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Management of High Output Ileostomy - Adult - Ambulatory [11]

Management of High Output Ileostomy - Adult - Ambulatory [11] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Practice Protocols


Practice Protocol Number: 11         
 
Practice Protocol Title: Management of High Output Ileostomy – Adult – Ambulatory   
 
Practice Protocol Applies to: 
Digestive Health Center Colo‐rectal Clinic; UW Health Transitional Care 
 
Target Patient Population: 
Adult patients with high output stoma  
 
Practice Protocol Champion:   
Charles Heise, MD – Department of Surgery ‐ Colorectal 
 
Practice Protocol Reviewers: 
Jane Hartman, RN, MS, Clinical Nurse Specialist ‐ Digestive Health Center 
Laura Sell, MS, BSN, RN – Coordinated Care 
Kristine Leahy‐Gross, MSN, RN, CPHQ – Coordinated Care 
Debra Raasch, NP– Department of Surgery 
Kimberly Williams, ACNP – Department of Surgery 
Tracy Schmotzer, RD – Clinical Nutrition 
Jennifer Murphy, RN – Digestive Health Center GI Surgery Clinic 
 
Responsible Department: 
Department of Surgery  
 
Purpose Statement: 
The purpose of this protocol is to provide Registered Nurses (RNs) with evidence‐based strategies for 
management of patients that experience high levels of output from a stoma. Dehydration and 
electrolyte imbalance can occur due to excessive loss of fluid via an ostomy. Hospital readmission may 
become necessary, therefore management of high output conditions is essential for optimal patient 
outcomes.  
 
Who May Carry Out This Practice Protocol 
UW Health Transitional Care and Digestive Health Clinic (DHC) Registered Nurses (RNs) who are trained 
in the recognition and management of high output stoma.  
 
Guidelines for Implementation: 
1. This practice protocol is initiated when patients are experiencing high levels of output from their 
stoma.  
2. Indications. Patient should be managed via this protocol if any one of the following apply: 
2.1. High output is defined as greater than 1200 mL in 24 hours. Patients are instructed to call if 
stoma output is greater than 1200 mL a day for 24 hours.  
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

2.2. Weight loss of greater than 1 kilogram (2.2 pounds) in one week. 
2.3. Urine output of less than 700 mL/day for 2 consecutive days. 
3. The RN will assess the patient and reinforce education related to ways to decrease ostomy output: 
3.1. Assess for other conditions that may cause high output loss (infection, medications, partial 
bowel obstruction). 
3.2. Assess for specifics of dietary intake, including amount and type of oral fluids. 
3.3. Assess for correct use of prescribed medications. 
3.4. Educate or reinforce importance of daily weights and measuring output from stoma and urine 
3.5. Educate patient about isotonic fluids, thickening foods, and foods and fluids to avoid 
4. During the comprehensive nursing assessment, if any of the following are identified, the RN will 
contact the advanced practice provider or physician. These conditions are considered “red flags” 
and require urgent intervention: 
4.1. High ostomy output continues despite use of approved food, fluids and fiber. See HFFY # 297.  
4.2. High ostomy output continues despite pharmacological interventions. These interventions may 
include doses of loperamide (Imodium), diphenoxylate‐atropine (Lomotil), tincture of opium, 
proton pump inhibitor (PPI) or H2 antagonist.  
4.3. Patient has pre‐existing renal disease (eGFR < 60 mL/min/1.73 m2) 
4.4. Patient has temperature > 100.5 F 
4.5. Patient has abdominal pain that is different than post‐surgical pain 
4.6. Patient is experiencing fainting/weakness/dizziness 
4.7. Patient is experiencing nausea/vomiting 
4.8. Patient has bloody output from stoma 
5. RN to call patient daily if signs of high output stoma present.  Continue to reinforce education to 
decrease ostomy output and notify provider if red flags (outlined in #4 above) are present. 
 
References: 
1. Arenas Villafranca J.J, Lopez‐Rodriguez C, Abiles J, Rivera R, Gandara Adan N, Utrilla Navarro P. . 
Protocol for the detection and nutritional management of high‐output stomas. Nutr J. 2015;14:45. 
2. Baker ML, Williams RN, Nightingale JM.  Causes and management of high‐output stoma. Colorectal 
Dis. 2011;13(2):191‐7. 
3. Gondal B Trivedi MC.  An overview of ostomies and the high‐output ostomy. Hosp Med 
Clin.2013;2(4):e542‐e551. 
4. Hanzlik TP, Tevis SE, Suwanabol PA, et al.Characterizing readmission in ulcerative colitis patients 
undergoing restorative proctocolectomy.J Gastrointest Surg. 2015;19(3):564‐9.  
5. Hayden DM, Mora Pinzon MC, Francescatti AM, et al. Hospital readmission for fluid and electrolyte 
abnormalities following ileostomy construction: Preventable or unpredictable? J Gastrointest Surg. 
2013;17(2):298‐303. 
6. McDonald A.  Orchestrating the management of patients with high‐output stomas. Br J Nurs. 
22014;23(12):645‐6. 
7. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin Vl.  Ileostomy pathway virtually eliminates 
readmissions for dehydration in new ostomates. Dis Colon Rectum.2012;55(12):1266‐72. 
8. Orcutt ST, Li LT, Balentine CJ, Albo D, et al.  Ninety‐day readmission after colorectal cancer surgery in 
Veterans Affairs cohort. J Surg Res. 201, 370‐377 2016;201(2):370‐7.  
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

9. Willcutts K, Touget‐Decker R.  Nutritional management for ostomates. Top Clin Nutr.2013;28(4):373‐
83. 
 
Collateral Documents/Tools: 
UW Health HFFY # 297 “High Ostomy Output” 
 
Approved By: 
UWHC Nursing Practice Council: April 2017 
 
Effective Date:  April 2017 
 
Scheduled For Next Review:  April 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Management of High Output Ileostomy – Adult – Ambulatory
04/07/2017
Indications for use:
Stoma output > 1200 mL/24 hours
Weight loss > 2.2 pounds in 1 week
Urine output < 700 mL/day x 2 days
One or more signs
exist?
No
Yes
Continue routine
follow up
Assess patient for:
1. Dietary intake, specific type, include PO fluids type and amount
2. Correct use of medi cations as prescribed
If discharged on OTC fiber supplement, RN may adjust dose. If not prescr ibed on discharge, RN may adjust
dietary changes only. Call provider if fiber is needed.
Other conditions that may cause high output: Infections, medications, pa rtial bowel obstruction.
Titration of fiber:
1. Increase number of doses to 3/
day.
2. I f no response, increase to 4
doses/day.
3. I f no response, call MD/provider.
No
Yes
Call APP/MD provider if any of the following exist:
1. High output continues despite dietary adjustments
2. High output continues despite correct use of pharmacological interventions
3. Pre-existing re nal disease (eGFR < 60 mL/min/1.73 m2)
4. Temperature > 100.5F
5. Abdominal pain that is diffe rent from post surgical pain
6. Nausea & Vomiting
7. Fainting/weakness/dizziness
8. Bloody output from stoma
Transitional Care RN
to call patient daily
if signs of high
output stoma
present
Educate & Reinforce:
1. Importance of daily weights
2. Importance of measurin g stoma and urine outputs
3. Importance of isotonic fluids only, us e of thickening foods and foods/fluids to
avoid (See Health Facts For You #297)
Symptoms
resolved?
Continue routine
follow up
Contact APP/MD
provider
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org