Challenges of Ostomy Care and Obesity

    The challenge of ostomy care and the very obese patient lies in the skill and planning required for successful physical, emotional, and spiritual recovery.¹ Many experts believe that from the onset, the obese patient having surgery is at a significant disadvantage because assessment is difficult, anesthesia is problematic, and technical procedures are more complicated.² Regardless, the number of obese patients requiring ostomy surgery is likely to rise, just as the prevalence of obesity is increasing. Once considered a high-risk group on which physicians avoided surgical intervention, currently 37% of surgical patients are obese and 17% are considered morbidly obese.³

Demographics

    In the United States, an estimated 13 to 16 million people are morbidly obese to the extent that medical intervention, simply based on obesity-related comorbidities such as pain management, immobility, skin injury, respiratory issues, and embolic threats is needed.⁴ This is a dramatic increase from 40 years ago when only a quarter of Americans were considered overweight. Today, more than two-thirds of adults and 25% of children are overweight and 10% to 25% of adults are obese - ie, have a body mass index (BMI) >30. Obesity is costly emotionally and economically; Americans spend close to $33 billion annually in attempts to control or lose weight, while $117 billion is spent on obesity-related health problems. Despite pressure to control weight, Americans continue to gain weight, and the implication to caregivers is that their care is more complex, requiring diligent interdisciplinary assessment and intervention to prevent costly and predictable complications. The value of an interdisciplinary approach is that some obese patients having ostomy surgery will develop complications that impact outcomes and are best managed by a diverse group of clinical experts such as nurses, pharmacists, physicians, and occupational/physical therapists.

Preoperative Preparation

    The preoperative period for the morbidly obese ostomy patient involves physical and emotional preparation. The wound ostomy continence nurse (WOCN), as a member of the interdisciplinary healthcare team, works closely with the ostomy patient as an important player in the patient's preoperative assessment and preparation. A stoma placement mark is especially necessary to long-term physical and emotional independence of the obese patient. The WOCN should take special care to place the mark away from folds or natural contours in an area visible by the patient and away from the belt line. A conference with the surgeon(s) may be necessary to determine what options are available to stoma placement. Arranging for a United Ostomy Association (UOA) volunteer visitor and having a discussion pertaining to the emotional and practical needs of the ostomy patient and his/her significant other(s) will further promote long-term adaptation. When planning for a UOA volunteer visitor, consider more than one visitor.

    Like all patients, the very overweight patient will need comprehensive preoperative teaching, which includes breathing and coughing instruction and appropriate leg exercises.⁵ Breathing and coughing exercises are especially important to prevent atelectasis and congestion that can result from shallow respirations as a result of incisional pain, depressive analgesia, inactivity, and obesity itself.⁶ Demonstrating deep breathing and coughing exercises should include splinting the involved surgical area and use of the incentive spirometer. Patients need to be reminded that gentle splinting will not interfere with ostomy function.

    Obese patients are at higher risk for postoperative thrombophlebitis, deep vein thrombosis, and pulmonary embolis. This may be due to an elevated hemoglobin and hematocrit that occurs in the presence of obesity hypoventilation syndrome (OHS). This is a biochemical and mechanical condition related to, but which can occur separate from, obstructive sleep apnea. In OHS, a very obese person does not utilize sufficient amounts of oxygen during sleep or while awake. Thus, increased red cell production is the body's natural response to hypercapnia and many obese patients experience this due to OHS and other respiratory issues.⁶

    Successful pre-operative preparation also includes the patient's family or other support person(s). This person will be instrumental in postoperative care and must be included in the teaching, especially if the patient has prolonged hospitalization, visual barriers caring for the stoma, or generalized weakness. An atmosphere of understanding, cooperation, and trust ensure a smoother postoperative course for the patient with an ostomy confronted with new emotional and physical challenges that are heightened because of his/her obesity.

