evidence & practice / clinical investigations series
STOMA CARE
Post-discharge care for patients following stoma formation: what the nurse needs to know Burch J (2017) Post-discharge care for patients following stoma formation: what the nurse needs to know. Nursing Standard. 31, 51, 41-45. Date of submission: 23 June 2015; date of acceptance: 22 December 2015. doi: 10.7748/ns.2017.e10198
Jennie Burch Head of gastrointestinal nurse education, St Mark’s Hospital, Harrow, England Correspondence [email protected] @jenburch24 Conflict of interest None declared Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software Contributing to the clinical investigations series To suggest an article for the series, please email [email protected] with a synopsis of your idea Online For related articles visit the archive and search using the keywords. Guidelines on writing for publication are available at: rcni.com/writeforus
Rationale and key points
This article discusses post-discharge care for patients following stoma formation. While the patient is taught the practicalities of managing the stoma appliance in hospital, this learning should be integrated into their daily life following discharge from hospital. Nurses are required to consider and address any issues that might affect the patient in the long term. These include changes in body image, adapting to having a stoma, preventing or treating complications associated with a stoma, and long-term follow-up. »» Most patients manage successfully with their stoma following a period of adaptation. »» Follow-up for patients with a stoma can occur over the telephone and/or face-to-face in the patient’s home or in the clinic. »» There are several support groups in the UK that can be accessed by patients with a stoma. »» Patients should seek advice and assistance from a stoma specialist nurse if any issues related to the stoma arise, such as leakage or sore peristomal skin.
Keywords
colostomy, ileostomy, peristomal skin, post-discharge care, stoma care, urostomy
Learning outcomes
After reading this article you should be able to: »» Understand the needs of a patient with a stoma following discharge from hospital. »» Recognise potential stoma-related complications, as well as treatment options. »» Advise patients with a stoma about the support available to them.
Stoma supplies
Before the patient is discharged from hospital, it is essential for the stoma specialist nurse to provide them with stoma supplies and to discuss how they can obtain further supplies in the future. Many patients with a stoma choose to have stoma supplies, such as stoma appliances and any accessories, delivered to their home, although collection from a chemist is also possible. A prescription for stoma equipment will
be required from a GP or nurse prescriber; however, having a permanent stoma will qualify the patient for a prescription fee exemption, irrespective of age. The patient’s stoma supplies should be replenished regularly and will have to be reordered each month; however, it is important that the patient does not accumulate large amounts of stock, which may lead to wastage. Skipper and Fake (2015) provided guidance on the average number of stoma appliances required in the management of a stoma, suggesting that a patient with a colostomy requires one to three bags per day. If the quantity used exceeds this, a review with the stoma specialist nurse will be necessary, because there may be an issue with the stoma itself.
Follow-up
There are no national standards to guide follow-up for patients with a stoma.
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evidence & practice / clinical investigations series
Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Readding (2005) stated that while an annual follow-up is not standard in the UK, a yearly review of the patient with a stoma is necessary to examine the stoma, and to assess the effectiveness of any products and whether the person is managing effectively. The Association of Stoma Care Nurses (ASCN) (2015) in the UK, recognised the importance of regular follow-up to identify and address any concerns the patient might have. Follow-up can ensure that expensive stoma products are being used effectively, as well as preventing the development of stoma-related issues (Persson et al 2010). Effective use of stoma products is important because the cost of stoma products for the 120,000 people with a stoma in the UK, represents 2.3% of the NHS prescribing budget (Mangnall et al 2013, Boyles and Hunt 2016). The cost of stoma appliances varies widely depending on the manufacturer, whether the patient uses one-piece, two-piece or convex appliances, and whether the stoma is prone to leaking, which requires frequent appliance changes. The optimum method of follow-up is unknown; however, it can take the form of telephone clinics, community nurse home visits or hospital-based consultations with a stoma nurse specialist. While certain factors, such as the patient’s diet can be addressed on the telephone, issues with peristomal skin, for example, require physical assessment of the patient. This assessment can take place in the individual’s home or in a hospital clinic. Davenport (2014) suggested that follow-up should consist of a telephone call within one week of the patient’s discharge from hospital, followed by a home visit at two weeks, then three-month, six-month and annual reviews. While Williams et al (2010) found that skin-related issues were common in patients with a stoma, Herlufsen et al (2006) reported that many patients did not recognise such issues, supporting the requirement for periodic review.
