Exploring the Intricacies of Stoma Care Date: 25 June 2018 Presented by: Bernadette Ambrose Stoma Care Nurse Specialist West Suffolk Community

Introduction Some common reasons for stoma formation Overview of the 3 types of stomas The importance of Skin Health ‘p’ Ratings in West Suffolk Accessory usage

Some common reasons for Stoma formation Carcinoma (bowel & bladder) Diverticulitis Inflammatory Bowel Disease Familial Polyposis Trauma Neurological damage (M.S.) Incontinence Congenital Disorders

Colostomy A colostomy is formed from the large bowel Can be permanent or temporary Can be a loop or an end stoma Output is usually formed or soft faeces Generally use a closed bag Pouch change depends on bowel function can be 2-3 times a day

Loop Colostomy

Ileostomy Formed from the ileum Generally on the R side May be temporary or permanent Loop or end, should be spouted (2.5cm) Output – loose, porridge like consistency Use a drainable bag Empty 4-6 x day and change alternate days

Urostomy Formed form a section of bowel used to form a conduit into which ureters are attached. Always permanent, end stoma Urine will always contains some mucus Pouch with a tap or a bung Emptied 5-6 times a day Bag changed alternate days

The ‘Perfect’ Stoma Until the advent of the Brookes ileostomy, there was no gold standard for the formation of a spouted ileostomy & ileal conduit.1 St Marks’ Hospital London UK published a paper written by Celia Myers and Robin Phillips to set the new standard for a slightly spouted colostomy.2 History of Ostomy Surgery – D. Doughty. Journal of Wound, Ostomy, & Continence Nursing Vol. 35, No. 1. 2008 2. Minimally Raised End Colostomy – B.M. Stephenson., C. Myers, R.K.S. Phillips. International Journal of Colorectal Disease Vol. 10. No. 4. 1995. In the mid 1950s Surgeon Bryan Brooke pioneered the protruding stoma which significantly improved clinical outcomes for ileostomy patients. Then in 1995 Myers and Phillips developed a slightly raised colostomy which enabled the patient to see better and improving management.

Perfect Ileostomy/Urostomy The perfect ileostomy/urostomy should have a 2-3 cm spout in order to avoid leakage

However…… Not everybody is perfect!!! And sometimes surgeons are limited with their siting options. We have an increasing obesity epidemic and with the aging process the skin and muscle tone of the abdomen lessen.

The Skin Largest organ Divided into 2 Layers Functions Epidermis Dermis Functions Thermoregulation Protection Waterproofing Synthesis of Vit D sensation Differs in appearance & Structure Location Age Disease nnThe skin forms the largest organ of the body, it has the ability to regenerate and, in the healthy individual, to repair damage which has been inflicted upon it. The skin itself is composed of two layers, the outer epidermis, which consists of cells that migrate from the basal layer to the surface. The epidermis is avascular and varies in thickness depending on location. It is composed of 5 layers, the uppermost layer is called the stratum corneum. The dermis is a thicker layer that contain sweat glands,blood vessels, nerve endings and hair follicles. The main functions of the skin include thermoregulation, protection, waterproofing, synthesis of vitamin D and the transmission of sensation. Skin differs in appearance and structure depending on location on the body, age, and in the presence of disease. 14

Consequences of a NOT so perfect stoma

The Problematic Stoma Many people with a stoma may experience complications at some point. Many factors contribute to a problematic stoma In 2008 we initiated the ‘P’ Rating system where each stoma formed at the WSH was given a rating depending on the number of accessories required to ensure a secure fit. The purpose of this was to initiate discussion and help improve the quality of the stomas formed, thereby improving the patients quality of life and reducing the cost in accessory usage. Type of stoma, Height of stoma, emergency or elective, BMI, gender, diagnosis

‘P’ RATINGS - A STOMA GRADING TOOL Number of Accessories Required Accessory Type p0 N/A p1 1 Convex p2 2 Convex, belt p3 3 Convex, belt, paste p4 4 Convex, belt, paste, seals p5 5 Convex, belt, paste, seals & extenders

‘p’ Ratings Overview of p0 – p1 Stomas 2008 2010 2012 2015 2016 2017 78% 82% 72% 77% 92% 98% In 2017 72% of all stomas formed at the WSH did not require any accessories to achieve the perfect Fit.

The Importance of a Good Fit

Conclusion My role as a Stoma Care nurse explores the intricacies of Stoma Care on a daily basis. Skin Health is paramount to ensure the patient continues to have the confidence and ability to lead an active and full life following this life changing surgery.