasiertochangeherapplianceandlikedhavingthephotocareplantorefertoduringappliancechanges.Herperistomalskinhadimprovedinthe3daysofusingtheAurumwithManukaHoney(Figure7)andMrsRalsocommentedthatshedidn’tfeel“itchy”aroundherstoma.Shewasnolongerrequiringanyassistancefromnursingstaffandwasconfidenttobedischargedhometoresumecaringforherhusband.MrsRwasdischargedhomewithdistrictnursesupport.
CONCLUSIONTheuseofunnecessaryproductsandnumerousstepsintheprocessofchangingbagscreatescomplicatedandconfusingtasksfortheagedorforthosepatientswithlimitedEnglish.Simplifyingtheprocessallowsforallpatientstobepresentedwiththesameeducationprocessandfacilitatescontinuityofcareashandoveroftheprocessforeducationisthenalsosimplified.The1,2,3stepeducationprocessrequiresonlyrepetitionandpractice.STNsprovidehands-onbedsideeducationtoallpatientsand,byusingthisprocess,canminimisethepotentialforvariationandmiscommunicationbetweenSTNsandbedsidenurses.
Note:Consentwasobtainedtousetheseimagesandcasestudyfromthepatientwithintheguidelinesoftheorganisation.
Figure1:MrsR’sstomapriortoeducation.Theperistomalskinisunprotectedduetoamis-fittingstomaappliance.
Figure5:PhotocareplanforthepatientshowingStep3:applyingthebag.
Figure3:PhotocareplanforthepatientshowingStep1:howtoremovethebag.
Figure2:Photocareplanforthepatientshowingthe1,2,3suppliesrequiredforbagchange.
Figure7.Reviewofthestoma–theperistomalskinshowedmuchimprovement.
Figure6:PhotocareplanforthepatientshowingStep3:checkingthepositionofthebag.
Figure4:PhotocareplanforthepatientshowingStep2:cleaningtheskinandthestoma.
WELLAND MEDICAL EVIDENCE OF INNOVATION
1New bag Wet cloth
2Rubbish
bag
3
1Remove Clean
2Apply
3
andthenthattherearethreestepstotake(Figures3–6):
Thisisdefinedastherebeingonlythreethingstocollectpriortochanging.
Aurum® 2urostomyflangeincombinationwithAurum® 2colostomypouch
AclinicalaccountbyNellekevandeVliert,NursingConsultant
PatientMale,75,colostomy
SourceNellekevandeVliert,NursingConsultant,WellandServiceTeam,WellandNederlands
ProblemPeristomalskincomplication
SolutionAurum®2urostomyflangeincombinationwithAurum®2colostomypouchandUltraFrame®flangeextender
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WELLAND MEDICAL EVIDENCE OF INNOVATION
Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.
CASE STUDY
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DIAGNOSIS AND TREATMENTTheWellandServiceTeam(WST)wasapproachedbyahospitalstomanurseforhelp.Theyhadapatientwithacolostomywhohadaseveremoist,redandirritatedperistomalcomplication.
Thehospitalnurseswereunabletodeterminethecauseofhisskinproblemandhadalreadyrecommendedatwopiecepouchingsystem,thisdidnotrelievetheskincomplicationandanAurum1piecewasgiventothepatient.Priortothis,thepatientusedmultiple1pieceflatflangecolostomypouchesfromseveralmanufacturers.
ToclearlyidentifytheproblemIvisitedthepatientathishomeaddress.
WhenImetthepatient,hewasonlyabletoleavethe1piecepouchinplaceforfourhoursastheflangestartedtoliftawayfromhisskin.
DuringthehomevisitIobservedthatthepatienthadmoistandredskinaroundhisstoma(Figure1).Inaddition,thepatienthadsomeproblemswithleakage,probablycausedbyhisverymoistskin.
Figure1.Patientbefore22-05-2019.
>>>
Thenextstepwastospeaktothepatientaboutwhatoneofthecausesoftheproblemcouldbe,namelythemoistskinwhichcausedmostoftheleakage.Idecidedtousea2piecesystemwithanAurum2urostomyflangeduetoitsabsorptioncapacity(Figure2).Iselectedatwopieceurostomyflangeasithasathickerflange,adeeperhydrocolloidbase.