Psychological issues
A stoma can affect patients in various ways
(Grant et al 2013). Changes in body image are commonly reported, with individuals finding the physical changes resulting from the stoma emotionally challenging. Patients might also experience anger about their stoma, which can result in some neglecting their stoma care (Grant et al 2013). Research has shown that patients have a variety of concerns relating to their stoma, including that the stoma appliance will leak onto their clothes, which can result in low self-esteem (Salter 1992). It has also been found that 20-25% of patients experience psychological issues following stoma formation (Wade 1990, White and Hunt 1997). Depression in patients following stoma-forming surgery has been reported (Krouse et al 2009); however, this tends to resolve in the months following the operation (Notter and Chalmers 2012). One study found no apparent differences in quality of life for patients with rectal cancer and a permanent stoma, compared to patients with rectal cancer without a stoma (Pachler and Wille-Jørgensen 2012). Quality of life was also found to improve in the first few months after a stoma was formed, as a result of patients becoming accustomed to their altered physical circumstances (Pittman et al 2009).
Supporting patients
Nurses can encourage patients with a stoma to recommence aspects of their former life, such as physical activity, when they feel well enough, thus enhancing their confidence. It is also important for nurses to encourage patients to have contact with their friends and family, as well as stoma support groups (Box 1). In addition, spiritual and faith-related centres, such as churches, BOX 1. Stoma support groups »» Colostomy Association: www.colostomyassociation. org.uk
»» The Ileostomy and Internal Pouch Support Group: www.iasupport.org
»» Urostomy Association: https://urostomyassociation. org.uk
(Last accessed: 8 August 2017.)
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mosques and temples, can assist patients with a stoma in adapting to their altered physical identity (Li et al 2012). Activities such as showering and swimming are possible with a stoma, and nurses can advise patients that bathing or showering is appropriate. Patients should be advised to bathe or shower with the old stoma appliance in situ, changing to a new appliance afterwards. Nurses should also advise patients with a stoma that swimming should be undertaken when the appliance is empty and that it is necessary for the appliance to be in place for at least one hour before it becomes wet. While specialist swimwear is available to purchase online, any swimwear or clothing can be worn.
Sexual relations
There are potential issues related to physical relationships for patients with a stoma. Where the placement of a stoma has the potential to affect the nerves in the groin and cause erectile dysfunction, the patient should have received counselling about this risk before surgery. In general, it is possible to continue sexual relations following stoma-forming surgery, and there are a range of methods that patients can use to increase their confidence engaging in intimate relationships. Simple advice includes emptying the stoma appliance before sexual activity. Patients might also choose to disguise the appliance using underwear or a specialist belt that can retain the appliance next to the abdomen so that it does not move during intercourse. Such products are available online or through support groups and stoma specialist nurses.
Common stoma-related issues
patients with a stoma experienced skinrelated issues, while Salvadalena (2013) found that 63% of patients with a stoma experienced sore skin (Figure 1) within the first three months of stoma-forming surgery. A study of UK stoma specialist nurses found that the most common cause of sore skin was output from the stoma leaking onto the skin (Burch 2014). Therefore, it is essential to ensure the stoma appliance is securely attached to the patient’s abdominal wall to prevent it from leaking onto the peristomal skin. Should the patient develop sore peristomal skin, this will often heal quickly with treatment, including careful cleaning and drying, resizing the stoma appliance aperture, and accurately repositioning the appliance over the stoma. Stoma powder can be used on skin around the stoma that is wet, sore or broken. To prevent the development of sore skin, a protective skin barrier in the form of a wipe or spray can be used following cleaning and drying of the skin and before a new appliance is attached. Prolapsed stoma A prolapsed stoma occurs when the patient’s bowel protrudes through the stomal opening on the abdominal wall. The size of a prolapsed stoma can be significant and may fill the entire stoma appliance. There are larger appliances available that can assist in the management of a prolapsed stoma. The prolapse can be manipulated back inside the patient’s body by a healthcare professional. However, Figure 1. Sore peristomal skin
