High-output Stomas: Education is Your Best Back-up

Karen Farid, RN, CWON, DNPEurop

In past blogs I have provided a multitude of strategies to help wound ostomy continence (WOC) nurses oversee care for inpatients and outpatients with high-output stomas. None of us work 24/7 and none of us is the ongoing primary caregiver across all settings (acute, rehab/long-term care, home care, palliative, and hospice) where ostomy care is needed. That responsibility falls on the family/significant others, who need WOC nurses to educate and instruct them.

So, WOC nurses, here goes:

Research the patient’s chart for relevant medical history (reason for and type of surgery, nutrition plan, and the probable duration of the stoma [most being permanent]) and determine the best method for effluent collection and the most appropriate appliance.

Always try to include the patient’s assigned nurse during your visits. This way, everything you say to the patient/family will help educate the nurse.

Speak to the Nurse Manager of the unit and as many of the assistants as possible. Once the Nurse Manager understands the scope of the physical care and the challenges of managing the high-output stoma, she will probably want to set up an equipment demonstration at the bedside. Once you have demonstrated the whole process, you can then provide support in the form of answering the patient/nurses/family’s questions and helping keep supplies on hand.

Case in point. About 3 years ago, I was called by the Nurse Manager on one of the units at our community hospital to help care for a patient who had terminal cancer and arrived on her unit following post emergency surgery for a rupture of his small bowel 3 months after a previous small bowel resection and anastomosis for blockage by a tumor. All the surgeons could do was divert the proximal length of the small bowel by suturing the end to the skin. The entire length of the small bowel from stomach to stoma was only about 3 feet. Once the patient was given permission to eat, everything ingested exited through the stoma within about 20 minutes. The effluent contained all the food and drink plus digestive fluids excreted into the bowel by the gallbladder, pancreas, and intestines. The patient was losing an enormous amount of fluids that were being replaced as much as possible intravenously. The patient was on a regular diet which caused chunks of undigested food to be part of the drainage. He stayed an inpatient at the hospital until he died 4 months later.

He needed a very large wound collector and very wide, corrugated respiratory tubing (the kind used for tracheostomy humidification collars and continuous positive airway pressure machines) to be attached to the appliance/collector, the large spout on the suction canister, and the machine (gastric suction at 50-80 mm Hg). However, the end of the wound collector was too narrow to insert the end of the wide tubing into the collector. Another stoma bag needed to be placed onto the front of the collector close to the side facing the suction machine with a hole cut in the faceplate and the wound collector bag where it was attached so the corrugated tubing could be passed up into the collector. Despite this Rube Goldberg innovation, within a week the nurses were doing all the care of the stoma, including successfully maintaining the intact appliance for several days at a time! The only thing I did was help teach the family what and why we were doing with this setup and keep up the supply of the customized appliances and canisters from central supply so the nurses would have one less concern. I made it my responsibility to inform the central supply manager that we were going to need several large suction canisters a day for this patient. Because the suction canisters in the hospital were disposable as per policy, the manager increased his par levels in the central supply. Before leaving at the end of each day or for the weekend, I premade several appliances and stocked them in the patient’s closet along with the necessary number of canisters.

Why do I go through such lengths to put the stoma drainage to suction? Continuous large amounts of stoma or fistula drainage need to be regularly emptied or else the bag/collector will leak, requiring constant changing. If stoma/collector appliances are changed daily or more often, the patient’s skin suffers “stripping” (top layers of the skin are stripped away) in addition to chemical skin burn caused by the corrosive drainage. Once the skin is damaged, appliance adhesives do not work anymore, causing the appliance to not adhere and creating a vicious cycle. Not only does the suction keep the appliance empty, but it also pushes the appliance adhesive firmly against the skin.

Another point about the part of the suction tubing that is inserted into the appliance: take the time to cut several holes about a half inch in diameter along this length. This way, if one hole gets blocked with food, there are several other holes removing the drainage. This precaution ensures that the appliance will stay empty and the suction will help to hold the appliance against the skin.

            Before I do anything, I obtain the physician’s order to “attach stoma appliance to suction to keep appliance intact and measure intestinal output.” Clearly, most physicians have never heard of this before; then again, most physicians never do stoma care. However, when told that the amount of drainage is enormous and that suction is the only way to adequately collect and measure it, every physician I have ever approached regarding this type of management has written the orders for me. Having a written order may not seem necessary to most WOC nurses, but there are definite advantages:

            1) The general nursing staff are generally more comfortable having an order, and this also discourages individual nurses from trying other ideas that are not effective in managing the drainage.

