14. Management of Patient with Ileostomy - Primary Education and Management

This class we're going to begin our discussion of Iliostomy patient management. We're going to focus on primary education, and a later class we'll discuss complication prevention. So, here we're going to talk about the normal function, normal output from an Iliostomy, what to expect, what's normal, and what is critical basic education for the patient with an Iliostomy. So, let's talk about normal function. Now, when you have a patient with an Iliostomy, you have either removed the colon and rectum or bypassed the colon and rectum, and remember that the colon is responsible for converting liquid stool to solid stool. So, there's going to be a major impact in terms of output and function. So, the first thing you'll notice is that an Iliost resolves pretty quickly with an Iliostomy. It turns out that the small bowel regains function first. So, typically, the order in which parasitotic activity is regained, first you get function back in the small bowel, typically then the colon, and the stomach typically parallels our parallels the colon. So, that means that the Iliostomy patient usually has output within 24 to 48 hours. Many of our patients are asked to chew gum postoperatively because when you chew gum, it simulates eating. It makes the body think you're eating and eating triggers peristosis in the small bowel. So, a lot of your patients will be on a gum chewing protocol, and the purpose of that protocol is to stimulate early return of parasitotic function, rapid resolution of Iliost. Now, initial output is typically low volume viscous, it's very mucoid, it's kind of dark green, it looks almost billious, but with a mucoid consistency. And then most patients go through a high output adaptation phase that takes typically several weeks to resolve. So, what's going on here? Well, remember, the colon is gone, and it takes several weeks for the small bowel to recognize that, hey, Charlie, the colon hasn't shown up for work in days. Maybe I better start doing part of his workload. So, over the first few weeks postoperatively, the body begins to realize that the colon is gone or bypassed, and the small bowel begins to compensate for that loss by increasing fluid absorption within the small bowel, but that takes several weeks. And during that initial adaptation phase is very common to have output volumes that range from one to two liters. Now, obviously, if you're losing two liters a day, as opposed to the 200 milliliters a day that you typically excrete through the colon, that is going to have a major impact on fluid and electrolyte balance. So, during this adaptation phase is critical for us to monitor output, is critical for us to assure adequate replacement of loss fluid. So, in addition to assuring that adults get the two liters of fluid they need at baseline, just for normal hydration needs, now we need to be sure that the patient is getting another one to one and a half liters of fluid to replace the amount that's being lost to the iliostomy, in the hospital, really not a problem because patients are receiving IV fluids, and it's very common to see in order to replace iliostomy output at the rate of one millilitre of IV fluids for every two milliliters of iliostomy output. So, if you had one liter of output on my shift, then I'm going to alert the next shift to replace 500 in addition to your baseline fluid intake. So, in the hospital, pretty easy for us to keep patients on track in terms of fluid and electrolyte balance, but that means that before that patient goes home, we need to assure that the volume of output has diminished to a level where that patient can keep up with oral intake, or we need to make sure that the patient is being followed by home health and that we send the patient home with a pick line if necessary so that the home health agency can provide IV fluid replacement when needed. Now long term, most individuals put out between 500 and 1100 milliliters a day. 1200 milliliters is considered by most clinicians to be the upper limits of normal, and most clinicians will tell patients if you're putting out more than 1200 milliliters a day, you need to let us know because we have to make sure we're providing adequate fluid replacement. So, to summarize, most patients go through high output adaptation phase where they're draining up to are more than two liters a day, typically that resolves within three to four weeks until output comes down to between 500 and 1100 a day, we've got a sure adequate fluid replacement either through oral intake or through a combination of oral and IV intake. Now, moving on to self care, pouch selection, patients with Iliostomies are going to be emptying their pouch multiple times a day, they will need a drainable pouch. Closed-in pouches are not typically used for Iliostomy patient management. Typically the only time we would recommend a closed-in pouch is if we had a patient who has some kind of limitation that meant they could not