Common stoma-related issues include sore peristomal skin, prolapsed stomas, leaking appliances, retracted stomas, parastomal hernia and blockage. While some of these issues may never occur, many patients with a stoma will experience leakage from their appliance at some time. Sore peristomal skin Smith et al (2002) reported that 73% of
Alamy
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evidence & practice / clinical investigations series
some patients will experience a recurring prolapse, which may require surgery (Burch 2008). Leaking appliance Richbourg et al (2007) found that 62% of patients with a stoma reported leakage from their stoma appliances. More recently, Ratliff (2014) stated that 87% of respondents in a study of patients with a stoma had a leaking appliance at some time, but most did not experience regular leaks. Appliances can leak when they are changed too quickly or where the change procedure is not performed carefully. Leakage may also occur if the patient’s stoma has increased in size, for example because of weight gain, but the appliance aperture has not been increased accordingly. Leaks can be resolved by changing the appliance carefully and/or resizing the appliance aperture. Retracted stoma A retracted stoma occurs when the stoma sits either flush with, or below, the abdominal skin, and can be the result of weight gain. A retracted ileostomy is one of the main causes of stoma appliance leakage (Redmond et al 2009); however, this can be prevented by using a convex appliance. A convex appliance has a domeshaped flange that exerts pressure on the abdominal wall, raising the stoma itself by supressing the surrounding skin and preventing the development of leaks. In addition to the convex appliance, an elastic belt can be attached to the appliance to assist in securing it to the abdominal wall. However, because of the increased pressure from the convexity of the appliance, the patient should examine their skin for bruising or signs of skin damage at each appliance change. If bruising or signs of skin damage are present, the stoma specialist nurse should be contacted to assess the peristomal skin and develop a treatment plan. Parastomal hernia A parastomal hernia occurs when the edges of the stoma separate from the muscle, allowing abdominal contents,
usually a section of the intestine, to protrude. This can occur with any type of stoma and causes a ‘dragging’ sensation or abdominal discomfort. Non-surgical treatment of a parastomal hernia involves the use of a support belt, which is fitted by a stoma specialist nurse and provides support for the hernia, assists in disguising it and prevents it from enlarging (Readding 2014). Performing specific abdominal exercises and wearing a support belt might prevent a hernia from developing (Thompson and Trainor 2005). Surgery can be performed on a parastomal hernia; however, this is associated with a risk of parastomal hernia recurrence. Ileostomy: food bolus blockage A blocked ileostomy can develop if undigested food accumulates in the lumen of the bowel. A patient with a blocked ileostomy can present with a distended abdomen, a non-filling stoma appliance and, if the situation persists, nausea or vomiting. In the initial stages of a food bolus blockage, the patient should be encouraged to consume fluids to attempt to flush the blockage from the stoma and into the appliance. If the patient develops nausea and vomiting, they should visit the hospital for intravenous fluids and the placement of a nasogastric tube. Symptoms will usually resolve following conservative treatment; however, food bolus blockage can be unpleasant and worrying for patients with a stoma (Burch 2008). Colostomy: constipation A patient with a colostomy can develop constipation, and those who were prone to constipation before surgery may remain so following the formation of a colostomy. To prevent constipation, the patient should be advised to consume a balanced diet containing a range of foods, including fruit and vegetables (Pearson 2008). Oral fluids should be encouraged – ideally 1.5-2L per day, unless contraindicated (Pearson 2008). Urostomy: urinary infection A patient with a urostomy is at a slightly increased risk of developing urinary
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infections because of the reduced length of the urinary tract (Fillingham 2008). A urinary infection may present as cloudy, malodorous urine with increased amounts of mucus (Fillingham 2008). A urine specimen should be taken from the patient’s urostomy rather than the stoma appliance, using a sterile urinary catheter and urine specimen pot. Antibiotics may be necessary to treat any infection.
Conclusion
Nurses can support patients following stoma-forming surgery in several ways. Providing appropriate advice and assistance can enable patients to manage their stoma and changes in body image with confidence. Nurses can also refer patients to stoma specialist nurses for further skin care advice, or to a GP for counselling referral, if necessary.
