Wound, Ostomy and Continence Nursing with Coleen Potts, BSN, RN, CWOCN

Podcast Transcript

Scott Steele: Butts N’ Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Welcome to another episode of Butts N’ Guts, I'm your host Scott Steele. I'm the Chairman of Colorectal Surgery here at Cleveland Clinic in Cleveland, Ohio, and I'm very pleased to have Colleen Potts here who is one of our department’s wound, ostomy and continence nurses here at Cleveland Clinic. Colleen, welcome to Butts N’ Guts.

Colleen Potts: Thank you.

Scott Steele: So tell us a little bit about yourself. Where are you from? Where did you train and how did you get into WOC?

Colleen Potts: I was actually born at Cleveland Clinic many years ago. I've pretty much never left since then. Most of my nursing career has been in ICU. But then I actually ended up with WOC nursing pretty much for personal reasons, which I'll get into, but I've been in the department for 16 years, and it's actually an awesome job.

Scott Steele: What is a wound, ostomy and continence nurse? What does it involve and how does one become one? And what's the training that's involved, and can you be a wound, ostomy, continence nurse without being some other type of nurse before?

Colleen Potts: There is some history that goes into this kind of nursing that dates back to about 60 years ago when Dr. Turnbull and Norma Gill actually pioneered the enterostomal therapy program. And Norma was an ostomate, a housewife’ she was not a nurse, and they definitely saw a need for caring for patients that have ostomies. At that time it was only ostomies, but it definitely expanded to an area where you have to be an RN with a bachelor's degree. And they expanded the part of nursing where it's called WOC — wound, ostomy, continence. And we definitely care for patients that have ostomies, fistulas, drains, wounds and the kind of incontinence disorders.

Initially the person had to have an ostomy themselves or they had a person in their family that had an ostomy to be this kind of therapist. Nowadays you have to be like I said have a BSN and we're all certified by the WOCN Nursing Society. Can you be a wound-certified nurse? Absolutely. You can take wound, ostomy or continence, could be certified in either area or all three. And to be a WOC nurse at Cleveland Clinic you do have to be certified in all three areas and that's a certification that occurs every five years.

Scott Steele: You used to have to have an ostomy in order to be a nurse?

Colleen Potts: Yep, that's right.

Scott Steele: God, I can't believe it, and again, as she said, my predecessor Dr. Turnbull, for sure the Department of Colorectal Surgery has an amazing history in terms of WOCN here at Cleveland Clinic. So you got your certification, how long does that take?

Colleen Potts: It's actually very different for each person. When I first started in the department I was certified within the first year and that was all three areas wound, ostomy, continence. I could take them on all the same day, the actual test, or you could spread them out. Now once you're hired into the department, you have to be certified within 24 months then it's every five years. I took the exams every five years for the first 15 years of being in the department, and I'm up for certification soon, and I did it a different pathway which is called professional growth points and that was life-changing. No exams so I'm good until 2023 now.

Scott Steele: Let's go a few definitions for some things that throw people off sometimes. Stoma versus ostomy versus colostomy versus urostomy versus ileostomy versus bag. What is all this terminology?

Colleen Potts: Ostomy and stoma basically mean the same thing. The origination of the word is from the Greek language, means mouth or opening. Anyone could tell you I have a stoma but until they tell you the prefix, where it's actually coming, from you won't know. So colostomy means it's an opening from the colon. Ileostomy means it's an opening from the ilium, urostomy means it's an opening that gives out urine. All of those diversions are all ones that I mentioned that need an external pouch to collect their urine or their stool.

Scott Steele: What services do WOC nurses provide?

Colleen Potts: We play a very important role in someone who's going to be facing ostomy surgery. Probably the two most important things that we do on a daily basis are pre-op education, where we actually tell the patient what is involved with having an ostomy, and then we do pre-op marking, which tells the surgeon where's the most appropriate position to place the stoma. So we don't want it in a crease that is sometimes traumatic for the patient to keep a good pouch seal. So we actually do the stoma markings and then after surgery we do education with the patient and the family to pretty much pick out the right pouching system so that they can carry on a normal life. What that means is they're going to have a predictable seal, they're not going to experience pouch leakage and if that does happen we explore other options to get them in the most appropriate pouching system and to keep their skin intact.

Scott Steele: Tell me about your average week what do you do?

Colleen Potts: So on an average week every day is different. I actually work in both outpatient clinic and in the hospital, which they're very different. This week I'm actually working in the hospital orienting one of our newest WOC nurses. The hospital, you're seeing more of the patients that are just out of surgery. We're teaching them how to place their pouch, how to clean their skin, how to empty their pouch. This is usually pretty life-changing for patients just to even look at their stoma for the first time.

