Body image changes and the physical alterations that come with ostomy surgery require major adjustments by the patient. Learning to adapt to these changes as well as acquiring necessary skills for stoma care can present a number of remarkable challenges. The ability to care for the stoma and its output are crucial steps toward the rehabilitation of the person with the new ostomy.
Patient education has become even more challenging in recent years due to changes in health care and the decreasing lengths of hospital stay limiting the time available to present the necessary information. However, it is also thought that preoperative education has an effect on length of hospital stay (WCET, 2014). In addition, comprehensive education delivered by a Wound Ostomy Continence (WOC) nurse can result in a positive adjustment to the ostomy not only in the immediate but also long term (Haugen et al., 2006).
It remains the most important function of the WOC nurse to provide instructions for self-care and encouragement and support to the person having ostomy surgery.
Cheng et al. (2013) found self-care ability strongly associated with psychosocial adjustment, and where possible patients should leave the hospital with optimal self stoma care ability.
The Joint Commission (2012) requires that the patient’s learning needs, abilities, preferences, and readiness to learn are assessed. The assessment should consider cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, language barriers, and financial implications of care choice.
It is important to include any family member that the patient wishes to receive instruction, for in many cases having a “back up” to assist with the technical procedures after discharge will be needed. Altschuler et al. (2009) describe the importance of the support of the patients’ partner on the adjustment capabilities of the patient and including them in the instruction process may contribute to their understanding and acceptance of the ostomy.
Ostomy education should include a preoperative and postoperative component by a specialized nurse such as a Wound, Ostomy, and Continence (WOC) nurse.
Components of a learning assessment should include the patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication. A patient’s readiness to learn can be affected by physical or psychological comfort such as pain, fatigue, anxiety, anger, or fear. In view of existing time constraints, teaching might begin with encouraging the patient to recognize the need to participate in his or her care. Asking the patient their views of living with the stoma and function, and how we can assist them to assume the necessary tasks that came with the stoma, can be a beginning of their recognition of their need for learning.
While it may seem in these days of shortened lengths of stay that consideration of learner readiness may seem unproductive. O’Shea (2001) states that the patient who does not recognize the need to learn, or is depressed or angry may not be amenable to learning. Recognition of these issues allows the WOC nurse to implement interventions that lead the patient to understand the need for learning and acquiring new skills.
Preoperative education may be very limited or not be available in many situations as patients may not arrive at the hospital until just prior to surgery.
The skill set recommended by the WOCN Society Ostomy Consensus Statement (2007) is described as the abilities of the postoperative patient to perform the actions listed in Box 11-1. O’Shea (2001) describes that teaching elder patient may require a longer time to learn, and suggests that relating ostomy teaching to previous learning or experiences helps the aged patient gain the necessary knowledge and skills without any extraneous facts. Teaching illiterate patients should involve verbal explanations, pictures, videos, audio tapes models, and demonstrations. Arrows showing the flow of the procedure in pictures can be helpful. It is also important to recall that illiteracy does not imply a lack of intelligence and these patients self-esteem should be protected.
BOX 11-1 Skill Set for the Postoperative Ostomy Patient
Manipulate pouch clip or spout
Empty the pouch
Remove and apply a pouching system
Additional skills if possible
Influence of medications on ostomy function
Peristomal skin care
Monitoring for complications
Sexual function (Colwell & Beitz, 2007)
Option for colostomy irrigation
Regardless of type of ostomy, there are principles that apply when managing a stoma with a pouching system. The pouching system should provide the person with an ostomy consistent wear time and containment of stomal output and protection of the peristomal skin.
There are one- and two-piece types of ostomy systems with both flat and convex skin barriers. The skin barrier is the part of the system that attaches to the skin; it should fit snugly around the stoma so that no peristomal skin will be exposed. Skin barriers are available as precut or cut to size to accommodate the stoma, which is irregularly shaped or is still shrinking. There are also barriers that may be molded to fit around the stoma without cutting. The pouch contains the output from the stoma and can be drainable and emptied several times per day as needed or may have a closed end where the pouch is removed and replaced rather than emptied. Pouch closures may be a separate clip or integrated into the pouch, closing with a spout or a hook and loop closure. There are many accessory products that are usually used to solve problems such as liquid skin barriers used on thin peristomal skin or paste, strips, or rings used to “caulk” around a stoma where the skin surface is uneven. See Chapter 10 for an in-depth discussion on pouching systems and the principles of pouching.
A convex skin barrier may be useful if the stoma is flush with the skin or retracted below skin level.
