Impact of an Ostomy on Self-Image/Self-Concept
Factors Affecting Ability to Adapt
Past Experience with Ostomy/Expectations
Support Provided by Significant Others
Assistance Provided by Health Care Team/WOC Nurse
Sexual FunctionPotential Impact of Pelvic Dissection on Sexual Function
Potential Impact of the Ostomy on Body Image/Sexual Relationships
Special Considerations/NeedsChemotherapy and Radiation Therapy
Physical and Mental Limitations
ConclusionsImpact of an Ostomy on Self-Image/Self-Concept
The goals of successful adaptation to an ostomy are to restore or improve the lifestyle the person had before the surgery. This process begins in the period before surgery and continues throughout the postoperative period where the person must learn new self-care techniques and adjust to changes and a lack of control of body functions. Research has shown that some psychological factors related to ostomy adjustment are not disclosed by patients unless asked by the nurse (White, 1998). In the immediate postoperative period, the patient’s ability to learn ostomy care is complicated by the need to accept and integrate the fact that the ostomy is present (Sirota, 2006a, 2006b). The WOC nurse can help facilitate transition and adaptation to these changes. Knowledge about self-care is an important factor in adjustment to the ostomy so the WOC nurse can play a pivotal role in patient education. Issues of social isolation, sleep disturbances, sexual dysfunction, and financial concerns have all been identified (Kenderian et al., 2013) in the postoperative period. It is important to discuss the potential for functional problems during preoperative counseling to allow the patient to begin to adjust to the changes and assess for these after surgery to facilitate adaptation.
CLINICAL PEARL
Preoperative appointment with a WOC nurse is very valuable in addressing any fears and anxiety the patient and family may have.
Stages of Adaptation Process
Borwell (2009) defines some milestones of psychological recovery such as beginning to look at and touch the stoma, then allowing others to look at the stoma, expressing interest, asking questions about care, beginning to take responsibility for aspects of stoma care, and finally, socializing with others. Ostomy patients adjust differently, so an individualized plan of care is vital. Gemmill et al. (2010) found that it took from many months to up to 10 years for patients to adjust and accept their urinary diversions.
The ability to adapt and adjust to an ostomy is a significant factor in how well a person can accept these changes in his or her life. Successful adaption is defined by Black (2004) as a return to everyday activities and relationships. Care planning to facilitate adaptation to the ostomy can be guided by the use of a theoretical framework such as the Roy Adaptation Model (Roy, 2009) or Orem’s Self-Care Model (Orem et al., 2001). According to Roy, the level of adaptation will affect a person’s ability to respond positively or negatively to situations. Roy (2009) described people as adaptive systems with biological and physical processes that are used to adjust effectively to changes in the environment. The two processes for individual coping are the cognator and regulator subsystems, which are integrated life processes that are manifested in a person’s behavior. The cognator subsystem include four cognitive–emotive channels of perceptual and information processing, learning, judgment, and emotion (Roy, 2009). According to Roy (2009), the process of adaptation is initiated when input or stimuli from the environment (internal or external) provoke a response in the human system. Three classifications of input or stimuli are identified in this model. The first classification is the focal stimulus or stimuli that are immediately affecting the system. Focal stimuli may be internal or external, and the system is aware of their presence. The contextual stimuli are all other stimuli that contribute to the effect of the focal stimulus, including age, gender, race, education level, insurance coverage, diagnosis, and household living situation. The residual stimuli are unknowns related to the presence of having an ostomy (Roy, 2009). The behaviors that result from the control processes of the regulator–cognator subsystem are observed in four adaptive modes (Roy, 2009) that are the physiologic, self-concept, role function, and interdependence modes. Roy defined the physiologic mode as “the physical and chemical processes involved in the function and activities of living organisms” (p. 89). Elimination is one of five physiologic needs in this mode. According to Roy, physiological integrity or the degree of wholeness attained by adapting to changes in elimination is necessary for individual health and functioning.
Roy (2009) describes the self-concept mode as “the composite of beliefs and feelings held about oneself that is formed from perceptions of others’ reactions” (p. 95). It is made up of two subsystems, the physical self and personal self. A person views his or her physical self as a physical being with traits that include bodily appearances, bodily functions, sexuality, healthy states, and illness states. Feelings about the physical self may influence adjustment to having a permanent ostomy, so body image should be assessed.
