by Susan Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary
Part 2 in a two-part series looking at the basics of preventing and managing moisture-associated skin damage in the long-term care setting. For Part 1,...
By Diana L. Gallagher MS, RN, CWOCN, CFCN
Part 2 in a series focused on ostomy management. For part 1, click here.
In order to teach patients, it is important to have some basic knowledge about ostomies. Sadly, as I shared last month, the majority of nursing students learn very little about ostomies or ostomy management. Most nurses have a good understanding of basic anatomy and physiology so this is not the focus of this blog. Instead, we are going to focus our attention on basic information that every nurse should know and competencies that every nurse should develop in order to provide quality care to their patients.
Patients facing ostomy surgery and those rehabilitating after the creation of an ostomy may be overwhelmed. Sensitivity and an appreciation of a patient's emotional state is important. They need to understand that their feelings are normal. They may still be reeling from a relatively new diagnosis of cancer, or grieving the loss of their bowel or bladder. They may be angry and feel that their body (and fate) have betrayed them. They may be afraid of the unknown, their change in body image, and dread how others will react to them. For many, it is hard to imagine any positives in living with an ostomy.
It is critical that you support patients in their grieving process and help them move forward. Accurate knowledge will be important to dispel misperceptions and negative concepts about living with an ostomy. Address your patient's concerns and offer solutions. If you are in a facility with a certified ostomy nurse (CWOCN or COCN) or a dedicated ostomy support nurse, please facilitate a consult. Those specially trained nurses will take the lead, but your interactions are equally important.
For example, a patient with a colostomy will be taught that odor can be effectively managed but that lesson will be rejected if every time staff walk into the room, odor eliminators are being sprayed. If a pouching system is intact and a filter is functional, there should be no odor. If there is odor, it is a great opportunity for teaching. It is time to check the security of the pouch and if there is a leak, use an immediate pouch change as a teaching opportunity. There is a natural odor that accompanies stool and that is still a reality when a patient has an ostomy. When a pouch is being emptied or if there is a leak, odor may be present, but when a pouch is securely in place, there should be no odor. With some patients, a sense of humor will help but with others, there may be nothing funny about any of this. Accept and support your patient but with repeated contacts, you may also need to use a bit of gentle nudging.
In a perfect world, every patient receiving an ostomy would benefit from an ostomy specialist for pre-operative ostomy education and stoma siting, a great stoma on a flat surface, ongoing ostomy teaching delivered in small, easily absorbed lessons, and appropriate follow-up. It is no surprise that we do not live or work in that perfect world. There may not be an ostomy specialist available. There may have been no opportunity for pre-operative education or stoma siting. This may happen because of a lack of awareness about its importance or because the ostomy was an emergency with no time or chance for anything more than urgent surgery. With advances in technology, hospital stays are dramatically shortened and patients may be discharged with an ostomy after just 2-3 days in the hospital. That is now the reality and we MUST still give our patients a firm footing to begin living their lives with an ostomy.
Your time with a patient will be limited so it will be important to make every minute count. When possible, match your teaching with an individual's optimal learning style. You can ask a patient how they learn best, but most patients are not going to know. Rely on models based on age appropriate learning as well as being a good detective. There are clues. Have you noticed your patient reading? If so, printed material should be appropriate. Is their smart phone always within reach on the bedside table? If so, videos may be their choice. Whenever possible, maximize your time with patients and teach with every encounter.
Teaching is more than formal, planned education; teaching happens with every interaction. When planning education, control those things that we can to make teaching more successful. If a patient is relying on the support of a significant other, schedule times to allow that support person to be present. If an ostomy is active, plan pouch changes at a time when the patient has not had anything to eat or drink for approximately 2 hours. Because of shorter acute care stays, some patients with colostomies or ileostomies may not have normal output until they are home.
In teaching, introduce basic information including key vocabulary. Remember: KEEP IT SIMPLE!
