By Diana L. Gallagher MS, RN, CWOCN, CFCN
I frequently write about the value and rewards of being a WOCNCB® certified nurse. It is an amazing job that allows me to save limbs and change lives on a daily basis. After decades of working in acute and outpatient care, I now work as an independent consultant. I teach, I write, and I see patients on a daily basis. Where I live, we currently do not have a single home health agency that employs a Certified Wound and Ostomy Nurse (CWOCN®). Routine wound and ostomy care can be easily managed but when there are those challenging patients with difficult wounds or unusual ostomies, there is a clear need for the care of a CWOCN.
The Challenges of Outpatient Ostomy Management
My challenge is that there are very few CWOCNs in this area. Most work in acute care, education, or management; very few are positioned to see outpatients. That leaves more patients that would like to be seen and those that need to be seen than I can easily manage. Currently, I follow patients who live over an hour's drive from my home base and maintain a challenging schedule. A few weeks ago, I had two morning patients in a town south of where I live. I took care of paperwork and calls to coordinate supplies for patients before heading out. I completed the scheduled patient visits and had just turned north toward home when I received a frantic call from a mother pleading for me to help her son. In the world of ostomy management, it was a story that is all too familiar.
Her son had had emergency surgery for diverticulitis and then developed an anastomotic leak. A second surgery was done as another emergency to create an ileostomy. There was no preoperative education or stoma siting done. Within the first week of being discharged, he was readmitted for dehydration. They returned home and followed the instructions that they had been provided, but continued to have increasing problems with maintaining a secure seal with the ostomy pouches that had been ordered.
As pouch after pouch failed, the peristomal skin paid the price. Irritant dermatitis developed and worsened with each pouch failure. Normal wear time was nothing more than a promise as actual wear time went from the ideal five to seven days to five to seven hours. The failures became more and more frequent as more and more skin was lost. This family did everything right. They carefully followed the basic information that they had been given. When that did not work, they researched the web for better information. They called the doctor's office, spoke with a physician at the emergency department and finally a nurse gave them my number and suggested that they call and work with a certified nurse.
When I got the call early on a Monday afternoon, I was still over an hour from home. I had other plans for the rest of the day, but could not in good conscience ignore their call for help. They had already changed the pouch four times that day and it was already leaking again. The day before, they had changed the pouch five times. No matter how carefully they followed the procedure, nothing seemed to work. The day before, they had called the hospital desperate for help. They were connected with a surgeon who told them to leave the pouch off if they could not maintain a seal. They knew that this did not make sense and asked how they were supposed to manage to contain the continual stooling. She understood that there had to be a better solution than simply catching the stool as it was expelled.
She was a mother on a mission and determined to provide for her child. That is a concept that does not change even when our children grow up. I offered to meet them in a local office that I use, but they were not able to drive in. Not only was there the issue with not having a pouch in place but the area was exquisitely painful. She explained that her son was near tears with any movement or contact with the peristomal skin because it was so painful. I simply had to try to help but it would mean going home first to collect some supplies before I could meet with them. I explained that I was still at least an hour from home and at the very best I would not be able to meet with them for at least 2 hours. They were ecstatic at the prospect of someone coming to them to try to help. I asked the mother to text me their address and changed my plans for the rest of the day.
As I drove, I made mental notes on what I needed to take with me. Using hands-free, I called the patient's surgeon to update him and get orders for my visit. When I arrived home and retrieved my text, I realized that the address was in a small town that was well over an hour east. Onstar was unable to access the address and I called for directions. I drove farther and farther out of town, the four lane highway changed to two lanes. The road twisted around curves and I kept alert for deer that might have posed a road hazard. I continued on what would have been a lovely drive in the country on any other day, but the reality was that Monday had already been a full day. During the long drive, I admit to questioning my sanity for agreeing to travel so far to see a patient. The doctor would have made them come to the office. I had not discussed payments or mileage compensation; I had not even given those business details a second thought.
Assessing a Failed Ostomy Pouch
I finally arrived, met the family and listened to their sad tale. I reviewed basic ostomy teaching and was not surprised that a few of the basic tenets of care were clearly new concepts. The patient, his four year old son and his parents could not have been more gracious or grateful. My patient was semi-reclining in a chair holding a soiled towel over his failed pouch. His animated four-year-old was curious about what I was going to do. His parents were clearly hopeful that I might be able to help. I enlisted the four-year-old and he happily demonstrated his counting skills as he stacked paper towels for me to use and later helped by holding the hairdryer so we could dry the peristomal skin.
When the soiled towels were removed and the existing system removed, the problem was evident. The stoma was flush with the inferior edge being recessed. There was a small wound along the lateral edge where a stitch had likely eroded. The biggest problem was the peristomal skin. The entire area surrounding the stoma was red and irritated, but the skin that should have been below the stoma was completely missing. This irritant dermatitis was from exposure to stool but it was comparable to any second-degree chemical burn. It was clearly very painful with high levels of exudate mixed with liquid stool. It had to be cleaned before we could hope to repouch.
The process was slow and no matter how gently I patted, there was no way to escape the pain. Using standard ostomy techniques and specialty pouches, we eventually repouched. Sadly, the pouch I had just applied failed before I left their house. Everyone was disappointed. My four-year-old helper had better things to do and headed outside to play. With a deep breath, we regrouped and began again. I taught them how to combine wound and ostomy care. We isolated the chemical burn and used Gold Dust®, a high absorbency dressing to manage the exudate. With this layer tightly secured, an appropriate ostomy pouch with convexity was applied. As we sat and reviewed the process, the pouch held securely and the pain was almost completely gone. It had been a lengthy visit and that long drive home still lay ahead of me.
The Value of Three Tomatoes
As I repacked my bag and left supplies behind for the next pouch change, my four-year-old apprentice reappeared to ask if I liked tomatoes. One of my morning patients had already given me more tomatoes than I could use in a week. Even with a basket of tomatoes in the car, I had to tell this bright-eyed, innocent face that, of course, I liked tomatoes but could not possibly eat more than two. He ran off and returned with three beautiful, home-grown tomatoes from his own garden. He brought me the three best because they weren't as big as others had been. As he proudly shared these treasures with me he solemnly told me "Thank you for helping my Daddy." That long drive home was not nearly as far.
About the Author
Diana Gallagher has over 30 years of nursing experience with a strong focus in wound, ostomy, continence, and foot care nursing. As one of the early leaders driving certification in foot care nursing, she embraces a holistic nursing model. A comprehensive, head to toe assessment is key in developing an individualized plan of care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.