Astheskinproducedsomuchmoisture,itwasdecidedtoinitiallychangethe2piecesystemdaily,wethen
extendedthepouchweartimeto48hoursduringthesecondweekandprogressedtoa72hourweartimefromthethreeweekperiodonwards.InthefirstweekUltraFrameflangeextenderwasusedtoensurethattheflangeremainedinplace.Theoutcomewasthattheurostomyflangeappearedtohaveabsorbedmostofthemoisturefromtheskinsurface.
Figure2.Aurum2urostomyflangeincombinationwithAurum2colostomypouch.
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HOME VISIT 06-06-2019Skinisstillredbutdry.Themoisturehasdisappeared.NoleakagehasoccurredsincetheuseofanAurum2urostomyflange(Figure4).ThepatientbrieflytriedanAurum1piececolostomypouch,butthisresultedinmoistandredskinagain.ThedecisionwasmadetopermanentlyuseanAurum2urostomyflangeincombinationwithanAurum2colostomypouchandthepatientisveryhappywiththissolution.
HOME VISIT 27-05-2019Situationafter5daysusinganAurum2urostomyflange.Skinisnotasmoistandtheleakageisresolved.WellandAurumwasspecificallychosentoenabletheskintohealandrecover(Figure3).
Figure3.Situationafter5daysusinganAurum2urostomyflange.
Figure4.Homevisit06-06-2019.
OUTCOME AND FOLLOW UPThepatientiscomfortablewiththeuseoftheAurum2pouchsystem.Aurumhashadapositivehealinginfluenceonthemoistandredskin(Figure5).Heisabletostarthishobbiesagain,suchasgardening.
Figure5.Homevisit23-08-2019.
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WELLAND MEDICAL EVIDENCE OF INNOVATION
DIAGNOSIS AND TREATMENTThegentleman,presentedtotheSanPietroHospitalinRome,Italyasanemergencypatient.Followingdiagnosisofapelvicabscess,thepatientunderwentemergencysurgeryresultingintheformationofaterminalcolostomyfollowingaHartmann’sprocedure.Thepatientcomplainedofitchingandburningacrosstheperistomalareaalongwithcontinuousdetachmentofthepreviousconvexpouch.
UponinitialassessmentbytheStomatherapistnurse,thestomawasassessedasflushtotheabdominalcontourwiththreeareasofperistomalulceration.ThesecanbeseeninFigure1.Itisassumedthatthesehavebeencausedbythepreviousstomaflange.
Thedecisiontochangethestomaflangetypefrom
flattoaconvexflangewastakenandtheperistomalareawascleanedandaprotectivepowderandpasteappliedpriortotheflangeapplication.
TheAurum2piecewasselectedasitprovidedasoftandflexibleconvexity,whilsttheManukahoneymayimprovetheperistomallesions.
TheperistomalskinintegrityimprovementcanbeseenfollowingtwoapplicationsoftheAurum2piececonvexpouch(Figure2).Thesameskinpreparationwasundertakenasdiscussedabove.
ThethreeulceratedareashavesignificantlyimprovedalongwiththegeneralperistomalskinareafollowingtheintroductionofManukahoneyintheflangeandthesoftconvexity.
PatientA75-year-oldgentleman,whoisdiabeticandhasaterminalendcolostomy
SourceLeilaFatemifar,StomaTherapistNurse,SanPietroHospital,Rome,Italy
ProblemItchingandburningacrosstheperistomalareaalongwithcontinuousdetachmentofthepreviousconvexpouch
SolutionAurum®2ConvexwithManukahoneycolostomypouch
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WELLAND MEDICAL EVIDENCE OF INNOVATION
Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.Printed with the kind permission of Teleflex.
23
ProvidingconvexityforapatientwithperistomalskincomplicationsusingAurum® 2piececonvex
AclinicalaccountbyLeilaFatemifar,StomaTherapistNurse
CASE STUDY
CONCLUSIONThedesiredoutcomewastoenablethestomaeffluenttodrainintothepouchfollowingtheinsertionofsoftpressurearoundthestomaviatheconvexflange,enablingthestomatoberaisedratherthancontinuingtorestsoclosetotheskin.
