Nightmare on Ostomy Street Becky Washburn BSN, RN, CWON Roxy Hampton BSN, RN, CWOCN Legacy Emanuel Medical Center Portland, OR *Details within this case study presentation are provided with patient’s written consent and for education purposes only.

Description of the Problem Very high output ileostomy since stoma creation Stoma is located at the base of a deep skin fold Abdomen is very soft Multiple barriers to stoma care 8/31/2018: Stoma view when at high Fowler’s position -Very high output ileostomy since stoma creation (more than 3 L of thin, liquid output with identifiable food particles). -Multiple barriers to stoma care: -Patient cannot do ostomy care due to poor manual dexterity, and inability to visualize stoma. -Challenge with training staff on how to do stoma care and drainage collection device maintenance. 7/15/2018: Stoma view in supine position after readmission from SNF due to peristomal rash and dehydration

Patient History “SL” is a 73 y.o. Female Surgical History: Medical History: Type 2 DM (insulin dependent) CHF PAD Multiple SBOs GI inflammation with PUD Gastroparesis Surgical History: Right BKA Cholecystectomy Colectomy and ileal resection in from anastomotic stricture due to cecal volvulus: 2017 Aorta-SMA bypass and small bowel resection and ileostomy creation in, and had primary closure in the same month: February 2018 Complications have included septic shock, PNA, candidemia, GI bleeding from AVM, high-output ileostomy and malnutrition requiring long term TPN, PICC related DVT s/p IVC filter April 2018.

Dietary Modification/Supplements Interventions Medical Antimotility agents TPN Octreotide Fiber supplements Dietary Modification/Supplements High fiber diet NPO Fluid restriction Post gastrectomy diet Puree diet Tube feeds Pouching Systems Flat 1 piece and 2 piece high output pouches Convex 1 piece and 2 piece pouches Wound manager pouches Ostomy Accessories Moldable barrier rings Convex round and oval barrier rings Stoma paste, powder, skin barrier spray Ostomy belt Bedside collection bag Respiratory vent tubing taped to end of pouch 24 hour urine specimen container connected to vent tubing Medical: IV fluids, electrolyte replacements Blood products for GI bleed Dietary Modifications: Banana flakes to tube feeds Different tube feed formulations Food texture and consistency modifications Has been NPO multiple times to decrease stoma output and limit electrolyte imbalance and dehydration. Fluid restrictions to decrease stoma output -------------------------------------------------------------- Convex 1 piece and 2 piece Soft and deep convexity Light convexity Firm convexity 2 sizes of wound manager system connected to low intermittent and continuous suction

Management of Ileostomy Complication with pouching system: Peristomal pressure injury at 12 o’clock of stoma due to rigid wafer FOR COMPLICATION PHOTO: Applied thin hydrocolloid dressing for moist wound healing and padding the plastic edge with foam. Pt is wearing a stoma belt. 24 hour collection container is graduated for tracking intake and output. Tubing and collection container is replaced with each pouching system change. View of pouching system and stoma with patient sitting at Semi-Fowler’s position Pouch-tubing junction sealed with barrier seal and high adhesive tape Vent tubing connected to 24 hour collection container, sealed with barrier ring to minimize odor

Latest photo of stoma and peristomal skin Patient Outcome Pouching system being changed Mondays and Thursdays for 7 weeks Nursing staff and patient assure that tubing is patent and that gas can vent out of pouch and effluent is not filling pouch -Continues to be on TPN, general diet for recreation. -Stoma continues to be high output (1.5-3L /24 hours)with thin liquid effluent with food particles, though output amount varies widely depending on the day. -Pouching system being changed exclusively by WOC RNs due to complex pouching system needs and need for continuum of care. Nursing staff and patient ensures that vent tubing is patent and that gas can vent out of pouching system. Latest photo of stoma and peristomal skin