The Application of Multimedia Messaging Services via Mobile Phones to Support Outpatients: Home Nursing Guidance for Pediatric Intestinal Colostomy Complications☆

Qiao-Ling Yang, Qin Wei, Ying Huang, Yu-Xiu Jiang, Dai-Zhen Chen, Ping Huang, Li-Jun Liang

Department of Pediatric Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China

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The Application of Multimedia Messaging Services via Mobile Phones to Support Outpatients: Home Nursing Guidance for Pediatric Intestinal Colostomy Complications☆

Qiao-Ling Yang, Qin Wei*, Ying Huang, Yu-Xiu Jiang, Dai-Zhen Chen, Ping Huang, Li-Jun Liang

DepartmentofPediatricSurgery,theFirstAffiliatedHospitalofGuangxiMedicalUniversity,Nanning,Guangxi530021,China

1. Introduction

In recent years, WeChat has become one of the most prominent chat or communication tools in daily life in China. Because WeChat is easy to use and has many functions, it has applications in various fields of health care, e.g., in community clinics and home nursing. Recently, our Department of Pediatric Surgery started to discuss modern, smartphone-based communication technologies and developed the idea of assisted health care management via WeChat to guide parents and support the in-home care of pediatric colostomy complications. Prior to home care support, we also provided the patients and their families with systematic information and extensive training in colostomy nursing and health education1to reduce colostomy complications and expedite recovery.

2. Material and methods

2.1. Clinical data

The surveyed group included 80 patients (52 male and 28 female) aged 3 hours to 11 years. These 80 cases included 21 cases of anorectal malformation, 15 cases of congenital megacolon, 13 cases of neonatal necrotizing enterocolitis, 12 cases of meconium peritonitis, 10 cases of intestinal atresia, and 9 cases of intussusception with perforation. Of these patients, 24 were treated with small intestinal colostomy and 56 were treated with colostomy. The observed complications included manure water dermatitis in 35 cases, allergic dermatitis in 12, electrolyte turbulences in 9, colostomy bleeding in 7, colostomy retraction in 7, fallen off colostomy in 5, and tracheostomal stenosis in 5. Nineteen patients suffered from two or more of the above complications at the same time.

2.2. Operational approach

During the children's hospitalization, the patients, parents and nurses underwent colostomy nursing2training under the guidance of the nurse-in-charge. Charge nurses educated the children and their parents about how to nurse a colostomy, to change colostomy bags, and how to plan the colostomy nursing routines according to the specific situation of the patients and their families. Moreover, through multimedia training software, parents gained a better understanding of the various types of clinical manifestations of colostomy complications to handle them more intuitively.

Immediately before the children were discharged from the hospital, the charge nurses again gave instructions to the parents about routine care procedures, such as how to change colostomy bags autonomously, and also evaluated and recorded their ability to master the required tasks. The charge nurse then established a written follow-up record and a checklist for each child. She obtained the parents' phone details and ensured that the WeChat application was installed and properly working. She then initiated and recorded the first telephone follow-up during the first week after discharge from the hospital; this was subsequently followed by regular calls during the first, second and third month.

After the children were discharged from the hospital, the parents were able to routinely transmit verbal or written information or pictures of the colostomy care situation to the nurse-in-charge using the WeChat application. The charge nurse or specialized, professional medical workers responded and provided general feed-back or specific care instructions. For minor issues or complications, they provided the necessary instruction for home care directly. In more serious cases, they advised parents to take their children to the hospital to prevent further deterioration of the condition.

2.3. Guidelines

Routine change of the colostomy bag: (1) Uncover the original colostomy bag and wash the skin surrounding the colostomy wound with a normal saline solution. (2) Wait until the skin is dry, and apply some colostomy skin protection powder. After 3-5 minutes, wipe the powder off. (3) Cover the colostomy skin with a protective film. (4) Measure the diameter of the colostomy. Cut the bottom ring of the colostomy bag according to the diameter. (5) Wait until the protective film dries, and then, paste the colostomy bag.