References Association of Stoma Care Nurses (2015) Stoma Care: Nursing Standards and Audit Tool. ASCN, London. Boyles A, Hunt S (2016) Care and management of a stoma: maintaining peristomal skin health. British Journal of Nursing. 25, 17, S14-S21. Burch J (2008) Stoma Care. Wiley Blackwell, Chichester. Burch J (2014) Current nursing practice by hospital-based stoma specialist nurses. British Journal of Nursing. 23, 5, S31-S34. Davenport R (2014) A proven pathway for stoma care: the value of stoma care services. British Journal of Nursing. 23, 22, 1174-1180. Fillingham S (2008) Urinary diversion. In Burch J (Ed) Stoma Care. Wiley Blackwell, Chichester, 163-181. Grant M, McCorkle R, Hornbrook MC et al (2013) Development of a chronic care ostomy self-management program. Journal of Cancer Education. 28, 1, 70-78. Herlufsen P, Olsen AG, Carlsen B et al (2006) Study of peristomal skin disorders in patients with permanent stomas. British Journal of Nursing. 15, 16, 854-862. Krouse RS, Herrinton LJ, Grant M et al (2009) Health-related quality of life among long-term rectal cancer survivors with an ostomy:
manifestations by sex. Journal of Clinical Oncology. 27, 28, 4664-4670.
ostomy surgery? Journal of Wound, Ostomy, and Continence Nursing. 36, 3, 254‐265.
Journal of Wound, Ostomy, and Continence Nursing. 40, 4, 400-406.
Li CC, Rew L, Hwang SL (2012) The relationship between spiritual well-being and psychosocial adjustment in Taiwanese patients with colorectal cancer and a colostomy. Journal of Wound, Ostomy, and Continence Nursing. 39, 2, 161-169.
Ratliff CR (2014) Factors related to ostomy leakage in the community setting. Journal of Wound, Ostomy, and Continence Nursing. 41, 3, 249-253.
Skipper G, Fake J (2015) Cost-effective collaboration between stoma care nurses and the medicines management team. Gastrointestinal Nursing. 13, 1, 19-27.
Readding LA (2005) Hospital to home: smoothing the journey for the new ostomist. British Journal of Nursing. 14, 16, S16-S20.
Smith AJ, Lyon CC, Hart CA (2002) Multidisciplinary care of skin problems in stoma patients. British Journal of Nursing. 11, 5, 324-330.
Readding LA (2014) Assessing support garments in the management of parastomal hernia. Gastrointestinal Nursing. 12, 4, 32-42.
Thompson MJ, Trainor B (2005) Incidence of parastomal hernia before and after a prevention programme. Gastrointestinal Nursing. 3, 2, 23-27.
Mangnall J, Lakin S, Burke D et al (2013) An alternative model of prescribing stoma appliances. British Journal of Community Nursing. 18, 10, 485-491. Notter J, Chalmers F (2012) Living with a colostomy: a pilot study. Gastrointestinal Nursing. 10, 6, 16-24. Pachler J, Wille-Jørgensen P (2012) Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database of Systematic Reviews. Issue 12. CD004323. Pearson M (2008) Nutrition. In Burch J (Ed) Stoma Care. Wiley Blackwell, Chichester, 210-232.
Redmond C, Cowin C, Parker T (2009) The experience of faecal leakage among ileostomists. British Journal of Nursing. 18, 17, S12-S17. Richbourg L, Thorpe JM, Rapp CG (2007) Difficulties experienced by the ostomate after hospital discharge. Journal of Wound, Ostomy, and Continence Nursing. 34, 1, 70-79.
Persson E, Berndtsson I, Carlsson E et al (2010) Stoma-related complications and stoma size: a 2-year follow up. Colorectal Disease. 12, 10, 971-976.
Salter MJ (1992) What are the differences in body image between patients with a conventional stoma compared with those who have had a conventional stoma followed by a continent pouch? Journal of Advanced Nursing. 17, 7, 841-848.
Pittman J, Kozell K, Gray M (2009) Should WOC nurses measure health‐related quality of life in patients undergoing intestinal
Salvadalena GD (2013) The incidence of stoma and peristomal complications during the first 3 months after ostomy creation.
Wade BE (1990) Colostomy patients: psychological adjustment at 10 weeks and 1 year after surgery in districts which employed stoma-care nurses and districts which did not. Journal of Advanced Nursing. 15, 11, 1297-1304. White CA, Hunt JC (1997) Psychological factors in postoperative adjustment to stoma surgery. Annals of the Royal College of Surgeons of England. 79, 1, 3-7. Williams J, Gwillam B, Sutherland N et al (2010) Evaluating skin care problems in people with stomas. British Journal of Nursing. 19, 17, S6-S15.
