Farid Blog: Ileostomy Management
Karen Farid, RN, MA, CWON
Managing Liquid Output
High-output, liquid drainage fluid loss is dangerous to the person with an ileostomy. The drainage must be thickened with antidiarrheal medication and/or replaced with IV fluids. The most common antidiarrheal medication is loperamide hydrochloride (Imodium®; McNeil Consumer Health, Fort Washington, PA). Loperamide hydrochloride works the same as the opiates and is very well tolerated, over-the-counter (OTC), and the patient will not develop a tolerance to it and it is nonaddictive so it can be used over long periods of time. The usual starting dose is 1 2-mg tablet (or half a 4-mg tablet), before breakfast, lunch, supper, and bedtime. Remind patients 1) to ask their physician before taking OTC medications and 2) to not take loperamide hydrochloride if they have Crohn’s Disease.
I discourage opiates because the patient needs a prescription; in addition, the pharmacist typically will not dispense the prescription until they can be sure the “diarrhea” is not caused by a Clostridium difficile infection. Also, a prescription for opiates are meant to be for a short period, which requires prescription renewal.
Food. Juices make the drainage very liquid and should be avoided; the acid in these drinks can loosen stools. The more acid coming from the stomach to the small intestines triggers the pancreas to pour alkaline fluid into the intestines to neutralize the acid coming from the stomach. The small intestines cannot digest food when the contents of the bowel are acid. Taking an over-the-counter anti-stomach acid (H2 blockers such as Zantac, Pepcid, and Prevacid, and their generic counterparts) also can help thcken the drainage. Decaffeinated tea or coffee, water, decaffeinated soda are fine (soda will create more gas expelled by the ileostomy). Again, patients should check with their physicians before taking OTC medications or if they have known allergies or negative reactions to any of the medications mentioned.
Use of a Convex Faceplate/Appliance
I prefer a precut faceplate; I never use a “cut-to-fit” appliance. To use, patients should:
- Have the faceplate/appliance all ready to go. Peel all the plastic/paper adhesive protectors off the both adhesives: faceplate barrier and paper tape. If you use a paste, squeeze a thin line around the hole for the stoma (of course, it goes on the sticky side of the faceplate). Put the prepared faceplate aside within reach.
- Prepare the skin. If there are no skin issues (just clean, dry skin), proceed steps 3, 4, and 5. If the skin has been compromised, see If there are skin issues.
- Stand up while applying the faceplate/one-piece appliance. Right-handed persons should use their left hand to pull up on the skin above the stoma to make the skin taut while applying the faceplate, which also raises the stoma up to allow a full view of the stoma.
- While holding the skin taut, gently place the hole in the faceplate over the stoma and lightly stick on around the stoma, but do not press down yet. The hole will stick lightly so you can let go and reposition the right hand. Let go with you right hand — the left hand is still holding the skin taut — and place your finger directly over the edges of the faceplate (through the front of the bag in 1-piece appliances).
- Press down firmly on the faceplate rim and hold the faceplate down firmly with your right hand while you let go with your left hand. Then press the paper tape border down with your left hand while you are holding the faceplate down firmly with your right hand. After the paper tape is down you can let go with both hands. If you are left-handed, reverse the left and right hand directions, depending on what is most comfortable.
If there are skin issues. The 2 common reasons for skin eruptions around an ileostomy are a fungal infection and/or chemical burn caused by leaking drainage around the stoma and under the faceplate (a poor-fitting faceplate and/or over-filling of the bag).
If the rash is purely fungal, it usually starts under the paper tape border around the faceplate. This is usually caused by the paper tape border being kept wet after a shower or swim by the plastic pouch overlying the tape. After a swim or shower, an absorbent paper towel or several layers of toilet tissue can be wrapped around the faceplate between the bag and the paper tape for approximately 15 minutes to absorb all the water out of the paper tape before letting the plastic of the bag lay over it. The patient’s underwear can help hold everything in place.
Whatever the cause for a rash around the stoma (leakage or a fungal infection), gentian violet 1% (a water-based antifungal, antibacterial dark purple solution) can be applied. It can be ordered by a pharmacist or purchased online. This product penetrates into small fissures that may not be visible to the naked eye. The solution is applied carefully with a gloved fingertip (it can stain objects in the immediate area, but this can usually be remedied on tile and sink tops with clorox). Then apply stoma powder over the gentian solution while it is still wet.
There usually is no need for a barrier wipe. This can take time to dry thoroughly and the ileostomy might drip on the prepared skin (requiring you to start over). It is important to take the least amount of time to prepare the skin and apply the faceplate.
Fit. The appliance can be assessed for a better fit by a stoma nurse. Sometimes, a scar or fold can compromise fit. THis can be fixed by filling the gap with a piece of strip paste and using tube stoma paste to fill in the cracks around the strip paste. A stoma nurse also can identify whether the choice of hole size is too large or too small.
Professional clinical advice for patients with new or existing ileostomies can make management of their situation easier for all concerned.