Intraoperative Care

    Intraoperative care is highly specialized and among other goals ensures patient safety while attending to prevention of caregiver injury. Generally, two nurses are required at surgical procedures - a scrub nurse and a circulating nurse. In caring for larger patients, some institutions provide a third nurse, especially at the beginning of the ostomy procedure. The third nurse may be necessary for positioning. The third nurse may need to help physically maneuver the anesthetized patient when placing foam wedges, lifting and securing the patient's arm and legs, or lifting and separating the legs for urinary catheter placement. A task as simple as placing a catheter can be technically difficult and an unnecessary embarrassment to the patient, so often the catheter is placed once the patient has been sedated or anesthetized - a time when the patient is unable to participate.⁵

    Another intervention of concern that has particular interest in caring for larger patients is the surgical scrub or preparation of the skin surface. The nurse must ensure that all areas are clean and painted vigorously. This can be especially difficult in the presence of deep skin folds and irregular contours. Excess skin cleansers should not be left to pool within skin folds because this can lead to irritation and subsequent breakdown in skin integrity. The third nurse is helpful to the circulation nurse in performing this task.

    Once the surgery is completed, a larger gown needs to be readily available, eliminating embarrassment to the patient at the last minute. Extra personnel may be required to place the patient onto a gurney or an oversized bed that will go with the patient to his or her room once recovery is accomplished. Recovery staff need to be notified that they will be receiving a larger patient, which allows for any necessary preplanning.

    Preplanning helps prevent last minute scrambling to find tools essential for postoperative assessment. Standard-sized equipment, such as a blood pressure cuff, may be insufficient to accomplish simple assessment. The patient may be discharged from the recovery room to either the intensive care unit or a general med-surg unit depending on medical assessment or hospital policy. Having a plan of care for bariatric patients in place before admission serves the clinical needs of patients and the safety needs of caregivers.

Postoperative Care

    In the acute setting, patients can experience complications related to immobility and physical dependence. Some patients will fail to progress postoperatively either because of surgical complications or a critical condition. Clinicians need to be familiar with the common obesity-related complications mentioned and modify patient care plans and clinical intervention to address or prevent them.

    Patient transfer. Although the patient is often awake and alert shortly after surgery, extra personnel are required to transfer the patient to the appropriate postoperative unit. Lateral transfers are a growing threat to caregiver safety - neck and shoulder pain is becoming as prevalent as back injury as an adverse outcome of moving dependent patients. A hover-type product may ensure a safe transfer while protecting the caregiver from injury.

    Mobilization. A number of conditions affect the patient's postoperative course. Early mobilization is critical in the recovery period. Many larger patients are able to turn, ambulate, and transfer soon after surgery, but others may have difficulty because of pain or sedation.⁷ As a member of the interdisciplinary team, the physical therapist can assess the strength, endurance, and equipment needs of the patient. Patients who weigh more than 300 pounds generally require some level of special accommodation. Many times, the only special accommodations needed are a bed wide enough for the patient to turn independently, a walker to support his/her weight for the first few postoperative days, and an overhead trapeze to help the patient reposition. These three items are thought to help the patient maintain strength and independence. Clinicians report that independent patients who have adequate supportive equipment are less likely to injure themselves or caregivers during that early postoperative period when frequent bathroom visits provide the most agreeable time to learn ostomy skills, such as emptying the pouch.8 Early activity is encouraged to decrease the chances of immobility-related complications. The patient may need encouragement to perform leg exercises and breathing and coughing exercises.

    Monitoring. Routine monitoring of vital signs and physiologic progress that require careful documentation include blood pressure, pulse, quality and number of respirations per minute, temperature, coughing, and deep breathing. Physical conditions can change quickly; therefore, a baseline assessment with frequent, regular monitoring can prevent delays in care.

    Avoiding complications. To aid patient breathing, the bed should be kept at a 30-degree angle to reduce the weight of the abdominal adipose tissue (which reportedly presses against the diaphragm) as an aid to patient breathing.⁹ In addition, in the early postoperative period, patients may have an increased morbidity from surgery and anesthesia in the form of atelectasis, deep vein thrombosis, and pulmonary embolis,¹⁰ along with skin injury and emotional distancing that will need to be addressed. Sequential compression devices to accommodate the larger leg are available; for example, foot "squeezers" are useful in that they usually better accommodate the larger patient. Full body rotation therapy is also a strategy for controlling atelectasis in the postoperative patient who has limited mobility.

