By Diana L. Gallagher MS, RN, CWOCN, CFCN
Part 1 in a series focused on ostomy management.
As a CWOCN® (Certified Wound Ostomy Continence Nurse), I have always been surprised that not everyone shared my passion about caring for and about ostomy patients. Ostomy management is one of my chosen specialties. Parents love each of their children and should not have a favorite. Managing multiple specialties is a lot like being a parent. I love each of my specialties for different reasons but, if I were forced to choose only one, caring for ostomy patients would be the winner.
The reality is that nursing is a diverse profession with a multitude of incredible specialties. Most specialty nurses are just as passionate as I am about their chosen field, and I understand that. Specialty practice is a unique blend of compassion, competence, and formal and ongoing focused education. Ostomy management is more than a set of skills owned by a nursing specialty; it is something that every clinician should be able to manage. Not every facility has a CWOCN on staff and the likelihood that you will have to care for an ostomy patient is very high. A nurse may encounter a patient with an ostomy in any specialty and any setting. It is because ostomy management is a skill that is needed in EVERY area of nursing that it is disappointing that more nurses have not developed a level of comfort and competence in basic ostomy management.
Every ostomy specialist has heard the "horror stories". The stories have a common theme; the nurse is normally very nice, good at other nursing tasks, but simply did not know anything of substance about ostomies. I cannot count how often patients have shared that while doing a routine assessment, a nurse would clearly communicate his/her distress at having to include an ostomy into a patient's routine care. Some even report remarks such as, "Oh, you have one of those."
Other patients share their frustration that their health care provider failed to read the chart and understand their situation. It may be as simple as a request to position for a rectal procedure or prostate exam only to have to be reminded that there is no longer an opening for that. An all too common problem is a leak after a well-meaning nurse applies ostomy paste over the entire back of the ostomy wafer not understanding that "paste" is a misnomer and the product is actually caulking. Just last week, a patient who was dependent on nursing for her care, understood that the burning that she suddenly experienced was a leak only to be told by her nurse that the ostomy was not leaking because the outer seal was still intact. The stories are endless, but being a common failure in practice does not make the situation any less distressing for the patient. Every health care provider, both nurse and physician, has a responsibility to provide basic care and intervention as well as a responsibility to refer when the situation exceeds the provider's skill set.
Ostomy Care: Building a Foundation of Knowledge
As a nursing student, I do not remember learning a great deal about ostomies. I mastered anatomy and physiology and developed basic competencies in medical/surgical nursing during both of my early nursing programs. I had a fair base of knowledge about gastroenterology and urology but that knowledge did not directly transfer to ostomy management. Looking back, I was a good student but my preparation left me ill-equipped to manage the emotional and physical needs of an ostomy patient. I would imagine that my experience was not that different than most.
I was a novice nurse when I encountered my first challenging ostomy patient. The experience has stayed with me for decades. It was a weekend shift and on my initial rounds, the patient's ileostomy pouch was leaking. I changed it using my basic skills and the patient's guidance only to have it leak again before lunch. I changed it again and sadly, a few hours later, the pouch leaked again. I explored my resources. The hospital had two certified ostomy nurses on contract but neither worked on the weekend. I sought help from my charge nurse who referred me to an LPN named Beverly. I remember asking if "Bev" was especially good with ostomies only to be told that since she had lived with her ostomy for decades, she might be able to help.
As a novice nurse with less than six months on that floor, Bev had been one of my "go to" resources. She had strong clinical skills and had repeatedly offered me excellent counsel. I was as close to Bev as I was to my preceptor and my charge nurse and I had no idea that she had an ostomy. I had never met anyone living and working with an ostomy. I was amazed. In that era, we all wore traditional white uniforms. Bev was always the image of professionalism in a uniform with a straight skirt. We had sat side by side in a tightly crowded room for report. I couldn't see a pouch and had never caught even a whiff of odor. I had worked with both of the ostomy specialists but it was Bev who patiently taught me to "crust", dry completely, and create a flat pouching surface. Together, we repouched my patient and the pouch held for days! Every novice nurse deserves to have someone like "Bev" but, sadly, all too often that is not the case.
What Every Nurse Needs to Know About Ostomy Management
Earlier this year, I was honored to help edit a nursing text book and the experience helped me understand why nurses are not as familiar with ostomy management as I would like. It is important to look at situations from a variety of perspectives. My viewpoint, as a clinician, was that I would like to see students provided with multiple experiences that would allow them to develop comfort and competency with ostomy patients. However, every educator will tell you that time and resources are very real challenges. There is simply not enough published about ostomies and not enough time to adequately teach the subject matter. From the student's perspective, there is the reality of information overload; only so much material is going to be retained.
But the challenge remains. Nurses do not necessarily need to be experts in managing ostomy patients unless they opt to specialize, but every nurse needs a basic level of knowledge and skill. Every patient deserves to have a caring and competent nurse. Over the next few months, this blog will explore the basics that every nurse should know, offer resources for additional information, teach basic pouching and provide a few tricks that may help with more challenging situations. Not every nurse is going to have an affinity for ostomy care. Some nurses will honestly share that they do not like taking care of ostomy patients. The reality is that every nurse has specialty areas that they like and other areas that are their least favorite. I contend that sometimes favorites are determined because of a pattern of successes. Even IF ostomy management is not your favorite, you need to know basic management skills. This will save your patients from pouch failures which can be devastating to their skin and self-confidence and by doing to job right the first time will save you from repetitive work.
Regardless of the setting that you work in, you are likely to encounter a patient with an ostomy. This series will help you competently care for your patients who are living with an ostomy. Perhaps it will pave the path toward an interest in learning more and even considering certification. At the very least, it will give clinicians accurate information and resources and offer ostomy patients the help that they critically need.
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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.