With the reality of short stay surgeries, a patient MUST BE able to demonstrate emptying their pouch before hospital discharge. They should have supplies for at least two complete pouch changes and access to ongoing education and support. That may be an ostomy specialist, home health, home teaching kits, online resources and/or sampling programs. Additional lessons on pouch changes and skin care are a bonus in the inpatient setting.
If you are in the role of teaching basic ostomy management, you will help your patient transition from successfully emptying their pouch to actually replacing their pouch. This is a BIG step for patients. They may be anxious and feel that they will NEVER be successful by themselves but with each pouch change, confidence will build. Reinforce successes and offer praise when appropriate.
Getting Started: Before beginning, teach patients to gather the necessary supplies. They should have a measuring guide, moistened paper towels, wash cloths or appropriate ostomy wipes, a way of drying the surrounding skin and the pouching system to be used. In addition, scissors may be needed to cut an opening that matches the size of their stoma or if they are using a moldable system, scissors will not be necessary. Sampling programs may have provided your patients with countless accessory products. They all have a role but as a general rule, less product is normally better. Teach patients to make ostomy management as simple as possible.
Ostomy Pouch Removal: With the gathered supplies readily available, gently remove the existing pouch. Some patients may prefer to remove their pouch in the shower while others remove the old pouch in the bathroom with their supplies readily at hand. Using a warm, moistened paper towel or washcloth, gently push down on the skin while lifting on the corner of the pouch. Begin at the top edge and work down to capture any stool or urine that can be captured in the old pouch. Once removed, the pouch can be discarded in one of the disposal bags that some companies provide or in any small trash bag. Do not tie the bag closed until you complete the pouch change so that you can add any additional items to be discarded. Now that the abdomen is bare, examine the stoma and surrounding skin.
New stomas will have visible sutures at the junction of the base of the stoma and the skin edge. Loop stomas may have a plastic bridge supporting the loop of bowel or a section of a red rubber catheter. These supports will normally be left in place for 7-10 days. A urinary stoma will have small stents that will normally remain in place 7-10 days. Both of these time frames may be extended based on physician preference and the patient's potential for healing. If there is a significant amount of hair around the stoma, shaving or clipping the hair may be necessary. It is important to remember that a new stoma will be slightly swollen and measuring the stoma will be important until the edema is entirely resolved and the stoma's size is stable for several consecutive measurements. With both newly created stomas and mature stomas, it is always important to assess the surrounding skin for any change from normal skin anywhere on the body.
Stoma Cleansing: Cleaning the stoma and surrounding skin can be done in the shower with pouch removal if patients are careful to rinse the stoma and surrounding skin with plain tap water. If they are changing their pouch at the bathroom counter the same applies. Cleansing is done with plain tap water. Soap, baby wipes, or those popular bathroom wipes are not necessary and can actually interfere with pouch adherence. Once clean, the skin surrounding the stoma should be completely dry. Fanning or a hair dryer on cool will help dry the skin quickly.
Ostomy Pouch Application: After the stoma has been measured, you will need to cut an opening that matches the measurement on the back of the barrier. If a one-piece pouch is being used, be sure to pull the pouch away to prevent cutting into the plastic. The opening should match the size of the stoma leaving no exposed skin. Soft paste strips, rings or paste caulking may be used at the cut edge to help seal the junction between the stoma and skin edges. Remember that stoma paste is NOT an adhesive but is only caulking. Secure the prepared barrier onto the skin and if a two piece system is being used, you will now add the pouch. If a patient has a new stoma and a tender abdomen after surgery, the pouch can be attached to the barrier BEFORE placing the barrier onto the skin. Encourage patients to place their hand over the stoma and appliance and apply light pressure for several minutes. This will help secure the seal.
Frequency of Pouch Changes: When a drainable pouch is being used, changes should be scheduled every 3-7 days depending on patient preference, the type of stoma, characteristic of the effluent, and type of pouch that is being used. Patients with a low colostomy and regular, formed stools may opt for a closed end pouch that can be changed with each bowel movement- normally once or twice a day. Regardless of when the next scheduled change is, patients need to be prepared to do an immediate change for any burning or itching around the stoma, noticeable odor (pouches are odor-proof when intact) or a clear indication of a leak.
