Stoma Care Nurse Specialist Gateshead Health NHS Foundation Trust GP Update on Stoma Care Heather Wilson Stoma Care Nurse Specialist Gateshead Health NHS Foundation Trust Handouts available for this talk

Aims of the Session To give a brief overview of stoma care management and the support of the patient/family/carer Discuss the role of the Stoma Care Nurse Specialist To discuss a variety of stoma problems that patients may face To outline the management of these problems

History First surgical stomas were created on battle casualties in the early in the early 1700s No documentation of the specific care of stoma patients in the nursing profession press until the late 1930s (Plumley,1939) The first stoma therapist was not a nurse , but a patient. Norma Gill, Ohio,USA In the UK Barbara Saunders a ward sister, set up the first stoma clinic in 1969. 1971 saw the first stoma care nursing posts

Types of Stomas Over 80,000 people in the UK living with a stoma Stoma greek word for mouth Colostomy (wet colostomy) Ileostomy Urostomy Loop or end, permanent or temporary

End Colostomy

End Ileostomy

Loop Ileostomy

Reasons for needing a stoma Varied Cancer – bowel/rectum or bladder Inflammatory Bowel Disease – Crohn’s Ulcerative Colitis Diverticular Disease Congenital abnormalities Bowel ischaemia Irradiation damage, fistula formation

Stoma Care Nurse Specialist Some are Colorectal Nurse Specialists Present in all major hospitals in the NE Some are community based Strong network, regional meetings, patient open days, study events, collaborative working/patient referrals Sub specialist nurses in Paediatrics and Urology

Senior Nurse who has undertaken formal training/examination in the field of stoma care/colorectal Clinical and consultative role Patient advocate, support and education Teaching Management, research, audit, change agent

Stoma Care Management Team approach – specialist nurses, ward and community nurses, medical staff, patient, carers and family Practical Support – how to look after the stoma and surrounding skin, dietary advice, types of appliances, holiday advice Psychological Support – emotional reaction to this type of surgery, lifestyle issues, sexuality and body image Preoperative preparation including siting Post operative support and education Continued support once patient is discharged into the community Aim is for the patient to become an‘expert’ in stoma management and adapts to life with a stoma

Stoma Problems Divided into 3 main areas Problems in the management of a stoma e.g. hernia, prolapse, stenosis Skin conditions which may arise due to the stoma or wearing of an appliance Psychological issues

Post op stoma shrinkage 6 to 8 weeks for stoma to shrink in diameter and spout. Patients may need to change appliance type e.g. Convex Need regular review by stoma nurse in the first 2 to 3 months.

Colostomy Effluent less corrosive to the skin Usual formed stool, closed pouch, 3x daily Transverse colostomy may need drainable Some patients may opt for irrigation Constipation –diet, fluids, drugs, age, mechanical e.g. Hernia, stricture, adhesions Oral laxatives/microlax enemas/suppositories

Diarrhoea – right sided/transverse stomas Chemotherapy/radiotherapy Infection – stool sample Drugs, diet, stress, malabsorption, disease e.g.crohn’s, cancer, sub acute obstruction Imodium

Ileostomy Effluent very corrosive to skin. 1-2 days. Output should be “porridgy”, 350-600mls per day. Imodium. Increased/fluidy output –infection, diet, drugs Obstruction- foods high in cellulose, adhesions, strangulated hernia, stenosis Stoma oedematous, cramps, fluid effluent then ceases Imodium High output stoma 800 -2 litres, TPN, electrolye replacement

Loop ileostomy can be difficult to manage due to its odd shape, mucus from distal part High output ileostomy – electrolyte drinks, TPN, appliance type Chemotherapy treatment- increasing stoma activity, skin more sensitive, reduced feeling in patient’s fingers

Urostomy Infection – clean specimen using a fine catheter, or place collecting bottle under clean stoma. Mucus shreds in the urine is normal PH of the urine should be kept between 5 and 7. Ascorbic acid 100mg, cranberry juice Phosphate deposits, Chronic papillomatous dermatitis around urostomies. 50% household vinegar soaks, appliance review.

Necrosis / Sloughy Stoma Early post op complication, too tight appliance Compromised blood supply Difficult surgery Post op stoma bridge Ill fitting appliance If superficial will slough off Use intrasite gel or orabase paste to aid removal of slough Refer to surgeon in severe cases

Necrosis and Dehiscence This picture shows a necrotic stoma which has dehisced from the skin. Treated by applying intrasite gel or orobase paste, covering with stomahesive paste or GX seal and appliance. Severe dehissance may need suturing.

Stenosis Narrowing of the lumen of stomal outlet Healing of necrotic tissue, dehiscence of stoma, poor surgical technique Secure appliance Patient may be taught to dilate Surgical revision Patients may need convexity type appliance to protect skin or the use of barrier protection sprays and pastes. These two pictures show stenosed stoma. The following picture is after reconstruction of the stoma.