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STOMA CARE
Post-discharge care for patients following stoma formation: what the nurse needs to know Burch J (2017) Post-discharge care for patients following stoma formation: what the nurse needs to know. Nursing Standard. 31, 51, 41-45. Date of submission: 23 June 2015; date of acceptance: 22 December 2015. doi: 10.7748/ns.2017.e10198
Jennie Burch Head of gastrointestinal nurse education, St Mark’s Hospital, Harrow, England Correspondence [email protected] @jenburch24 Conflict of interest None declared Peer review This article has been subject to external double-blind peer review and checked for plagiarism using automated software Contributing to the clinical investigations series To suggest an article for the series, please email [email protected] with a synopsis of your idea Online For related articles visit the archive and search using the keywords. Guidelines on writing for publication are available at: rcni.com/writeforus
Rationale and key points
This article discusses post-discharge care for patients following stoma formation. While the patient is taught the practicalities of managing the stoma appliance in hospital, this learning should be integrated into their daily life following discharge from hospital. Nurses are required to consider and address any issues that might affect the patient in the long term. These include changes in body image, adapting to having a stoma, preventing or treating complications associated with a stoma, and long-term follow-up. »» Most patients manage successfully with their stoma following a period of adaptation. »» Follow-up for patients with a stoma can occur over the telephone and/or face-to-face in the patient’s home or in the clinic. »» There are several support groups in the UK that can be accessed by patients with a stoma. »» Patients should seek advice and assistance from a stoma specialist nurse if any issues related to the stoma arise, such as leakage or sore peristomal skin.
Keywords
colostomy, ileostomy, peristomal skin, post-discharge care, stoma care, urostomy
Learning outcomes
After reading this article you should be able to: »» Understand the needs of a patient with a stoma following discharge from hospital. »» Recognise potential stoma-related complications, as well as treatment options. »» Advise patients with a stoma about the support available to them.
Stoma supplies
Before the patient is discharged from hospital, it is essential for the stoma specialist nurse to provide them with stoma supplies and to discuss how they can obtain further supplies in the future. Many patients with a stoma choose to have stoma supplies, such as stoma appliances and any accessories, delivered to their home, although collection from a chemist is also possible. A prescription for stoma equipment will
be required from a GP or nurse prescriber; however, having a permanent stoma will qualify the patient for a prescription fee exemption, irrespective of age. The patient’s stoma supplies should be replenished regularly and will have to be reordered each month; however, it is important that the patient does not accumulate large amounts of stock, which may lead to wastage. Skipper and Fake (2015) provided guidance on the average number of stoma appliances required in the management of a stoma, suggesting that a patient with a colostomy requires one to three bags per day. If the quantity used exceeds this, a review with the stoma specialist nurse will be necessary, because there may be an issue with the stoma itself.
Follow-up
There are no national standards to guide follow-up for patients with a stoma.
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evidence & practice / clinical investigations series
Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Readding (2005) stated that while an annual follow-up is not standard in the UK, a yearly review of the patient with a stoma is necessary to examine the stoma, and to assess the effectiveness of any products and whether the person is managing effectively. The Association of Stoma Care Nurses (ASCN) (2015) in the UK, recognised the importance of regular follow-up to identify and address any concerns the patient might have. Follow-up can ensure that expensive stoma products are being used effectively, as well as preventing the development of stoma-related issues (Persson et al 2010). Effective use of stoma products is important because the cost of stoma products for the 120,000 people with a stoma in the UK, represents 2.3% of the NHS prescribing budget (Mangnall et al 2013, Boyles and Hunt 2016). The cost of stoma appliances varies widely depending on the manufacturer, whether the patient uses one-piece, two-piece or convex appliances, and whether the stoma is prone to leaking, which requires frequent appliance changes. The optimum method of follow-up is unknown; however, it can take the form of telephone clinics, community nurse home visits or hospital-based consultations with a stoma nurse specialist. While certain factors, such as the patient’s diet can be addressed on the telephone, issues with peristomal skin, for example, require physical assessment of the patient. This assessment can take place in the individual’s home or in a hospital clinic. Davenport (2014) suggested that follow-up should consist of a telephone call within one week of the patient’s discharge from hospital, followed by a home visit at two weeks, then three-month, six-month and annual reviews. While Williams et al (2010) found that skin-related issues were common in patients with a stoma, Herlufsen et al (2006) reported that many patients did not recognise such issues, supporting the requirement for periodic review.