With each lesson, encourage an increasing level of patient involvement with a goal of complete independence within a reasonable number of lessons. Review the lessons with each visit and add new information and accessory products when appropriate.
Teaching is about more than managing basic pouch changes. With so many good options available, patients need to be able to select supplies that best meet their lifestyle. If a CWOCN is available, he/she may be very helpful in identifying the best options and helping place the initial order. Options include but are not limited to standard vs extended wear, one piece systems vs two piece systems, adhesive coupling vs snap together two piece systems, flat vs convex barriers, fecal vs urinary options, drainable vs closed end, clear vs. opaque pouches, filtered vs non-filtered pouches, and options in pouch size and length. Ostomy supplies are readily available from a wide number of sources such as specialty pharmacies, companies offering durable medical equipment, and online catalog companies. You may need to help patients find the best distributor for the equipment that they need and one that works with their insurance. Most policies will pay 80% of Medicare allowable charges and most ostomy supplies have limits based on normal medical necessity.
In addition to teaching basic pouch changes, it is your responsibility to teach patients how to live full and productive lives with their ostomy. That includes basic information such as emptying a drainable pouch whenever it is one-third to one-half full. Pouches should be emptied directly into the toilet from a sitting position whenever possible. Although pouch failures should be rare, ostomy patients should be taught to ALWAYS travel with the equipment necessary for an unexpected pouch change. As patients are recovering, it is important to remember that they have had abdominal surgery. Lifting more than ten pounds may increase their risk of complications such as the development of a hernia.
Good nutrition is important for healing but nutrition is another area that will require some teaching. Patients with an urostomy will need to drink adequate amounts of fluid throughout the day to maintain a continuous flow of urine and prevent infections. The recommended amount is at least 30cc/kg/day consumed at regular intervals throughout the day. Patients with an ileostomy are at a higher risk of bowel blockage because of the decreased lumen of the small bowel. This can cause insoluble fiber to lodge near a fascia-muscle layer. Although there are common foods that have been tied to an increased risk of blockage, other foods can cause blockage as well.
Patients need to judiciously add foods such as corn, cabbage, celery, popcorn nuts, raisins, etc., in small amounts that are consumed slowly, chewed well and taken with plenty of fluids. In addition, because ileostomy patients no longer have the colon available to reabsorb water from the stool, increased intake of fluids must be encouraged. Dehydration is a common complication in the early post-op period. Colostomy patients will advance their diet like most surgical patients and may maintain a low-residue/low-fiber diet during the first few weeks until their edema has resolved. After that, they can eat any of their favorite foods.
Sexuality is a very real part of being human. When providing pre-operative or post-operative ostomy teaching and support, it is important to introduce the topic of sexuality. You cannot wait for your patient to ask, you have to open the discussion so that patients are comfortable addressing any concerns that they may have. Sexuality needs to be discussed with every post-adolescent patient. This is regardless of sexual orientation, marital status, or age.
Finally, patients are entitled to ongoing support as they adjust to their life with an ostomy. The United Ostomy Association of America is a wonderful resource, providing access to local support groups and a wide variety of online discussion rooms. With nurses providing quality education and facilitating ongoing support for patients, hope will be infused, independence reestablished and a normal life regained.
This blog is intended as a cursory overview of basic ostomy management. Space and the intent of this blog are not intended as a comprehensive outline on best practice for assisting ostomy patients. Nurses who would like to know more about ostomy management should seek further information and specialty training.
About the Author
Diana Gallagher has over 30 years of nursing experience with a strong focus in wound, ostomy, continence, and foot care nursing. As one of the early leaders driving certification in foot care nursing, she embraces a holistic nursing model. A comprehensive, head to toe assessment is key in developing an individualized plan of care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.