High output stomas and their impact on Quality of ... - Disabled Living

<strong>High</strong> <strong>output</strong> <strong>stomas</strong> <strong>and</strong> <strong>their</strong>
<strong>impact</strong> on Quality of Life
Carolyn Swash
Community Stoma Care Nurse
Hollister Limited

Aims of presentation
What is quality of life
Define <strong>High</strong> <strong>output</strong> stoma
Look at reasons why they occur
Guidelines for managing them
Case study presentation
Issues that affect those in the case studies
Conclusion

What is Quality of Life?

What is Quality of Life

Quality of life
‘Is the product of interplay among social, health,
economic <strong>and</strong> environmental conditions which affect
human <strong>and</strong> social development.’
Ontario Social Development Council 1997

Definition of a high <strong>output</strong> stoma
Defined as a stoma or fistula, normally found
within the small bowel, that has an <strong>output</strong> of
more than 1000ml/day
Normally an ileostomy, found at the end of
the terminal end of the ileum, has an <strong>output</strong>
of between 500-800mls/day

Causes of <strong>High</strong> <strong>output</strong> <strong>stomas</strong>
Bowel resections within the small bowel
meaning that the stoma is placed high within
the ileum/jejunum
Sepsis
Treatment ie chemotherapy
Acute disease ie Crohn’s
Spontaneous fistula development
More common in females tend to have a
shorter small bowel

Treatment
Establish length of bowel left
Fluid balance
Daily bloods / regular weight recorded
Treat any sepsis
Use of loperamide /codeine
Use of PPI’s
Use of artificial feeds ie sip-feed/ distal limb feeding/
TPN
Reverse the stoma when possible

Case study 1
56yr old lady, admitted with abdominal pain
Previous history of multiple laparotomies for
adhesions
1 st op: Laparotomy with extensive division of
adhesions <strong>and</strong> small bowel resections x2
2 nd op: Laparotomy finding a leak in the proximal
anastomosis- double barrelled jejunumostomy
formed
Tpn commenced

Case study 1
3 rd op: 2/12 Returned to theatre for closure
of jejunumostomy
4 th op: 3/7 Laparotomy finding a leak in the
distal anastomosis resulting in formation of
end ileostomy with mucus fistula
End ileostomy high <strong>output</strong>, approx 1.5
litres/day difficult to manage
Discharged on home TPN

Issues affecting QoL
<strong>High</strong> <strong>output</strong> stoma, experiencing multiple leaks per
day
Unable to eat or drink, reliant on TPN
Financial, unable to work, prolonged stay in hospital
Professional visitors to house on daily basis
Redefining of bedroom in house (2 bed to 1 bed)
Reliant on others for practical aspects of daily life

Stoma Issues
Referred 23 rd Dec 2011
<strong>High</strong> <strong>output</strong> stoma, sore skin, multiple leaks, clothes
<strong>and</strong> bedding ruined, disturbed sleep, weepy but
refusal to go back into hospital for control
management
Impact on life: unable to go out, dependence on ex
partner, changing pouch 8-10 times each day, pain

Assessment
Poor historian due to amount of surgery <strong>and</strong> being
so poorly during this time
Drugs, loperamide 10mg QDS <strong>and</strong> codeine
phosphate 60mg QDS, Omeprazole 40mg BD,
On home TPN, line, bloods, temp okay. Unable to
tolerate anything orally
Skin no signs of dryness indicating dehydration

Stoma Assessment
Ileostomy <strong>and</strong> mucus fistula
side by side
Pink <strong>and</strong> healthy
Peristomal skin excoriated
Skin examined for creases
Pain felt on removal of
pouch
Examination of adhesive
area of pouch
Output watery
Excoriated skin
stoma

Actual Stoma
Mucus Fistula
End Ileostomy
Skin showing
signs of old
inflammation

Management
Stoma not suitable for
use of convexity
Some skin creases
<strong>High</strong> <strong>output</strong> pouch
needed
Needed to be easy to
manage
Would require the use
of accessories
<strong>High</strong> Output Pouch
Barrier rings

Problematic stoma
Retraction
Is a stoma which requires one or more accessories
to keep patient dry for a minimum of 24 hours
Cottam (2007)
Stoma
Seperation

Results
Pouch lasts 12-24 hours dependant on <strong>output</strong>
Self caring
A little more confident in going out
Skin improved
Took about 4 days to get ‘recipe’ right
Remains dependent on medication at high
levels
No expected date of reversal for 12-18
months

Nutrition
TPN, commenced August 2011 will continue until at
least 2013
Unable to take oral nutrition due to pain
Reliant on the Willow team of nurses
Bedroom now a treatment room, delivery of feed
each 14 days
Weekly bloods to monitor kidney <strong>and</strong> liver function
Risk of sepsis in line

Financial implications
In hospital August to December, loss of income
Loss of one bedroom, turning it into a treatment
room
Increase use of washing machine
Needs different wardrobe of clothes
Increased heating cost
Increased electricity use, fridge for TPN
Unable to go to work, Willow nurses am <strong>and</strong> pm
Referred to social worker for assessment 11 week
wait on results of assessment

Reliance on others
Unable to clean house due to abdominal operations
risk of herniation
Unable to shop by self, panic attacks
Need to go by taxi not public transport due to line
Need for professional involvement

Recent Events
Admitted to hospital with severe abdominal pain
focus right iliac fossa spreading into back
CT Scan NAD
Reliant on stronger analgesia
Looked grey prior to admission
Own concerns re staff’s ability to care for TPN line
<strong>and</strong> stoma (expert patient)
Discharge after three days in hospital
No cause found for pain

The Future

Over to Lily