2.4. Care instructions in cases with complications

2.4.1. Fecal dermatitis

This is the most common, early complication that is seen in approximately 3.8%-26.9% of cases. It normally occurs as a cutaneous inflammation, congestions, edema, erosion or even ulcer formation and causes significant local pain. Charge nurses should help the parents to choose the most suitable colostomy supplies and instruct the parents on the proper procedure for changing the particular bag type. For example, when leakage occurs, the colostomy bag should be changed right away. If there is no ulceration of the skin, the skin protective film should be applied. If ulceration of the skin is visible, then both the skin protection powder and the skin protecting film should be applied. For patients with severe dermatitis, un-bonded colostomy bags or dressings should be used instead of bonded colostomy bags. When using un-bonded colostomy bags or dressings, they should be replaced frequently to protect the skin.

2.4.2. Allergic dermatitis

When the bonding parts or the entire area around the colostomy bag has red spots and blisters, the colostomy aid supplies should be replaced more frequently. In less severe cases, Fuqingsong ointment can be applied to the areas displaying an allergic reaction. Alcohol-based colostomy aid supplies are not to be used for newborns. Severe cases of allergic dermatitis have to be treated in a hospital.

2.4.3. Electrolyte imbalances

This condition is mainly caused by diarrhea and dehydration due to enteritis. High intestinal colostomy can easily cause a large loss of intestinal and digestive juices and creates electrolyte imbalances, metabolic acidosis, and nutrient malabsorption. Parents should care for the children's dietetic hygiene and nutrition. If the child vomits or suffers from diarrhea persistently, they need to be taken to the hospital.

2.4.4. Colostomy bleeding

The clinical manifestation of this condition occurs when the mucous membrane of the colostomy has a small amount or sometimes even more pronounced bleeding. The charge nurse should ask the parents to closely observe the condition and the development of the bleeding. Depending on the amount of bleeding, it can be stopped by applying a cotton ball in less severe cases. Severely bleeding patients should be taken to the hospital for hemostatic treatment.

2.4.5. Colostomy stenosis

The clinical manifestation is an opening of the skin incision that is too small to see the colostomy mucosa. The charge nurse should ask the parents to observe the colostomy defecation exhaust and abdominal distension. The nurse should also advise the parents that intestinal lavage or anal dilatation is required if the defecation is not smooth. Moreover, the nurse should teach the parents to use the anus dilator to dilate the colostomy: anal dilatation should be performed once or twice a day for 10 to 15 minutes each time that it is indicated in such cases.

2.4.6. Colostomy retraction

The manifestation of this condition is that the colostomy invaginates (sinks) under the skin surface. Parents can use colostomy powder with zinc oxide oil to protect the skin surrounding the colostomy. The parents should wash the surrounding skin and change the dressing contaminated with feces. Washing the damaged skin too frequently is not recommended. Severe cases have to be treated in the hospital.

2.4.7. Colostomy prolapse

Normally, the colostomy mucosa is elevated approximately 2.0-2.5 cm above the surrounding skin. If the opening of the abdominal colostomy is too large or loose, the child might cry, scream, crouch or, if the abdominal pressure increases, the intestinal tube might even become detached. Intestinal detachment occurs when the colostomy turns inside out for about several inches or 10-20 cm. Colostomy prolapse may cause edema and hemorrhage, anabrosis, volvulus, and ischemia, followed by necrosis. If the detached intestinal tube is ruddy, it will return automatically after the patient is calm. If it does not return, the parents can use disposable gloves to put it back in place. Severe cases have to be treated in the hospital.

2.5. Dietary instruction

After starting with liquid or semiliquid food, the patient can progress to soft foods. Parents should pay special attention to food hygiene and the nutrition balance of the diet for children and should observe their defecation after eating. When necessary, oral astringent (Smecta) can be given. Points for attention: (1)Eating boiled eggs, glutinous rice, corn, peanuts and other non-digestible foods is not allowed within one month after surgery. (2)Lard is contraindicated to prevent diarrhea. (3)Eating crude fiber food (oranges, celery, Chinese chives) is not allowed. (4)Foods causing aerogenesis (e.g., onion, garlic, and potatoes) are contraindicated to prevent intestinal distention.