    Pressure ulcers. Obese immobile patients often present with atypical pressure ulcers. Pressure ulcers occur when external pressure exerted for a sufficient period of time causes cellular necrosis and tissue destruction. Pressure within skin folds can be sufficient to cause skin breakdown. Tubes, catheters, and even a tail closure clip for the ostomy pouch can burrow into skin folds, which can further erode the skin surface. Pressure from side rails and armrests not designed to accommodate a larger person can cause pressure ulcers on the patient's hips. This atypical skin breakdown can be minimized with appropriate, vigilant assessment and monitoring and by using properly sized equipment. From the very beginning, an oversized bed should be equipped with a pressure prevention or treatment surface tailored to the patient's width, height, and clinical condition in order to reduce or eliminate pressure ulcers. The patient needs to be repositioned at least every 2 hours, as do tubes and catheters. Tubes, catheters, and clips should be placed so the patient does not rest on them. Tube/catheter holders may be helpful in this process.¹¹

    Wound healing. Wound healing can be problematic in some obese patients with an ostomy. Blood supply to fatty tissue may be insufficient to provide an adequate amount of oxygen and nutrients. This can lead to wound dehiscence, evisceration, or infection - all delaying healing. Wound healing also may be delayed if the patient's diet lacks essential vitamins and nutrients. Infection can be a problem because many morbidly obese patients have associated medical problems, particularly type II diabetes mellitus. In fact, 80% of non-insulin dependent patients with diabetes are obese.¹² This contributes to delayed wound healing.

    Although hematoma formation rarely occurs, seroma formation is a common problem.¹³ Drains are routinely placed after surgery to prevent seroma formation. Clinicians should observe for drain clotting, unintentional removal of the drains by the patient, or pressure sufficient to occlude flow from the drains simply because the drain became lodged in a skin fold. Patients frequently are discharged to home with drains in place. Patients or their caregivers will need to demonstrate emptying and care of the tubes, as well as a plan in the event the tube clots or falls out.

    All skin should be keep clean and dry, especially in skin folds where excess moisture and bacteria can accumulate. As the patient with an ostomy becomes more independent in stoma care, added precautions must be taken to keep skin folds free of pouch contents from a loosened pouch or if spillage occurs during the emptying process.

    In the event wounds develop, drainage must be contained, especially in folds. The area must be cleaned frequently with a non-toxic cleanser and dry dressings secured to absorb excess moisture. Irregular body contours can present challenges in securing dressings. Flexible cloth tapes can mold to the contours as necessary to ensure that the dressings are fixed securely to the intended area.

    Further, excess body fat also increases the tension at the wound edges.¹⁴ To reduce the occurrence of abdominal wound separation, some clinicians use a surgical binder to support the area. Binders not only provide comfort to the patient, but also are designed to minimize the shearing forces between the abdominal wall and abdominal skin.¹³ However, if the binder does not fit properly, skin breakdown or patient failure to comply with the plan of care may occur. The binder will need to be large enough to comfortably fit the patient; bariatric-sized binders are available to meet this requirement. Proper sizing is especially important in the patient with an ostomy because pressure on a full or filling pouch can lead to leakage and subsequent skin issues.

    Pain. Pain is thought to interfere with mobility and therefore must be considered in the care plan. Excess body fat can alter drug absorption, depending on the medication. For example, drugs such as diazepam and carbamazepine are highly soluble in fat and therefore are absorbed mostly in adipose tissue. Therefore, pain medication dosage must be calculated using the patient's actual body weight. Drugs that are absorbed mainly into lean tissue, such as acetaminophen, should be calculated using the patient's ideal body weight - what the patient should weigh.¹⁵ Trying to remember which drugs fall into which category is almost impossible. A clinical pharmacist can be an important resource to ensure that the drug dose is accurate.¹¹

    Postoperative care is essential in beginning the recovery period for the patient. Early ambulation, appropriate use of specialized equipment, attention to the risks of wound and pulmonary complications, IV access, and pain management all work together to that end. A comprehensive explanation and rationale for care may encourage the patient/support person's willingness to participate in care.

Planning for Home Care

    In the home care setting, obese patients frequently pose serious management problems related to obesity as well as its associated comorbidities. Planning and providing care to obese patients can be challenging. Although not all obese patients will require special accommodation at home, patients with limited mobility are likely to have specific needs that require special accommodation, especially with respect to learning new skills and adapting to a new ostomy.

    In a one study,¹⁶ nurses reported five specific challenges in the home care setting: equipment, reimbursement, access to resources, client motivation, and family/significant other support. The challenges cited most frequently involved issues around specialized equipment.