Psychological issues
A stoma can affect patients in various ways
(Grant et al 2013). Changes in body image are commonly reported, with individuals finding the physical changes resulting from the stoma emotionally challenging. Patients might also experience anger about their stoma, which can result in some neglecting their stoma care (Grant et al 2013). Research has shown that patients have a variety of concerns relating to their stoma, including that the stoma appliance will leak onto their clothes, which can result in low self-esteem (Salter 1992). It has also been found that 20-25% of patients experience psychological issues following stoma formation (Wade 1990, White and Hunt 1997). Depression in patients following stoma-forming surgery has been reported (Krouse et al 2009); however, this tends to resolve in the months following the operation (Notter and Chalmers 2012). One study found no apparent differences in quality of life for patients with rectal cancer and a permanent stoma, compared to patients with rectal cancer without a stoma (Pachler and Wille-Jørgensen 2012). Quality of life was also found to improve in the first few months after a stoma was formed, as a result of patients becoming accustomed to their altered physical circumstances (Pittman et al 2009).
Supporting patients
Nurses can encourage patients with a stoma to recommence aspects of their former life, such as physical activity, when they feel well enough, thus enhancing their confidence. It is also important for nurses to encourage patients to have contact with their friends and family, as well as stoma support groups (Box 1). In addition, spiritual and faith-related centres, such as churches, BOX 1. Stoma support groups »» Colostomy Association: www.colostomyassociation. org.uk
»» The Ileostomy and Internal Pouch Support Group: www.iasupport.org
»» Urostomy Association: https://urostomyassociation. org.uk
(Last accessed: 8 August 2017.)
nursingstandard.com 42Downloaded / 16 August from 2017 RCNi.com / volume 31 51 bynumber ${individualUser.displayName} on Aug 20, 2017. For personal use only. No other uses without permission. Copyright © 2017 RCN Publishing Company Ltd
mosques and temples, can assist patients with a stoma in adapting to their altered physical identity (Li et al 2012). Activities such as showering and swimming are possible with a stoma, and nurses can advise patients that bathing or showering is appropriate. Patients should be advised to bathe or shower with the old stoma appliance in situ, changing to a new appliance afterwards. Nurses should also advise patients with a stoma that swimming should be undertaken when the appliance is empty and that it is necessary for the appliance to be in place for at least one hour before it becomes wet. While specialist swimwear is available to purchase online, any swimwear or clothing can be worn.
Sexual relations
There are potential issues related to physical relationships for patients with a stoma. Where the placement of a stoma has the potential to affect the nerves in the groin and cause erectile dysfunction, the patient should have received counselling about this risk before surgery. In general, it is possible to continue sexual relations following stoma-forming surgery, and there are a range of methods that patients can use to increase their confidence engaging in intimate relationships. Simple advice includes emptying the stoma appliance before sexual activity. Patients might also choose to disguise the appliance using underwear or a specialist belt that can retain the appliance next to the abdomen so that it does not move during intercourse. Such products are available online or through support groups and stoma specialist nurses.