Figure1. Figure2.AftertwoweeksofusingAurum®2piececonvex.
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WELLAND MEDICAL EVIDENCE OF INNOVATION
25
PatientMrs.D,Female,38,ulceratedcolitis.Underwentanelectivetotalcolectomywithendileostomy
SourceKaty-MartinSkurr,StomalTherapyNurseSpecialist,Omnigon,NewZealand
ProblemUlceratedlesionscausedbypyodermagangrenosum(Pg)
SolutionAurum®ConvexwithManukahoneyIleostomypouchandHyperSeal®WasherswithManukahoney
Data held on file.The views and opinions expressed in this article are those of the source and do not necessarily reflect the views and opinions of Welland Medical.Printed with the kind permission of Omnigon.
TheuseofManukahoneyinthetreatmentofPyodermaGangrenosumrevisited
AclinicalaccountbyKatyMartin-Skurr,StomalTherapyNurseSpecialist
CASE STUDY
Thiscasestudyidentifieshow,asnurses,wearechallengedbyourpatientsinoureverydaypracticewhichtestouringenuityandresourcefulnessandhowweneedtoconstantlyrefreshourclinicalknowledgebank.IhopethatthroughthisclinicalreflectionwecancontinuetoshareclinicalpracticeandpatientoutcomesasWalls(2016)statedthisimprovesourpracticeandhelpstoaddtoourarmoury.
MoiraEvans,ClinicalMarketingManager,WellandMedical.
PRESENTATION AND HISTORYMrs.Dhashadsevereulcerativecolitiswhichwasdiagnosedin2012.Herbowelsmoveupto10timesadaypassingbloodandmucouswithassociatedurgency,incontinenceandcrampingabdominalpain.
Becauseherconditionhasbeenresistantandnon-responsivetomedicaltreatmentMrs.Dunderwentanelectivetotalcolectomywithendileostomy.Sherecoveredwellfromsurgery,discharginghomeafter4daysinhospital.
Mrs.Dmanagedherstomawellaftersurgerywithnoconcerns.Herstomawashealthy,32mmindiameterandwellspouted.
Shewasfollowedupinthecommunitybyboththelocaldistrictnursesandthestomaltherapynurse.
PARASTOMAL ABSCESS OR PYODERMA GANGRENOSUM?OnemonthfollowingsurgeryMrs.DwasseenintheDistrictNursingclinic.Shewastroubledbyaremainingsutureandhypergranulationtissueatthe6o’clockposition(Fig1).Thesuturewasremoved,andthegranulomawastreatedwithsilvernitrate.
Overthefollowingmonththeareabecameinflamedwithwhatlookedlikeasutureabscessappearing.Mrs.Dreportedslightdiscomfortfromthisarea.Theareaappearedtoresolveusingstomapowder.
AmonthlaterMrs.Dattendedsurgicalclinicwithwhatappearedtobeareformationoftheabscess.TheStomalTherapyNurse(STN)suggestedtheuseoftopicalbetadine.Aweeklater,withlittleimprovementMrs.DwasprescribedantibioticsbyherGP.Thisresultedinsomeslightimprovement.
Aweeklateranewareaofconcernat11o’clockwasalsonotedbytheSTNandaphotographwastakenandsenttohersurgeon.
>>>
Figure1.Firstappearanceofpainfulareaat6o’clockpositioninferiortostoma.
26 27
3monthspostherinitialsurgeryMrs.Dattendedclinic.Hersurgeonarrangedheradmissiontohospitalforincisionanddrainageoftheapparentparastomalabscess(2.5mmx0.8mm).Theareawasexcisedandopenedleavingalargerareaoftissuewhichwaspainfulduringpouchchanges(Fig2).AtthispointIbecameinvolvedinMrs.D’scare.IwassuspiciousthatasMrs.DhadulcerativecolitisanautoimmunediseasewewerelikelytobedealingwithPyodermagangrenosum(PG).