Then by the time they come back to the outpatient clinic they are more used to having the stoma. They're getting predictable seals, they're getting back to work, and they do need you still to make sure that they're pouching systems are reliable and the correct pouching system they should be in.

Scott Steele: I come from a small town in northern Wisconsin, Nemak, Wisconsin. I don't know presently if there is a WOC nurse up there. So let's say you do live in some of these small towns where WOC nurses don't exist, and I'm a patient that's about to have surgery. What are some things that can happen? 

Colleen Potts: One of the things I do tell patients if there's kind of a time between the time they come to Cleveland Clinic and have surgery they could potentially go to a local support group. The national group is called UOAA.org, United Ostomy Association of America. And you could go to these groups and actually sit in on their meetings where they're actually having roundtable discussions, and everyone there has an ostomy. That's actually very helpful. And the other thing you can do if you want to seek out a WOC nurse in your area is go to WOCN.org, and there's actually a search box where you can find a local WOC nurse. 

Scott Steele: We have a lot of different people that listen to the podcast. We have providers and patients. Now put on your hat as an educator, and I'm a young surgeon out there and I don't have an ostomy nurse, and I'm going to have to mark patients. What are some tips that you could give to that position?

Colleen Potts: I would definitely say make sure that the patient can see it. Make sure that you mark within like the six-pack muscle, that gives a little bit more support, and try to stay on at least about two inches of smooth skin where a pouch will be able to adhere to the abdomen. Typically an ileostomy is marked in the right lower abdomen. A colostomy is in the left lower abdomen. But if someone is overweight or they can't see it then we could potentially go to the upper quadrants of the abdomen. Being a WOC nurse, one of the biggest challenges is when patients have a deep crease. Their stoma is within a deep crease, and the pouching system isn't working for them. We really do have a lot of different methods and techniques where we can fill in those creases. But it's challenging for the patient who hasn't done it as much as we have done.

Scott Steele: Let's talk about an ostomy themselves. So first of all do ostomies change over time?

Colleen Potts: Typically any kind of ostomy that someone has gotten surgically usually they do change with time. They're usually swollen in the beginning and then by the six-week mark they're usually shrunk down to the size they're going to stay at. And then if someone typically loses weight or gains weight the ostomy can also do the same. 

Scott Steele: What are some of the more common conditions that you’re asked to see specifically as regards to the ostomy itself?

Colleen Potts: Typically for someone who has an ileostomy, the number one reason for skin irritation would be the stool actually coming in contact with the skin which causes an irritant dermatitis. They’re usually in the wrong pouching system, or they're using the wrong accessories maybe cutting the pouch size too large, and that stool is somehow getting in contact with the skin. For colostomies, that isn't usually such a big problem because there’s less enzymes in that stool. But we see a lot more ileostomies here at Cleveland Clinic than colostomy.

Scott Steele: Take the person that has bad skin irritation. What's your general approach to this patient?

Colleen Potts: Many times the patient, when they go from the hospital, they're in a pouching system that is appropriate. They're in a flat system which means that they don't have a whole lot of support. By the time the belly softens up and gets back to its normal contours, they might need what they call a convex system, and convexity could make the biggest difference. And for anyone with an ostomy, leaking trumps everything because that really affects your quality of life. People usually can deal with skin irritation, but it's when they're leaking that they usually seek out a WOC nurse and that's important that you really should seek out a WOC nurse because there's so many pouching systems available nowadays that no one should really have to put up with a leaking pouching system. 

Scott Steele: Let's talk about a couple of other conditions. So what’s stoma prolapse? 

Colleen Potts: Stoma prolapse is when the stoma actually elongates out and sometimes could look almost like an elephant trunk. It actually protrudes sometimes as much as the actual pouch is which is very long could be like you know 10-12 inches. And that is a condition that patients are not normally used to seeing, and it is a complication. One of the big things is we tell them it's usually a panic situation for the patient, but it's something that patients could sometimes live with. It could be treated surgically if it's really causing a lot of problems for the patient with pouching. Also it's an issue where you could maybe just get a supportive belt to help support the prolapse. And there is a way that you can actually reduce the prolapse. We have different techniques in our department that we can actually manage the prolapse.

Scott Steele: How about a parastomal hernia?

Colleen Potts: So kind of on the same lines, parastomal hernia is when you could see a bulge around the stoma. This is pretty common. One of the things that we usually have patients do when they do get a hernia is to come in and get fitted for a support belt which helps to kind of keep the hernia from getting any bigger and kind of keeping it reduced and not so easy to see under your clothes. In really severe situations where it's causing issues with pouching or if they're getting blockages because of the hernia surgery might be indicated, but it's not usually the first thing that we jump to is have surgery.