empty a pouch, maybe they're doing Iliostomy care one-handed, and in that case they would have to have a two-piece system so that they could snap one pouch off, snap another one on, because it would never be appropriate to remove a pouch multiple times a day you would get into skin damage. Now, one thing we should be thinking about is what about a high output pouch? So a high output pouch has higher volume capacity, and also is much easier to empty because of the spout, furthermore you can connect a high output pouch to a bedside drainage bag, which makes management much easier for a patient who's having high volume liquid drainage. So to put all that together if a patient's in the adaptation phase with very high volume output we should be thinking about a high output pouch routinely. Once output comes down to 500 to 1,100 a day we should have that patient in a drainable pouch, unless there is some extenuating circumstance that mandate shoes of a closed-in pouch. Pouch emptying, again when the pouch is one-third to one-half full, typically patients will empty at least four times a day. In general, when patients empty the pouch, they're emptying about 200 to 240 milliliters. So if you think okay, average output is somewhere between 500 and a liter, then they're going to be emptying three to four times a day. What about pouch and room deodorants? Well, early-ostomy patients have variable degrees of odor, there are some who do not feel the need for use of deodorants, but the vast majority do prefer to use deodorants. One reason may be that early-ostomy patients are going to have to empty their pouch in the the work setting, you're going to have to empty their pouch and social settings. because of the volume of output and the frequency with which they have to empty. They're going to be very sensitive to odor in settings other than home. So we definitely want to talk to them about odor management and the option to use pouch deodorants as well as room deodorants. What about pouch change procedure? Well, they're going to use standard approach to pouch removal, pushpull, use of adhesive releaseer. They're going to learn to clean their skin just with warm water in a soft cloth. They're going to learn to measure their stoma and cut the pouch or the barrier wafer out to match stoma size. So one thing that is different with an iliostomy patient, remember they have high volume liquid in somatic output. So we routinely recommend use of a barrier ring or barrier paste right around the cut edge of the barrier or right around the stoma to caulk to prevent undermining to provide better wear time. We have to teach the patient that the output from their iliostomy is highly enzymatic. We tell them it contains a lot of chemicals that the body uses to digest your food. Those chemicals can be very, very damaging to your skin. So it's critically important that we protect all of your skin from any contact with the output. We don't want anything touching your skin. Otter control is we've said even though the patient with an iliostomy typically has less odor than the patient with a colostomy, many times they're more sensitive because these are young individuals. They're going back to work. They're resuming social activities. They're resuming sexual activity. Otter control is of concern. So we want to again enforce the importance of cleaning the spout thoroughly. We want to explain that the pouch is waterproof. The pore size and the pouch material is smaller than the fecal odor molecule. So as long as their pouch is intact, as long as the spout is clean and closed, they will have no odor. Once again, we discourage rinsing of the pouch. If not necessary, takes more time, makes the emptying procedure a lot more complex and increases the risk of undermining and loss of seal. We have talked about pouch deodorants in the past. Again, you want to provide iliostomy patients with the same information. There are commercial deodorants available from the ostomy suppliers. They reduce odor when the pouch is emptied. You add the deodorant when the pouch is initially applied. You re-add deodorant every time you empty. Puberty can be used in the toilet to reduce odor. Oral breathments can be used. A lot of people use those. And you're going to want some kind of room spray before you empty. Oral products are used probably more by iliostomy patients than by colostomy patients. So in our previous discussion, we mentioned Daraphill chlorophyll and copper complex. 