While general instructions for stoma care are described, over time and when back at home in his or her own environment, the person with the new ostomy is encouraged to find a comfort level with this care and make the techniques and practices his or her own. The WOC nurse might instruct in current practices, but in order to incorporate the ostomy into his or her life, the patient may fine-tune some of these new procedures until they work well for them.
How to Empty
There are many ways of emptying a pouch, and while the WOC nurse will instruct patients on methods of emptying, the person will adjust the practices to suit her or her lifestyle, along with ease of performing the tasks. Once the patient is comfortable enough to rework the instructions into his or her routine, it is a sign of the beginning of adjustment to the stoma.
Emptying the pouch into the toilet after placing toilet tissue in the bowl to prevent splash back is the most common way to empty pouches (Colwell & Fichera, 2005). Sitting on the toilet emptying the pouch between the legs and in the case of a fecal ostomy, cleaning the bottom edge with toilet tissue is a practice used by many people while others turn the end of the pouch back on to itself to form a cuff with a pouch that uses a clamp. Some people find it easier to face the toilet and empty the pouch down into the bowl, while others use a two-piece system, detach the pouch from the skin barrier and empty into the toilet, and then replace the pouch on the flange. This is an area that the patient can adjust to his or her own comfort level, front facing, back facing, or standing, patient preference can be accepted and can help the patient to feel some control over his or her care.
Some people with a fecal ostomy wish to rinse out the pouch, either with each emptying or daily, although this is not necessary, as long as the tail edge of the pouch is kept clean. Pouches are manufactured to be odor proof, which means they will contain the odor in the pouch; however, when the pouch is emptied, there may be some unpleasant odors. Pouches are available with gas filters that are charcoal and allow gas to escape from the pouch while absorbing the odor. These do not perform as well when the output from the stoma is very liquid, as in an ileostomy, as the liquid stool may clog the filter. There are in-pouch deodorants, odor eliminators, and systemic pill deodorants than can assist in the elimination of odor when emptying pouch. (See Chapter 12 and Box 11-2 for simple pouch emptying instructions.)
BOX 11-2 Instructions for Pouch Emptying
1. Sit on the toilet, as far back as possible.
2. Hold up the pouch and remove/open the bottom of the pouch (clamp or plug tip).
3. Turn up the end of the pouch back on itself to form a cuff—plug tip or self-closure mechanisms form a spout when opened.
4. Place a piece of toilet paper into the toilet and drain pouch into the toilet (reduces splash back).
5. Clean cuffed end of the outlet with toilet paper or wipe—rinsing pouch is not necessary.
6. Undo the cuff—close the end of the pouch or fasten plug tip. If needed, in-pouch deodorant may be used at this time.
Based on Doughty, D. (2005). Principles of ostomy management in the oncology patient. Supportive Oncology, 3(1), 59–69; Bak, G.P. (2008). Teaching ostomy patients to regain their independence. American Nurse Today, 3(3), 30–34.
When to Empty
This is typically the first skill the person with a new ostomy must learn. It is the most frequent task they will have to perform with the ostomy, sometimes four, five, or six times daily with an ileostomy or urostomy, less often with a colostomy. It is very important that this skill be acquired before the patient leaves the hospital, and he or she should be able to demonstrate his or her ability to check the pouch for filling, empty, and close the end spout or use the clip successfully.
Since there is no sensation of urine or stool coming through the stoma, it means the patient must get into the habit of feeling the pouch to see how full it is. The pouch should be emptied when it is half to one third full to avoid strain on the adhesive seal, or sooner if the person finds this uncomfortable. As noted, as soon as they are able, the patient should be responsible for checking the filling of the pouch and alerting to the need for emptying. As recovery continues, the patient should be responsible for pouch emptying before discharge from the hospital, since they will be as soon as they get home.
Indications for Pouch Change
Most pouches are routinely changed twice per week or any time there is evidence of leakage or skin irritation. Usually itching, burning, and feeling of moistness under the skin barrier are indicators that there is moisture in contact with the skin under the barrier. Leakage outside the edges of the barrier should never be “fixed,” repaired, or taped over. Doing this merely traps the leakage onto the skin and will result in skin irritation or peristomal irritant dermatitis. Pouching systems should be changed as soon as possible whenever leakage is noted.
Many people with an ostomy will change the pouching system prior to sexual activity to ensure a leak-free experience, others may find that religious observations require a clean pouch; otherwise, most people establish a routine so that the pouching system is changed prior to any signs of leakage.