CONCLUSIONAnearlierdiagnosisofPGmayhavepreventedthesurgeryandMrs.D’sprolongedrecovery.WiththerepeatedsuccessfuluseofWellandManukahoneyproductsforthetreatmentandpreventionofPGreoccurrence,Iwouldnowconsiderandrecommendusingthisproductrangeasafirstlinechoiceinpatientswithautoimmunediseases.
Figure3.ConfirmeddiagnosisofPyodermagangrenosum.
Figure4.8weeksfromcommencementoftreatment.
Figure5.10weeksfromcommencementoftreatment.
PYODERMA GANGRENOSUM (PG)
PGisarareauto-inflammatorydisorderalsoknownasneutrophilicdermatosis.Itis
associatedwithotherautoimmunedisordersincludingthatofinflammatoryboweldiseases
suchasulcerativecolitisandCrohn'sdisease,rheumatoidarthritisandsomehaematological
conditions.PGmaystartasasmallpustule,redbumporbloodblisteroftenstartingsuddenlyafteraminor
injury.Theskinbreaksdownresultinginextremelypainfululcerswithraggededgesandundermining.Theremaybeabluishcolorationtothewound’sedges.Surgeryiscontraindicatedasittendstoextendtheareaandnotcontributetohealing.
DuetomyprevioussuccessusingtheWellandManukahoneyproductrangeforthetreatmentofPGIcommencedusingtheAurum®ConvexpouchwithWellandHyperSealwasherwithManukahoney.
IaccompaniedMrs.Daweeklatertohernextclinicappointment.ThesurgeonagreedwiththePGdiagnosisandaskedforanurgentDermatologyreview.TheDermatologistattendedclinicandconfirmedoursuspicions(Figure3).ApplicationofLocoid®cream,asteroid,wasrecommended.
WecontinuedtousetheWellandManukahoneyproductsasthePGhadshownsomeimprovementfromthepreviousweeks.
ThepouchwasmaintainingagoodsealhoweverMrs.Dpreferredherpreviousproduct.ToallowMrs.D’schoiceofproductwenegotiatedtocontinuetheuseofManukahoneyandthehealingofherPGbyusingalargeWellandHyperSeal®washerwithManukahoneyunderneaththeproductofherchoice.ThisallowedfullcoverageofthePGandsurroundingperistomalskin.
WiththeabovetreatmentsMrs.Dcontinuedtohaveamarkedimprovementinthepain,inflammationand
healingsothetreatmentplanwascontinued.Thehealingprocesstookapproximately3monthsfromPGdiagnosistocompleteresolution.
ThecurrenttreatmentinusetomaintainhealthyperistomalskinandpreventthereoccurrenceofPGisthesmallerWellandHyperSealwasherwithManukahoney(40mm)andintermittentuseofLocoid®creamwhenMrs.Dsuspectsaflareup(tingling/discomfortandslighterythema).
Figure2.Followingincisionofwhatwaspresumedtobeanabscess.
WELLAND MEDICAL EVIDENCE OF INNOVATION
WELLAND MEDICAL EVIDENCE OF INNOVATION
29
A GU
IDE TO
THE LIFECYCLE AND PROPERTIES OF MANUKA HONEY
Howandwhydoesmedical-grade
Manukahoneypromoteskin
health?What’sthestoryandthe
sciencebehindthisnaturalremedy,
usedforcenturiesinwoundcare.
28
16 ⁺UMFMEDICAL GRADE MANUKA HONEYisusedinAurum®ostomypouchesandaccessories.
30
WELLAND MEDICAL EVIDENCE OF INNOVATION
31
LIFECYCLE AND PROPERTIES OF MANUKA HONEY
THE PLANT
Leptospermum scoparium
isashruborsmalltreenativetoNewZealand,thatbloomsjust2-6weeksperyear.CommonlyknownastheManukaorteatreebush.TeatreearosebecauseCaptainCookusedtheleavestomakea‘tea’drink.1
THE NECTAR
Manuka Power of Three
TherearethreekeynaturalmarkersinManukaHoney(Methylgloxal,Leptosperin,andDihydroxyacetone),whicharetestedinregisteredlaboratoriesandtheresultsmeasurethe“Manuka-ness”ofthehoney.3
THE GRADE
Unique Manuka Factor (UMF)
Thisistheofficialstamponhoneythathasbeenscientificallytestedandgradedappropriately.ThehoneycompaniesthatusethisgoldstandardsgradingsystemareofficiallicenseesoftheUMFHoneyAssociation(UMFHA),whichhasstrictcriteriaandauditsitsmembers’packagingandmarketingmaterial.TestingforMGOlevelsisimportantastheycanvarygreatly–notallManukahoneyisequal!3
LeptosperinAnaturallyoccurringchemical
foundonlyinthenectarofManukaplants.Itstaysstable
overtime,whichmakestestingforLeptosperininhoneyagoodwayof
identifyingifitcontainsManuka,andifitisconcentratedenough
tobelabelledasManukahoney.