100 milligrams, once or twice a day, contraindicated for children under 12. Less commonly used by people with iliostomy because it tends to make the stool more liquid and they already have liquid stool. So iliostomy patients are much more likely to use business subgalate, which is devrom or devco. One to two tablets, chewed three to four times a day. Very effective in minimizing odor, also thickens the stool, reduces gas, changes stool color to kind of a dark green black. There are contraindications, children, renal failure unless their own dialysis because business subgalate is cleared by the kidneys. We have to be aware that it could interfere with absorption of anti-coagulants and antibiotics. But what patients will tell you and what you will find is once the patient's been on this for three to four days, the intensity of the odor goes way, way down. I've had patients who are much more concerned when they ran out of business subgalate than they were when they ran out of their anti-coagulant or their anti-hypertensive or their cardiac meds because it made such a difference to quality of life. So be aware of that. Share that information with your patients. It's not a prescription it's over the counter. Gas control. Gas control is a major concern for most people with an iliostomy, actually for almost anyone with a fecal diversion. Now most people with an iliostomy have less gas than patients with colostomies because they have lower bacterial counts. But that doesn't mean they're not worried about gas. Remember these people are in their teens, 20s, 30s most of the time? Are they going to be worried about gas? Yes. So we want to provide them with all of the critical information. We want to explain to them that high volume gas is common during the early post-op period because the bowel prep cleared all the stool out of the bowel. Surgery added air to the bowel and we have to get all that air out. Post-operatively gas is extremely noisy because you have a mix of air and liquid and it's very much like air in your pipes. So if you've ever gotten air in your pipes you know you turn on the tap and it's like oh my goodness. That's what it's like early post-op especially for someone with an iliostomy because of that mixture of gas and liquid. But once we clear the bowel out we get all that gas out and now it's full of mushy stool. The volume of gas goes way down. So we just want to reassure them this is a short-term problem. Then they're going to want to say they're going to ask do you well am I going to have gas after this? Yes. Everyone has gas. How am I going to manage that? Well I'm going to encourage you to keep a chart where you write down what you eat and drink. You write down how much gas you have whether you have diarrhea or your stool is pretty thick and mushy. I want you to figure out which foods cause you more gas. And I want you to also pay attention to what we call lag time. After you eat that food how long does it take before you have gas? You need to know that then you can pick and choose when to eat those foods. Most people will tell you I'm very careful with what I eat at lunch because during the evening I'm usually around other people and I don't want to have a lot of gas. But if it's the weekend and I'm hanging out with my family then I'm going to kind of eat what I want to and just turn up the volume on the TV. You want to make sure that you teach the muffling technique to your patient with an iliostomy. Every one of them we're going to find themselves in situations where they have gas. They can feel it rumbling around. They need to know how to muffle. Arm or hand over the stomach. They want their canned disclaimers so they know how to manage an embarrassing situation. If you know what you're going to do you know what you're going to say is much less stressful than if you're worried all the time and you don't know what you're going to do if that happens. Can they use bino as aimethicone? Yes, just like we say with a colostomy patient. It is fine to take bino with gas forming vegetables to reduce gas formation at the outset. Also siimethicone can help because it breaks up gas bubbles into little bitty bubbles that are reabsorbed into the bowel. We talked about flatus filters in vents so I'm hoping Can you remember the difference? a filter in a vent. A filter gradually releases gas from the pouch but forces it through charcoal so that it is filtered before it's vented. So it's deodorized before it's released into the environment. So most of your fecal pouches do come with latest filters. Now, latest filters are a work in progress. You'll have issues. Patients will tell you that filter works really well for a couple of days and then it pretty much stops working and my pouch poofs up. Yes, that's a common problem. Again, companies are working to improve the effectiveness of latest filters. What about vents? Vents provide rapid release of gas. They rapidly decompress a pouch. Vents are add-on structures so you apply it. You poke holes in the pouch. You apply the vent and then if your pouch fills with gas you just open the vent and it lets all the gas out but it lets all the odor out too so you have to be in a safe place to do that. And finally, remember that if this patient is wearing a 2-piece system they had the option to burp the pouch, to walk away from other people, left the pouch away from the wafer, allow the gas out. What about diet? That's a huge concern. Remember that a lot of these people are very young so can I eat normally? Can I go out with my friends? Can I