The ability to engage in self-care activities is reflected in the role function mode (Roy, 2009). How individuals relate with others and the quality of one’s support systems constitute the interdependence mode. The level of social engagement was measured to reflect effective or ineffective interdependence mode adjustment.
Orem’s theory (2001) consists of three interrelated theories described as self-care theory, self-care deficit theory, and nursing system theory. Self-care theory describes why people act to take care of themselves. This is a learned behavior developed by active participation in self-care. Orem et al. (2001) defines the ability to participate in self-care as self-care agency. The self-care deficit theory defines when nursing is necessary to assist the patient with self-care. This can be determined by a thorough nursing assessment. Nursing systems theory describes the different relationships between the patient and the nurse to meet self-care needs. Orem et al. (2001) describe nursing agency as meeting the self-care needs of the patient while assisting the patient to develop self-care behaviors. Nursing agency occurs in three systems (Orem et al., 2001). The wholly compensatory system occurs when the patient is unable to perform effective self-care activities, so the nurse performs the care. The partly compensatory system occurs when then the patient participates in self-care but cannot meet all self-care demands. In the supportive-education system, the patient is able to perform self-care, so the nurse promotes this.
Orem’s theory (2001) uses a three-step nursing process that directs the nurse to use effective interventions to develop effective solutions. Nursing diagnosis and prescription can be determined by assessing the ostomy patient’s self-care demands and self-care agency (Martinez, 2005). Design for regulatory operation involves selecting interventions that promote self-care agency and developing a plan to implement these interventions. This includes encouraging the patient to look at the stoma and verbalize concerns about the ostomy (Martinez, 2005). Production and management of nursing systems includes reassessment and modifying interventions as the patient progresses towards self-care.
Factors Affecting Ability to Adapt
There are many factors that impact adaptation to the ostomy. These include the diagnosis that necessitated the ostomy, age, social support, and self-care ability. Bekkers et al. (1996) found that ability to take care of the ostomy using an ostomy pouching system that has a reliable wear time was an important factor in coping and adaptation to the ostomy. Psychosocial needs of ostomy patients can be met by identifying and monitoring those who experience difficulty adjusting to the ostomy and isolating the problem unique to the person (Simmons et al., 2009). The role of religion/spirituality in the ostomy patient’s life can be used for support. Li et al. (2012) found that spiritual well-being was associated with psychosocial adjustment to the ostomy.
There are many tools available to measure adjustment to an ostomy. One example is the Ostomy Adjustment Inventory-23 (OAI-23), a 23-item self-report tool that assesses psychosocial adjustment to an ostomy (Simmons et al., 2009). The Ostomy Adjustment Scale (OAS) is a 34-item tool to measure psychological and social adjustment and another example of a way for the WOC nurse to assess adjustment (Olbrisch, 1983).
Self-Esteem/Coping Skills
Persson & Hellstrom (2002) and Williams (2012) found that altered body image was a central theme in adjustment to stoma. Once the initial stress of the surgery and recovery is resolved, body image, physical appearance, and sexuality become greater concerns. Identification of coping skills used for other life stressors may help the patient with a new ostomy apply these skills to adapting to the ostomy. Gemmill et al. (2010) found gender differences in psychological well-being with women having significantly lower scores than did men and found that over 75% of participants had difficulty adjusting to the ostomy. The average participant had undergone surgery 9 years prior to the study concluding that many people have long-term difficulties with ostomy adaptation. They also found that mastering self-care was an important part of adjustment to the ostomy.
Past Experience with Ostomy/Expectations
Identification of previous experiences with ostomy and exploring expectations of the person anticipating ostomy surgery are needed in a baseline assessment. Preoperative counseling should include an assessment of how the disease has affected his or her functional abilities, lifestyle, and sexuality. Negative previous experiences with an ostomy can result in anxiety and fear in the person facing surgery. Exploration of the details of this and education about current management strategies can help allay fears. Anticipation of the change in body function and body image by forward planning allows the ostomy patient to predict the loss and assume a more positive approach that will promote adjustment (Borwell, 2009). The person who has undergone emergency surgery has not had that opportunity prior to surgery, so this should be considered in the postoperative period.