Common stoma-related issues
patients with a stoma experienced skinrelated issues, while Salvadalena (2013) found that 63% of patients with a stoma experienced sore skin (Figure 1) within the first three months of stoma-forming surgery. A study of UK stoma specialist nurses found that the most common cause of sore skin was output from the stoma leaking onto the skin (Burch 2014). Therefore, it is essential to ensure the stoma appliance is securely attached to the patient’s abdominal wall to prevent it from leaking onto the peristomal skin. Should the patient develop sore peristomal skin, this will often heal quickly with treatment, including careful cleaning and drying, resizing the stoma appliance aperture, and accurately repositioning the appliance over the stoma. Stoma powder can be used on skin around the stoma that is wet, sore or broken. To prevent the development of sore skin, a protective skin barrier in the form of a wipe or spray can be used following cleaning and drying of the skin and before a new appliance is attached. Prolapsed stoma A prolapsed stoma occurs when the patient’s bowel protrudes through the stomal opening on the abdominal wall. The size of a prolapsed stoma can be significant and may fill the entire stoma appliance. There are larger appliances available that can assist in the management of a prolapsed stoma. The prolapse can be manipulated back inside the patient’s body by a healthcare professional. However, Figure 1. Sore peristomal skin
Common stoma-related issues include sore peristomal skin, prolapsed stomas, leaking appliances, retracted stomas, parastomal hernia and blockage. While some of these issues may never occur, many patients with a stoma will experience leakage from their appliance at some time. Sore peristomal skin Smith et al (2002) reported that 73% of
Alamy
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evidence & practice / clinical investigations series
some patients will experience a recurring prolapse, which may require surgery (Burch 2008). Leaking appliance Richbourg et al (2007) found that 62% of patients with a stoma reported leakage from their stoma appliances. More recently, Ratliff (2014) stated that 87% of respondents in a study of patients with a stoma had a leaking appliance at some time, but most did not experience regular leaks. Appliances can leak when they are changed too quickly or where the change procedure is not performed carefully. Leakage may also occur if the patient’s stoma has increased in size, for example because of weight gain, but the appliance aperture has not been increased accordingly. Leaks can be resolved by changing the appliance carefully and/or resizing the appliance aperture. Retracted stoma A retracted stoma occurs when the stoma sits either flush with, or below, the abdominal skin, and can be the result of weight gain. A retracted ileostomy is one of the main causes of stoma appliance leakage (Redmond et al 2009); however, this can be prevented by using a convex appliance. A convex appliance has a domeshaped flange that exerts pressure on the abdominal wall, raising the stoma itself by supressing the surrounding skin and preventing the development of leaks. In addition to the convex appliance, an elastic belt can be attached to the appliance to assist in securing it to the abdominal wall. However, because of the increased pressure from the convexity of the appliance, the patient should examine their skin for bruising or signs of skin damage at each appliance change. If bruising or signs of skin damage are present, the stoma specialist nurse should be contacted to assess the peristomal skin and develop a treatment plan. Parastomal hernia A parastomal hernia occurs when the edges of the stoma separate from the muscle, allowing abdominal contents,
usually a section of the intestine, to protrude. This can occur with any type of stoma and causes a ‘dragging’ sensation or abdominal discomfort. Non-surgical treatment of a parastomal hernia involves the use of a support belt, which is fitted by a stoma specialist nurse and provides support for the hernia, assists in disguising it and prevents it from enlarging (Readding 2014). Performing specific abdominal exercises and wearing a support belt might prevent a hernia from developing (Thompson and Trainor 2005). Surgery can be performed on a parastomal hernia; however, this is associated with a risk of parastomal hernia recurrence. Ileostomy: food bolus blockage A blocked ileostomy can develop if undigested food accumulates in the lumen of the bowel. A patient with a blocked ileostomy can present with a distended abdomen, a non-filling stoma appliance and, if the situation persists, nausea or vomiting. In the initial stages of a food bolus blockage, the patient should be encouraged to consume fluids to attempt to flush the blockage from the stoma and into the appliance. If the patient develops nausea and vomiting, they should visit the hospital for intravenous fluids and the placement of a nasogastric tube. Symptoms will usually resolve following conservative treatment; however, food bolus blockage can be unpleasant and worrying for patients with a stoma (Burch 2008). Colostomy: constipation A patient with a colostomy can develop constipation, and those who were prone to constipation before surgery may remain so following the formation of a colostomy. To prevent constipation, the patient should be advised to consume a balanced diet containing a range of foods, including fruit and vegetables (Pearson 2008). Oral fluids should be encouraged – ideally 1.5-2L per day, unless contraindicated (Pearson 2008). Urostomy: urinary infection A patient with a urostomy is at a slightly increased risk of developing urinary
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infections because of the reduced length of the urinary tract (Fillingham 2008). A urinary infection may present as cloudy, malodorous urine with increased amounts of mucus (Fillingham 2008). A urine specimen should be taken from the patient’s urostomy rather than the stoma appliance, using a sterile urinary catheter and urine specimen pot. Antibiotics may be necessary to treat any infection.
Conclusion
Nurses can support patients following stoma-forming surgery in several ways. Providing appropriate advice and assistance can enable patients to manage their stoma and changes in body image with confidence. Nurses can also refer patients to stoma specialist nurses for further skin care advice, or to a GP for counselling referral, if necessary.
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