3. Results

This extended service assisted the home care of patients with pediatric colostomy complications, improved the quality of life of the patients and caregivers and was accepted by all parties involved upon initiation. The service provided support to the parents at all hours, efficiently reducing the level of complications for this type of patient and facilitating fast referrals to hospital care in cases of emergencies. Furthermore, it paved the way to a successful second stage surgery, provided direct feedback to the charge nurse and improved the work satisfaction and sense of achievement of the nurses involved.

4. Discussion

4.1. The concept of pediatric intestinal colostomy

Pediatric intestinal colostomy involves the temporary modification of the path of feces to rescue patients who have either an anorectal congenital malformation or intestinal necrosis with shock or intestinal perforation caused by extensive abdominal infection or a congenital megacolon that cannot be corrected in a one-stage operation. The biggest difference between pediatric intestinal colostomy and adult intestinal colostomy is the temporality (impermanency). Three to 6 months after the colostomy, or after the clinical symptoms disappear or after the symptoms have been relieved after 1 to 2 years, colostomy closing surgery can be undertaken to restore normal intestinal function.3

4.2. The significance of pediatric intestinal colostomy

In-between the two-stage operations (the colostomy and the colostomy closing surgery), patients need home care by their parents because they are too small to take care of themselves. Because the skin of children is very tender and their immune system is not yet strong, the probability of complications is increased and their morbidity is higher than adult colostomy patients. The latter is also related to the quality of postoperative care.4 In severe cases, the level and quality of care might affect the child's growth or even influence their entire life.

4.3. The advantages of mobile phone WeChat support

First, the responsible nurse can immediately help the children and their families solve the specific home care problems of individual colostomy cases. The support system can reduce the chances of complications becoming more severe or critical and can reduce the anxiety or stress of the caregivers or parents. Second, the patient is not required to be physically present in the hospital, thus reducing the family's financial and time burden. Third, the mobile phone intervention is economical, widely available and easy to use. It can support the communication between parents, doctors and nurses using either phone calls, voice messaging, SMS, or even colored pictures or video sequences. The latter really improves communication and provides the medical staff with an unbiased accurate indication of the situation, e.g. the extent of the bleeding, extent of dermatitis, leakage or extent of invagination or prolapse. The phone applications are straight forward to use, specifically for caregivers under stress. Thus, by guiding the home care of pediatric colostomy patients, the WeChat application can increase the quality of life and satisfaction of both the children and the parents. At the same time, the application significantly reduces the cost and time required of parents and reduces hospital administrative expenses. If WeChat is combined with meticulous record keeping of all communications, it also improves the level of care quality and support that medical staff establish in a concise medical case history. This idea is worthy of expansion across different areas of home care. All 80 cases of two-stage operations for pediatric colostomy included in this study were successfully treated.

5. Conclusions

All 80 cases that underwent two-stage pediatric colostomy operations that were supported via WeChat were successfully treated. The response of the parents and the medical staff involved was very positive. This method is easy to use, economical to operate and could be applied more generally to support home care.

Conflicts of interest

All contributing authors declare no conflicts of interest.

1. Liu JH, Yan Y, Nursing progress of colostomy. Chin Gen Nurs. 2009;148(7):1773-1774[in Chinese].

2. Huang JJ, Li HL, Li HZ. Research and application on colostomy nursing by both patient and nurse. Lab Med Clin. 2009;6(8):570-571[in Chinese].

3. Liang ZB. Pediatric intestinal fistula main postoperative complications prevention. Theory Pract Med. 2002;15(5):519[in Chinese].

4. Chen J, Ma LL, Chen L. Analyzing and nursing 149 cases of pediatric colostomy. Nurs Res. 2011;25(1):49-50.

☆This work was supported by the Guangxi Zhuang Autonomous Region Health Department (No.Z2013099).

*Corresponding author. E-mail address: weiqin103@126.com (Q. Wei). Peer review under responsibility of Shanxi Medical Periodical Press. http://dx.doi.org/10.1016/j.cnre.2015.01.001