Before removing the pouch, the patient should assemble all the necessary equipment at hand so that they do not have to look for items once the pouch is removed and while the stoma is functioning. Most people keep their supplies together on a shelf or in a box or bag for all of their ostomy equipment, including the pouching system and any accessory products they are using paste, belt, tape, or scissors. If the stoma has been recently created, a measuring guide may be used to recheck the stoma circumference since it will shrink postoperatively. After a month or so, if stoma size is stable, a presized barrier may be ordered. If not using a presized skin barrier, it is best to trace the size from the measuring guide onto the paper on the back of the skin barrier, and cut out the skin barrier and apply paste (if used) prior to removing pouch. Most pastes contain alcohol, so allowing the alcohol to dry before application of the skin barrier helps to protect the skin from the effects of the alcohol.
Assessing Peristomal Skin
The skin around the stoma should not look very different from the rest of the skin. While the pouch is off, examine the area for any redness, rashes, or open skin areas. Inspect outer edges of where adhesive tape attaches to barrier for any signs of skin irritation.
Examine the adhesive side of the skin barrier to see if there is any erosion especially around the stoma opening. This might indicate that the pouching system has been in place for too long. If there are any changes to the peristomal skin such as breakdown, erosion, or rashes, instructs the patient to contact the WOC nurse for an appointment. It has been noted that many patients accept skin breakdown under the barrier as normal, they should be instructed that this is cause for a follow-up visit with the WOC nurse.
The stoma will shrink for some time after surgery due to decreasing edema. This means the patient will have to resize the stomal opening of the skin barrier until the size stabilizes. Most ostomy equipment comes with measuring guides that allow placing the openings over the stoma to facilitate selection of the correct stoma size. If the stoma size is not round, usually the WOC nurse will send home a pattern for the patient to trace onto to the skin barrier, but the patient must assess that the pattern to see if it remains the correct size while the stoma continues to shrink.
Peristomal Skin Cleansing
There are many products available for cleansing and protecting peristomal skin, if soap is used it should be rinsed off thoroughly and soap with oils should be avoided (Doughty, 2005). Most people use warm water and a paper towel that can be disposed of rather than washcloths that require laundering. The area should be wiped with warm water and patted dry. If the peristomal area has a large amount of hair growth, shaving or clipping should be considered, in case the hair interferes with adhesion of skin barrier or causes discomfort upon pouching system removal.
Removal of Pouching System
Some people remove the pouch in the shower and wash the peristomal skin with mild, non-oily soap and water. Others prefer to remove the pouching system in the bathroom and apply the system they have laid out ready for application. Gentle removal using a push pull technique from the top down helps to protect the peristomal skin from mechanical injury.
Placement of Pouching System
If the person received preoperative stoma site marking, the stoma location should be visible and application of the pouching system easily accomplished. Many people apply the skin barrier while standing, others find sitting or lying down easier, usually this is a matter of patient preference. For most people, it is important that the area around the stoma be as flat as possible to enhance the pouching system seal.
The spout part of the pouch is usually in the 6 o’clock position, which allows the effluent to fall to the bottom of the pouch and ease of emptying into the toilet. If the patient wears a belt this is the position that keeps the belt tabs in the 3 and 9 o’clock locations. This again can vary with patient preference.
Problem Identification, When to Seek Assistance
Many issues with stoma management do not occur until the patient is at home, attempting to integrate the new ostomy into his or her actual existence. Richbourg et al. (2007) in a small survey identified some of the challenges the person with an ostomy commonly faces after discharge from the hospital—these include pouch leakage, skin irritation, odor, depression, or anxiety. Because of this, the authors recommend WOC nurses remaining in contact with their patients and in fact calls for the creation of nurse-run ostomy clinics. These clinics would provide the patient with assistance in incorporating the ostomy into their lives and dealing with these common problems associated with a new ostomy.
The United Ostomy Associations of America (UOAA) has published recommendations for the patient on when to call his or her doctor or nurse (Box 11-3). The person with a urostomy, who develops fever, chills, abdominal or retroperitoneal pain, and bloody, cloudy, or foul smelling urine may have a urinary tract infection, and should seek an appointment for follow up (Bak, 2008).
BOX 11-3 When to Seek Medical Attention
Severe cramps lasting more than 2 or 3 hours.
Deep cut in the stoma.
Excessive bleeding from the stoma opening (or a moderate amount in the pouch at several emptyings).
Continuous bleeding at the junction between the stoma and skin.
Severe skin irritation or deep ulcers.
Unusual change in stoma size and appearance.
Severe watery discharge lasting more than 5 or 6 hours.
Continuous nausea and vomiting.
No stoma output for 4 to 6 hours plus cramping and nausea.
Increase in the frequency the pouch requires emptying.