1. 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.

2. 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

3. 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.

4. 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

5. 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

6. 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