            2) A physician’s order keeps various medical/surgical practitioners engaged in the overall patient management.

            3) Having the ability to determine exact output justifies the doses of loperamide that are frequently necessary to ensure some absorption from the gut to augment the intravenous fluids in keeping the blood volume adequate to produce urine (and prevent renal shutdown). Acid-reducing preparations (famotidine, ranitidine, omeprazole) available over-the-counter also can help conserve bodily fluids. These medications reduce gastric acid in stomach contents before they enter the duodenum, which reduces the stimulation that causes the pancreas to release bicarbonate-containing fluids into the gut to neutralize the acid.

 

Care at home

I frequently have to help with the management of high-output stomas in the patient’s home. The caregiver in the home has be in charge of changing the appliance (as usually the patient cannot do this independently due to constant bursts of drainage) and ordering supplies and/or notifying the covering home care agency when to reorder supplies (canisters and appliances). The WOC nurse has to demonstrate how to set everything up before the appliance change (barrier powder, skin barrier prep, precut appliance with paper peeled off the adhesive, an empty canister [best to use reusable canisters in the home care venue] with tubing attached to suction). Everything should be in place before removing the used appliance.

The procedure is as follows:

  1. After the nurse demonstrates the appliance change of the appliance, the suction tube is inserted into the end of the appliance, the suction turned on, and the end of the appliance secured around the tubing by tying it with a length of nonsterile glove (I like to cut the glove in half lengthwise so it is easier to tie — gloves are always on hand).
  2. Tape the tubing to the patient’s thigh or wrap it with a rubberband and pin to pant leg. The tubing must always be taped or pinned, or the tubing will twist the appliance and/or pull on the appliance.

Note: the WOC nurse will most likely have to have the caregiver give several return demonstrations before the caregiver can take over the procedure.

Patient issues. The patient plays a large role in complying to the management program. Frequently, the family fails to comply with parts of the program because the patient complains of not wanting it. For example, a common problem is that the patient does not like attaching the appliance to any kind of tubing. I frequently have this issue with patients with urostomies who don’t like to connect the appliance to the bedside drainage bag. The patient thinks emptying the bag a couple of times during the night is sufficient. Urine is a much greater challenge to the appliance adhesive than fecal drainage, and most people have more diuresis during the night than during the day. In addition, there is no feeling in stomas to signal excretion. At least half of my patients complaining that the urostomy bag leaks is because they do not attach to night drainage. In the same way, many of my patients with high output stomas do not like to use the suction to keep the appliance empty.

Another problem with patient interference with the management program is “fussing” with the appliance and constantly flipping it back and forth to see if it is leaking. This is especially problematic when the appliance is attached to suction. Moving the appliance causes tension on the suction tubing.

A third problem is the family members preference to extend their dependency on the professional caregiver—in this case, the WOC nurse. They go through the motions of watching and nodding and thanking the WOC nurse when he/she demonstrates what needs to be done, then call her again when the appliance leaks. In the same way, lay caregivers do not monitor the suction canister to make sure it is emptied in a timely manner and end up calling the WOC nurse to fix the suction when it doesn’t seem to be working. It is not uncommon for the WOC nurse to respond to a call, only to find an appliance/suction disaster area and have to clean and correct everything. The best way to handle this situation is to print out simply and exactly what needs to be done and how often. I do one set of “rules” (I call them) for the suction and one for the appliance change (see Figures 1 and 2). Then, each involved family member does a return demonstration (as many as necessary) until they get it right. Have them refer to the written “rules” (I say, “look at the rules…”) instead of asking me for the answer.

SUCTIONRULES_Page_1SUCTIONRULES_Page_2ApplianceChangeRules_Page_1ApplianceChangeRules_Page_2

Maintaining realistic expectations. Readers can readily see how the role of the WOC nurse reverts back and forth between the doer and the facilitator. In the facility, he/she must be realistic regarding the weak points in the program (eg, readily available supplies or the educational needs of the nursing staff). It is wise to give regular feedback to the unit Nurse Manager and be ready to teach staff members on evenings and nights. In the case of the patient described above, the assistant managers on evenings and nights were excellent regarding their follow-through with the staff on their shifts. The WOC nurse is wise to choose the correct equipment and products (eg, if the patient is on a regular diet [as opposed to liquid shakes], choose the large respiratory tubing). Cautioning the patient to chew all the food until there are no lumps never works; nursing staff cannot be expected to spend precious time unclogging the suction tubing. For care at home, the more comfortable the caregiver is with the tasks involved, the less the WOC nurse will have to play rescue. Education in all settings is the key to success.