DHADihydroxyacetone
TheManukaflowernectarcontainsDHAwhichbeesconvert(thanks
toenzymesintheirsaliva)tomethylglyoxal(MGO).
MGOMethylglyoxal
AnaturallyoccurringcompoundwithantibacterialandantimicrobialpropertiesthatmakesManuka
honeysospecial.
THE PRODUCT
From Hive to Harvest
Beekeepersgatherthehoneyattheendofthesummerseason.ThisharvestedhoneyistestedbyTheNewZealandMinistryforPrimaryIndustries(MPI)standardsandcertifiedusingtheUMF-approvedgradingsystem.
32 33
WELLAND MEDICAL EVIDENCE OF INNOVATION
SKIN FRIENDLY PROPERTIES
SKIN HEALTH IN STOMA CARE
Anti-inflammatory
•Reducesoedema,whichreducespainfrompressureontissues
Provides a moist wound healing environment
•Hygroscopicthereforedrawsmoisturefromenvironmenttowound
•ClinicalevidencehasbeenpublishedtosupporttheantibacterialpropertiesofManukahoneytospeedupgrowthofnewtissuetohealwounds
Antimicrobial activity
•LowpH:Inhibitsbacterialgrowth
•Highsugarcontent:Reduceswateravailableforbacterialgrowth
•Methyglyoxal(MGO):non-enzymaticantibacterialcompounduniquetoManukahoneyandisreflectedthroughtheMGOcontent.Onewaytolookatthisisthat'traditional'honeyandManukahoneycanbothexhibitantibacterialproperties,butManukahoneyhasauniqueadditionalcomponent(MGO)whichreliesonnon-hydrogenperoxideactivity
•Highviscosity:Formsprotectivebarrieragainstbacteria
The importance of skin health in stoma care
•Thewasteoutputfromthestomacandisruptthenormalskinbarrierfunction
•TheskinpHisusuallybetween4.1-5.8,butthewastematterfromthestomaisalkalinewhichdisruptsthisbalanceandcancauseirritation,breakdownandinfectionoftheskin
•Somestudiesreportupto75percentofpeoplewithanostomyexperienceaperistomalskincondition* withManuka Honey
MANUKA HONEY
Acidic Alkaline
SkinpH
Neutral
THE PH SCALE
34
WELLAND MEDICAL EVIDENCE OF INNOVATION
35
'Manuka' MeaningMaoriaretheindigenouspeopleofAotearoaNewZealandandhaveaculturalconnectiontoitstaonga(treasure)Manuka.Maoriaretangatawhenua(peopleoftheland)whoareresponsibleforprotectingourtaongaforcurrentandfuturegenerations.
“Manukahasawhakapapa(genealogy)fromaMaoriworldview.TaneMahuta–thegodoftheforests–wasresponsibleforseparatinghisparentsRanginui(skyfather)andPapatuanuku(earthmother).Aftertheseparation,PapatuanukuwasnakedandvulnerablesoTaneMahutacoveredherintrees.TaneMahutamarriedTawake-toroandtheyhadManuka.Therefore,fromaMaoriperspective,Manukaisnotjustanameonalabelbuthasawhakapapa.ThisisourMaoristoryandonlywecantellthis.”