Retraction Bowel under tension Surgical technique, post op weight gain Can be difficult to manage –skin damage/leaks/difficult for patient to see stoma. Appliance review. Convex products, rings, pastes, belt May need to change pouch more frequently Surgery may be indicated

Parastomal Hernia Affects 40% plus an increasing problem More common in older patients Loss of muscle tone Appliance review Support garment Observe patient Surgery This is a common condition. Affect the patients lifestyle, clothing, confidence and self-esteem. Problems with appliances adhering to the skin, leaks and sore skin. Patients may need to change type of appliance - larger appliance with wider flange or oval shaped appliance, use a belt or support garment. Not all patients need surgical intervention- if surgery is contraindicated or hernia not causing any problems.

Prolapse Defined as when a length of bowel prolapses out onto the exterior of the abdominal wall More common in transverse loop colostomies (larger stoma) Fit larger appliance Reduce prolapse Surgical intervention Can be distressing for patient and family. Need reassurance, explanation and support. Severe prolapse will need assessment by surgeon. Risk of damage to the bowel tissue and necrosis. Some patients may not need surgical management and can be managed with larger type appliance, to contain stoma and effluent.

Pancaking Colostomy effluent does not fall to the bottom of the pouch, collects around the stoma. Can be difficult to manage. Leaks, frequent pouch changes Sore skin Odour issues – blocked filter Cover filter, tissue paper in pouch, lubricating gel, diet, 2 piece pouch

Trauma to Stoma Many causes Most common ill fitting appliance Cause laceration on stoma. Bleeding. Usually heals quickly Use of special powders e.g. orahesive, hollister May need suturing Other causes of trauma Self-harm- needs careful assessment Major bodily trauma e.g. RTA patients can fit adaptations to seat belt to limit damage to stoma. Contact during sports activities - can use protective stoma shields.

Over Granulation Occurs at the junction between stoma and skin Can occur at any time Probably a reaction to irritation Bleeding Soreness Powders Silver nitrate Liquid nitrogen Need to check size of appliance aperture which may be rubbing on the stoma and causing overgrannulation. If patients are having no symptoms just observe.

Skin Problems (1) Very common 1/3 of people with colostomies 2/3 ileostomy or urostomy pts experience skin problems Lyon & Smith, (2001) Many causes - poor fitting appliance, flush stoma, poorly sited stoma, hernia, weight gain, pre-existing skin condition e.g. eczema These two pictures show quite a flush ileostomy. Spout pointing downwards, effluent which is very corrosive to the skin is leaking under the bag and lifting it from the skin. Result very sore, inflammed skin which can prevent further appliances from adhering. This patient needed a convexity type product where the flange is domed shaped providing extra protection around the base of the stoma and pushing the stoma further out. This reduces the chance of stomal effluent collecting around the stoma a leaking under the bag. Some patients may need the size of appliance aperture reducing so that it fits snugly around the stoma.

Skin Problems (2) Allergic reaction Allergic contact dermatitis Patch test. Change pouch type. ? Refer to dermatologist May need topical steroid . Lotion, inhalers, nasal spray Most stoma appliances are designed to be kind to the skin. Some patients can get an allergic reaction as demonstrated in this picture. Treated by changing appliance type/manufacturer. Patients may get a reaction to the plastic - use of cotton covers. Severe reactions may need patch test - refering to a dermatologist. Application of alcohol-based lotions do not interfere with appliance adhesion e,g treatment of psorasis.

Check stoma spout, abdomen examination Check stoma effluent Appliance review May need barrier spray, wipes or powder to heal skin Use of accessories e.g. Rings/paste , skin creases, dips

Patient Impact Stoma formation and stoma complications can effect the physical, psychological, sexuality and social well being of the patient Loss of self-esteem Change in body image Loss of confidence Social recluse Affecting work, relationships, social activities / holidays Regular support especially early in recovery period is vital Early assessment of any stomal complication cannot be overestimated. Patients need constant information, reassurance and support. As highlighted the impact of such complications can be dramatic not only for the patient but also for the family as well.

Patient Support Healthcare Professionals Clinical psychology National and local patient support groups e.g. Urostomy association One to one patient support Stoma appliance manufacturers, pharmacy, dispensing appliance contractors

Conclusion Stomal problems should be assessed holistically Using multi-disciplinary team No one simple answer to any of the complications Patients need easy access to specialist nurse for ongoing advice and support Nurses need to involve other specialists where appropriate e.g. tissue viability nurse, dietitian Dealing promptly and affectively with a problem will minimise patient anxiety and promote adaptation.

Conclusion Stoma care management can be varied, challenging and at times complex. Careful assessment, prompt management and good communication within the team is essential, as is ongoing patient support. The reward is a confident patient who is able to just get on with life. Thank You for listening. There are handouts at the front Enjoy your lunch.

Thank you for listening Any questions ?