    In the event that significant deconditioning occurs during a prolonged hospitalization, many care providers report difficulty turning, transferring, or lifting heavier patients.¹⁷ Family members and caregivers can be at risk for injury when caring for the obese patient in the home where fewer personnel are available to help. Oversized wheelchairs and walkers with higher weight limitations than standard equipment are readily available in major medical supply centers. They are usually available for purchase or rent. Both items promote independence and dignity. Equipment that nurses find most helpful in the home include wheelchairs, walkers, commodes, electronically-controlled bed frames, support surfaces, and lifts.

    When planning for oversized equipment in the home, consider the weight limits, width, and electrical needs of the equipment. In other words, does the patient have a sliding glass door or extra wide doorway through which the equipment can be delivered or will the equipment dissemble so it can be delivered through a standard-sized doorway? If the patient or support person is unable to proficiently empty the pouch in the home setting, the patient may need additional support such as extended care, in-home community service, or other provision to ensure 24-hour coverage until the basic skill is mastered.

Case Study

    Ms. S was a 58-year-old woman diagnosed with a ruptured diverticuli that required emergency surgery. She was not premarked for the procedure due to the nature of the situation. She had a medical history of obesity, smoking, diabetes type II, and hypertension. During the procedure, cancer was discovered involving the bladder and some of the adjacent muscle wall. A cystectomy was performed.

    The resulting urostomy, located in a crease and low on the right abdomen was red, moist, viable, and not flushed (see Figure 1). It was very difficult for Ms. S to care for this stoma when standing because it would lay on the lower abdominal curve. Initially, Ms. S selected a convex appliance two-pieced system.

    Stoma construction can be technically difficult for the surgeon because the bowel, which is attached to the mesenteric blood supply, may not easily reach the skin surface. If the blood supply is compromised, stomal necrosis can occur; if an adequate amount of bowel is not brought to the skin surface, stoma retraction can occur. In Ms. S's case, the colostomy was placed in a slightly higher location on the left abdomen (see Figure 2). The stoma was red, moist, viable and raised - even if only slightly. The fecal output was liquid secondary to the chemotherapeutic agents and antibiotics and leakage was a problem. Although a stool thickener was not used in this case, products are available for that purpose.A two-piece appliance was used initially but was changed over to a convex wafer due to some leakage of stool the patient. Ms. S was able to visualize this stoma better while standing, although achieving a good, smooth surface on which to apply the wafer was difficult.

    Although no skin challenges emerged in caring for the urostomy, Ms. S developed a severe peristomal skin irritation and scald around the colostomy from the leakage. A number of positions (sitting, leaning, and standing) were tried with little success. Getting the wafers on securely without the skin folds and creases interfering was easier when lying down but a difficult task for her to perform on her own. The question became how to provide a practical method for the patient to manage independently.

    The CWOCN acquired a large hand mirror from the drug store and procured a cymbal stand from the local pawn shop. The hand mirror was attached to the stand, which had a swivel head on it (see Figure 3). Ms. S assumed the supine position and carefully maneuvered the mirror until it reached an angle that enabled her to clearly see her stomas and apply the wafers. She quickly learned how to perform her own care in this manner.

    It was fortunate that a successful system was in place for Ms. S to perform her own care because the weight loss she experienced during the course of her treatment resulted in deep folds and creases across the stomal field. Despite significant weight loss, the standing mirror enabled her to apply the wafers in the supine position with smooth skin surfaces that had quite a different appearance when she stood (see Figure 4). With the weight loss and abdominal shape changes, she experienced an increase in pouch failure with position changes during the day, and subsequently she was converted to a one-piece convex pouching system to accommodate the numerous folds and prevent appliance separation when moving throughout her day. Ms. S has continued to do well with this routine.

Conclusion

    With obesity on the rise, clinical experts best serve the patient with an ostomy by employing strategies to reduce or prevent costly complications. A comprehensive approach to understanding and providing intervention throughout the operative experience will provide such a strategy. Care of the obese patient requires an interdisciplinary approach. The entire healthcare team must be diligent in caring for the ostomy patient. An awareness of the possible complications and corresponding interventions is necessary to prevent potential hazards to both patients and caregivers. Numerous resources are available to patient care across practice settings, and use of resources in a timely and appropriate manner are thought to improve measurable therapeutic, cost, and satisfaction outcomes. 

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