The story of Manuka“Ranginui(skyfather)andPapatūanuku(earthmother)werelockedinaneternalembrace.Theirchildrenbecamefrustratedwiththecrampedconditionsanddecidedtoseparatetheirparents–TaneMahuta(godoftheforests)layonhisbackandforcedhisparentsapart.HeadornedRanginuiwiththesun,moonandthestars.Healsocloakedhismotherwithtrees.TaneMahutahadaunionwithTawake-torowhichgaverisetoManuka.TaneMahutaalsointroducedallournativetreespecies,ournativebirdsandinsects.TaneMahutaalsobreathedlifeintothefirstfemalegivingrisetohumankind.”
Victor Goldsmith, Ngati Porou Miere Limited Partnership Managing Director
MAORI
MANUKA STORY
TaneMahuta=
Tawake-toro
Manuka
36
COLOSTOMY UK RUGBY MATCH ULTRAFRAME® INTERVIEW
So, you are now wearing UltraFrame, how do you feel?
Oliver: Yeah,Icanfeelitextendsthenaturalpartofthepouch
Kav: Ialwaysfeellikethenaturalpartofthebagyouhaveisn’tquitebigenough.So,anythingtosupportroundtheedgeshelps.
Chris: Andtheyfeelinvisibleandyoucan’tfeelit.
Oliver: Andthebestthingis,youjustforgetaboutit.Whichiswhatyouwant.
Have you worn them before, during physical activity?
All three:Ihave,yeah.
Chris: Tothegym.Theybendandmovewithallyourmovementsandreallywellshaped.
Kav: Youdon’treallyfeellikeyou’vegotanythingon.
How easy were they to apply?
Oliver: Prettysimple.Followthenumbers.Aslongasyoucancountto4,you’llbealright!
What does it mean to you to represent Team Colostomy UK?
Kav: Itmeansanawfullot.It’sgoodtoshowwhatispossible.Especiallythistimeround,withthepublicity,thisonehasbeenimmense.
Chris: ThereasonIwantedtoplayisjusttoshoweverybodywhohasastomayoucandoallthethingsyoudidbefore.
Oliver: Ididn’tevenplayRugbybeforeIhadastoma.So,I’veonlyjuststartedplayingsinceI’vehadit.Formeitsbeengreattostartanewsportandmeetlotsofpeoplewhoareinasimilarsituation.
How did you find the game today?
All three:Great,reallygood.
Did your stoma bag remain secure throughout the match?
Chris: Absolutelynoworries.Noproblemsatall.
How does UltraFrame compare to other flange extenders?
Kav: It’salotthinnerthanalltheothers.Evenineverydayactivities,youdon’tfeelit.Itmouldstoyourbody.It’sgreat.
Oliver: Youdon’tnoticeit.Youwantittobeasstrongaspossible,butnotactuallynoticeit’sthere.
Does it give you the confidence to play without holding back?
Chris: You’veseenthefilm.Idon’tthinkanyonewasholdingbackatall!
What was the best part about playing for team Colostomy UK today?
Oliver: Ithinkprobablyawareness.Youcanseehowmanypeopleareheretodayandthedifferencethatcanmake.Peoplejustknowingaboutwhatitisliketohaveastomaandit’snotabarriertodoingwhatyouwanttodo.
Chris: IfyouaskedoneoftheChorleyplayerswhoinourteamhadastoma,theyprobablywouldn’tbeabletotellyou.(Allthreeshowtheirstomabags).
Chris: andI’vegottwo!
WELLAND MEDICAL EVIDENCE OF INNOVATION
37
ManythankstoOliver,ChrisandKavforsharingtheirthoughtsonUltraFrame®.
TheviewsandopinionsexpressedbythefeaturedusersonUltraFramearetheirownanddonotnecessarilyreflectthoseofWellandMedicalPID7379
WELLAND MEDICAL EVIDENCE OF INNOVATION
REFERENCES
393938
Page 4-5
1.https://www.england.nhs.uk/year-of-the-nurse-and-midwife-2020/accessed19.02.2020
2.https://www.azquotes.com/quote/614045
3.ClinicalgovernanceforostomatesatriskofperistomalskincomplicationsWhiteP,EvansM(2019)BritishJournalofNursing,2019,Vol28,No16
4.https://everydaypower.com/florence-nightingale-quotes/accessed13.5.19
Page 6-7
1.Cairns,B.A.,Herbst,C.A.,Sartor,B.R.,Briggaman,R.A.andKoruda,M.J.,1994.Peristomalpyodermagangrenosumandinflammatoryboweldisease.ArchivesofSurgery,129(7),pp.769-772.