Support Provided by Significant Others
The WOC nurse should discuss the amount of involvement of family or significant others and determine from the patients if this meets their needs. Including significant caregivers in ostomy teaching can ease transition from hospital to home, ease fears, and facilitate adaptation for the patient with a new ostomy.
Assistance Provided by Health Care Team/WOC Nurse
The WOC nurse and the multidisciplinary team including the surgeon, dietician, nursing, and discharge planners collaborate with the patient to provide education, psychosocial support, physical care, management of complications, and long-term follow-up.
Impact of Ostomy Visitor
The support of an ostomy visitor can be invaluable to the patient undergoing a new ostomy procedure. Ostomy visitors are former patients who have an ostomy and have received specialized training, so they can assist the patient’s transition to living with an ostomy, and share experiences, although this should not substitute for professional medical advice in any way. Many take advantage of online resources for support and education (see Appendix B).
Ostomy support groups can enhance recovery from surgery and promote adaptation by providing an atmosphere of acceptance and mutual respect and helping to develop coping skills to manage day-to-day life with an ostomy. These groups provide peer support and role modeling for people with ostomies. Many WOC nurses facilitate ostomy support groups. The WOC nurse also can encourage patient participation in these groups as they follow the patient through his or her pre- and postoperative course (Cross & Hottenstein, 2010).
CLINICAL PEARL
The WOC nurse should provide support and be a resource for the Ostomy support group.
Age/Developmental Stage
Knowledge about the lifespan, developmental stage, and basic human characteristics assist the nurse to make an accurate assessment of the individual’s psychosocial needs (Sirota, 2006a, 2006b). An adolescent with a new ostomy will have different challenges than an adult in a stable married relationship in terms of sexuality, body image, and socialization (Sirota, 2006a, 2006b). Nursing care must be individualized to the person’s situation for best results. The psychosocial phase of adolescence is described by Erickson as identity versus role confusion where altered body image and appearance are the focus. They may also fear loss of sexual function and inability to have a normal relationship (Junkin & Beitz, 2005). The WOC nurse must ensure privacy for the patient, and consider using a low-profile appliance to ensure that the appliance is concealed under clothing. Elastic-type support garments are available to secure the ostomy system. Facilitating an ostomy visitor who is the same age is often beneficial.
For the young adult, intimacy versus isolation is the focus of this phase. The ostomy patient may fear rejection or commitment at the time when long-term relationships may develop. Support of the patient by family and significant others can facilitate adaptation. Educating and including the significant other can allay fears of both partners. Partners sometimes have fears of hurting the patient or the stoma that can be allayed with open communication.
The focus of the middle-aged adult in Erickson’s model is generativity versus stagnation. Fears of loss of occupation or spouse and role changes dominate this phase. Assessment of job role and how care of ostomy will impact this are important in the preoperative phase. Does the patient travel? Is heavy lifting required? What are the bathroom facilities like in the work setting? These discussions will help the patient and nurse determine individualized management strategies to ease the transition back to work.
For the older adult, integrity versus despair is the phase. At this stage, loss of spouse and independence, loneliness, and change in living environment are the primary concerns. Physiologic and psychological changes related to the ostomy are compounded by other medical problems. Maintaining a positive attitude, continuing the usual daily routine, and not allowing the ostomy to interfere with normal life are helpful in the elder (Reynaud & Meekder, 2002). Brief frequent teaching sessions with small amounts of information work well for the elder. Assessing and modifying care for the ostomy patient are important for adaptation. Does the patient have arthritis or other conditions affecting mobility? Are vision and memory adequate for self-care? (See Chapter 12).
CLINICAL PEARL
It is important to include another family member during the teaching sessions.