eat what my friends are eating? And basically the answer is yes. But there are restrictions for the first six to eight weeks post-operatively and these restrictions should be maintained until the swelling is resolved. Till all the stomula dima goes away. Now how do you know that all the stomula dima has resolved? You know that because you have the patient measuring the stomula at each pouch change. Once the stomula remains the same size for two weeks you can be pretty confident that all the swelling in the bowel wall has resolved. Now why do Ileostomy patients have these restrictions when colostomy patients do not? Remember the difference in the diameter of the wall of the small intestine compared to the large intestine the colon. So the Ileum is typically one inch in diameter that's not very big. The colon is two to two and a half inches in diameter more than twice the size. You start out you have a one inch lumen then you think about the fact that immediately post-operatively you have a dima that further narrows the lumen. When you have a narrow channel if the patient eats a large amount of insoluble fiber it could create a blockage. It could form a bolus of undigested food that could get stuck just proximal to the stomach at the point where they turn the bowel to bring the bowel through the fascia muscle layer. When they bring the bowel through the fascia muscle layer it's very common to get a little bit of narrowing right at that point and you can actually see that in the illustration on the bottom. So you start out you have narrow lumen to begin with. You have post-operative edema further reducing the lumen of the bowel and then you have that little area of additional narrowing where they turn the bowel to bring it through the fascia muscle layer. So this patient has to be careful they do not want to end up with a blockage. And here are their guidelines for preventing a blockage. First of all we give them a list of foods high in insoluble fiber and we tell them don't eat these foods for the first six to eight weeks. Don't eat these foods until the stoma size remains the same for two weeks. At that point the edema has resolved and you're pretty much at maximum lumen. Once you get to that point you can start adding foods that are high in insoluble fiber but you want to add them one at a time in smaller amounts and you want them to chew well. So if I've been craving these foods I shouldn't eat them all at once. I shouldn't go to a cookout and say oh coleslaw man have I missed coleslaw yeah I'll have a big serving of that and baked bean juice yes yes absolutely give me that and is that are those marinated mushrooms I love marinated mushrooms and I won't cook enough pie for dessert no you're going to be in the emergency room because you've just added all this fiber all at once what you want to do is say I have really really missed coleslaw so I'm going to take a small amount maybe a quarter cup a third of a cup I'm going to chew it really well I'm going to pay attention to see if I have any evidence that I didn't tolerate this well what would my signs of intolerance be well if I'm cramping if I'm having diarrhea then it tells me I didn't manage that very well and I need to put it on the do not eat less for a few more weeks but let's say I ate a quarter cup a third of a cup I did really well it's like okay well that's the food I can tolerate as long as I chew it well and drink plenty of fluids now I'm ready to move to another food to test it out so here are some of your foods that are high in insoluble fiber and as I tell patients all the time it's foods that you can look at and you can say oh that's going to be hard to digest so what about raw veggies or veggies that are cooked crisp tender what about raw broccoli raw cabbage raw carrots raw celery that's going to be hard to digest you have to wait on those what about nuts and large seeds like sunflower seeds yeah those are very hard to digest dried fruits trail mix granola anything with peels so yes you can eat an apple but you've got a peel at first you can eat a potato but not the peel anything with membranes like oranges and grapefruit and then mushrooms because they're very fibrous they really do not break down what you do with your teeth is the only thing that happens olives coconut corn all of those foods we know are hard to digest we need to wait to add them back to our diet so in summary you can have a temporary eleasement you can have a permanent eleasement the things that we need to teach our patients and we need to emphasize is the importance of peristomal skin protection because the output is enzymatic the importance of gas and odor control and specific strategies because individuals with eleostomy will need to empty their pouch wherever they go the critical importance of hydration maintenance because their output is always going to put them on the edge of dehydration and finally dietary modifications to prevent food blockage and we'll talk about complications in a later class thank you