Scott Steele: Let’s debunk a few myths here. I can't do blank because of my stoma. There are a lot of different things, I can't go swimming. I can't go out in public. I can't work out. I can't do X, Y or Z because now I'm going to have a stoma. What do you say to those patients?

Colleen Potts: If you have a predictable pouching system — by that I mean you can leave the house and you are confident you're not going to have a leak — you can do anything. You can fly on an airplane, you can swim, you can go in a hot tub. You can do anything that you really want to do, horseback ride, go on roller coasters. There's nothing that the ostomy should stop you from doing. Of course, if you have the experience that you're having pouch leakage that would obviously have your quality of life definitely affected but then that's like I said before, you should really be refitted by a WOC nurse.

Scott Steele: I can't live with a stoma because everybody's going to smell it or they're going to hear me pass air. What about that?

Colleen Potts: I definitely think there's still a stigma out there as far as no one really wants to have an ostomy. The technology has taken us to a place now where our pouches are all odor proof and waterproof, so no one should know you have an ostomy unless you want to tell them. The actual pouch is made of like a plastic material but it's not something that you hear stool going into. The gas on the other hand, you can sometimes hear it. There's ways to muffle it. There's lots of different products on the market to actually muffle the sound, and as far as anyone smelling it, no one should know you have an ostomy by the smell unless you're emptying or changing your pouch. 

Scott Steele: How often do people need to change their pouch?

Colleen Potts: People need to normally change the pouch completely every three to four days.

Scott Steele: And why is that?

Colleen Potts: Mostly because you want to take off everything so you can clean the skin, inspect the skin and especially with someone who has an ileostomy, you can get skin breakdown even if the pouch is intact. You still want to be able to keep that skin very healthy, because it is always covered with your pouch.

Scott Steele: So let's shift gears a little bit. Tell just a little bit about your story and what inspired you to become a WOC nurse.

Colleen Potts: About 30 years ago I had my son and soon after he was born I got very sick, very quickly and was admitted to Cleveland Clinic with severe ulcerative colitis. Was admitted into the hospital four weeks after he was born. And they tried to stabilize me medically which was unsuccessful. So the one day they came in, and one of the fellows said “you're just going to have to have the ostomy,” and that pretty much rocked my world. It was something really life-changing.

However, I got my health back. I got to be a mom. And so I actually did have the surgery. They took my colon out left the rectum behind and gave me an end ileostomy. At the time, I still was an ICU nurse, but felt that I lived such a good life with an ostomy that I wanted to pursue WOC nursing. So I didn't have my BSN at the time so I had to go back to school. And that's why I am a WOC nurse today.

Scott Steele: I've heard patients saying you know I would rather die than have an ostomy, I can’t have a quality of life. And I know you touched a little bit about this briefly earlier but speak to that a little bit.

Colleen Potts: So no one ever really wants an ostomy. No one wants to have an external pouch on their belly but if it means quality of life meaning you can do the things you want to do, then I really think that there is an acceptance that it doesn't come overnight. For me was getting my health back and being able to do the things I like to do and not have any abdominal pain. It definitely is a psychological thing. Yes there's physical part of it, but wrapping your head around having an ostomy is sometimes bigger than the physical part of it. No one ever wants it. But when you do have it and you have your life and you have your health there's nothing better than that.

Scott Steele: That's absolutely well said. So we're going to wind up here with a couple of quick hitters to get to know you a little bit better. So Colleen what's your favorite sport or activity?

Colleen Potts: Cavaliers, the basketball.

Scott Steele: And your favorite meal.

Colleen Potts: I love salmon.

Scott Steele: And the last book that you read.

Colleen Potts: The last book was by Regina Brett and the title was God Never Blinks.

Scott Steele: And what's the best thing you like about living here in Cleveland?

Colleen Potts: I probably have to say that my favorite thing is the casino.

Scott Steele: That’s fantastic. That's great. What's the take-home messages you want the listeners to be able to get in terms of WOCN or just anything about living with an ostomy?

Colleen Potts: The take-home message would be you can live a good life having an ostomy. It is life-changing, but it could really bring you your good health back and a good life.

Scott Steele: That's absolutely well said. So to learn more about wound ostomy and continence nursing please visit ClevelandClinic.org. That's ClevelandClinic.org. Colleen thanks so much for joining us on Butts N’ Guts.

Colleen Potts: Thank you.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts N’ Guts.