2.BrooklynT,DunnillGandProbertC.Diagnosisandtreatmentofpyodermagangrenosum.BMJ2006;333:181–84.
3.Wallace,A.,2017.Bestpracticemanagementofperistomalpyodermagangrenosum.JournalofCommunityNursing,31(1),pp.24-32.
4.HeffernanMP,MilanJA,SmithDI(2007)Adalimumabtreatmentforpyodermagangrenosum.ArchDermatol143(3):306–8
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1.ShinJH,HyangSS,KimEA.Influenceofpost-traumaticstressdisordersonqualityoflifeamongpatientswithostomy:focusedonthemediatingeffectofresilience.KoreanJournalofAdultNursing2017Dec;29(6):657–666.
2.EvansM.TheuseofManukaHoneywithinstomacaretomaintainperistomalskinintegrity:theostomatesperspective.WCETJournal2018;38(2):40–40.
3.SimmonsKL,SmithJA,BobbK-A,LilesLL.Adjustmenttocolostomy:stomaacceptance,stomacareself–efficacyandinterpersonalrelationships.JAN;LeadingGlobalResearch2007;60(6):627–635.
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1.WorldHealthOrganization[Internet].Mentalhealthofolderadults;2017[cited2018Oct].Availablefrom:http://www.who.int/en/news-room/fact-sheets/detail/mental-health-of-older-adults
2.AustralianBureauofStatistics[Internet].Australiandemographicstatistics;2018[cited2019Mar].Availablefrom:https://www.abs.gov.au/
3.GoldsteinS.Thebiologyofaging.NewEnglandJournalofMedicine1971;285:1120–1129.
4.AustralianBureauofStatistics[Internet].MigrationAustralia2016–2017;2018[cited2019Mar].Availablefrom:https://www.abs.gov.au/ausstats/
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1.Lyon,C.Etal(2000)ParastomalPyodermaGangrenosum:Clinicalfeaturesandmanagement.JanAcadDermJun42(6)992-1002
2.Cullen,J.PyodermaGangrenosumandRelatedDisorders.BMJ2006;333:181
3.Simon,A.etal.MedicalHoneyforWoundCare-StilltheLatestResort?AdvancedAccessPublication7Jan2008
4.Mandel,M.&Mandal,S.Honey:itsMedicinalPropertyandAntibacterialActivity.AsianPacificJournalofTopicalBiomedicine2011(1)2:154-160
5.Dunford,C.etal.(2000)UsingHoneyasaDressingforInfectedSkinLesions.NursingTimes96(14)7-9
6.WallsP,(2016)Faecalfistulae:fromdespairtohopeusingstomaltherapy'tricksofthetrade'JournalofStomalTherapyAustralia–Volume36Number3September2016
Pages 30-31
SourceJ.T.Salmon,TheNativeTreesofNewZealand,Reed,1973
Source:https://www.botany.one/2018/04/what-is-it-that-gives-Manuka-floral-nectar-its-unique-composition/
https://www.hollandandbarrett.com/the-health-hub/food-drink/food/Manuka-honey/Manuka-honey-facts/
Source:www.kanoaManuka.com/leptosperin
Source:haddrells.co.nz/pages/umf
Source:https://www.umf.org.nz/manuka-honey/
www.temarareo.org/TMR-Manuka.html
Page 32-33
Source:Presentation'AurumasaFirstLineDefenceinMaintainingPeristomalSkinHealth'byArashMoavenian.PID5945
Mandal,M.&Madel,S.(2011)Honey:itsmedicinalpropertyandanti-bacterialactivity.AsianPacificJournalofTropicalBiomedicine.1(2)154-160.
RappCG,LRichbourg,JMThorne.DifficultiesExperiencedbytheOstomateAfterHospitalDischarge.JWOCN.2007;34(1):70-79.
Page 34-35
Source:https://www.umf.org.nz/manuka-honey/
PID9214•07-2020•Volume3
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