Sexual Function
Potential Impact of Pelvic Dissection on Sexual Function
Pelvic surgery, cancer, and radiation therapy can have a short- or long-term impact on sexual health (Junkin & Beitz, 2005). Men can develop erectile dysfunction, retrograde ejaculation, and loss of libido, while women can experience loss of desire, dyspareunia, and vaginal dryness (Majid & Kingsnorth, 2002) after ostomy surgery. The shape and angle of the vaginal vault change when the rectum is removed. Erectile dysfunction can be temporary or permanent. Men with urinary diversions have a high rate of erectile dysfunction. Pelvic radiation may also cause symptoms of vaginal stenosis and dryness. Vaginal lubricants are helpful for some women as is experimentation with different positions to determine which is most comfortable.
The WOC nurse should reassure the patient that giving and receiving sexual pleasure can continue to be a part of his or her life, even if different because of bodily changes after ostomy surgery (Junkin & Beitz, 2005).
Potential Impact of the Ostomy on Body Image/Sexual Relationships
Persson & Hellstrom (2002) found that altered body image was a central theme in adjustment to stoma.
Concerns about appearance of the stoma and ostomy system, odor, noise, potential for leakage, and fear of abandonment may occur, often after the acute fear of surviving the illness (Lamb, 1990). Careful assessment, guidance, validation of experiences, education about disease and impact on sexual health, and referrals when indicated form the basis of the WOC nurse role in this area of care (Junkin & Beitz, 2005). A baseline preoperative assessment of sexual functioning will assist the WOC nurse to identify postoperative concerns. Basic suggestions for managing sexual relations should be given to the patient and partner including being prepared for sexual activity by having a clean, secure, and empty pouching system and maintaining open and clear communication between partners (Junkin & Beitz, 2005).
The stoma should never be used for sexual purposes. Firm objects may damage the bowel or mucocutaneous junction, cause bleeding, and cause possible scarring and constriction since the bowel does not distend like the rectum. Stimulation of the stoma will not produce the pleasurable response that may be experienced with stimulation of the anal area as the stoma is not an erogenous area.
PLISSIT Counseling Model
Permission, Understanding-Limited Information, Specific Suggestions, Intensive Therapy (PLISSIT) (Anon, 1976) provides four levels of response to issues with sexual health and encourages the nurse to intervene at the level he or she is most comfortable with. WOC nurses should be able to function at permission and limited information stage (Junkin & Beitz, 2005). It is important for the WOC nurse to be aware of his or her own personal attitudes and values toward sexuality in order to identify sexual health needs in their patients (Ayaz, 2009; Junkin & Beitz, 2005). Understanding anatomy and physiology of male and female reproductive system and nervous system function will help to teach patients about bodily changes.
The permission stage is a beginning exploratory phase that helps the person acknowledge that he or she needs assistance to discuss sex. Active listening and sensitivity are needed to assist the patient to express concerns or questions (Borwell, 2009). The use of open-ended questions, such as asking how the ostomy has affected relationship with the partner or what kind of changes the patient has experienced in his or her sexual life will encourage the patient to discuss and ask questions (Ayaz, 2009). It is important to instruct the patient that other ostomy patients may have the same problems they are experiencing.
The understanding-limited information phase allows the nurse to assess if there are any difficulties and if a referral to a WOC nurse is required. A sexual history, identification of problems and goals, and expectations of the patient should be identified so an action plan can be developed (Borwell, 2009). Interventions at this level are geared toward increasing the patient’s knowledge level in areas such as treatment side effects, emotional changes, and sexuality (Ayaz, 2009).
The WOC nurse can provide reassurance in the specific suggestion phase. Written information on sexuality can be provided. The United Ostomy Associations of America (UOAA) has many resources including Intimacy after Ostomy Surgery, Sex and the Male Ostomate, Sex and the Female Ostomate, and Sex and the single ostomate available on their Web site www.ostomy.org.
Pouch covers, minipouches, and specialized underwear are available. Internet search or ostomy supply catalogs have many options for undergarments to meet personal preferences. Experimentation with different positions may help if there is discomfort during intercourse.
The intensive therapy stage usually involves WOC nurse involvement to address possible psychological, interpersonal, or physical needs. The WOC nurse should be aware of appropriate resources and refer as needed (Anon, 1976).
CLINICAL PEARL
The WOC nurse should take time to ask and answer any sexual concern the patient may have.
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