Optimizing Outcomes for Ostomy Patients Challenges and Potential Solutions

Impact of Ostomy Surgery Change in body function (new skills required) Change in body image (major adaptation) Issues related to underlying diagnosis

Major Concerns New Ostomy Patients Self-care, odor, noise, leakage Embarrassment Ability to resume usual activities Intimacy/sexuality Cancer diagnosis Body Image Supply Costs

Factors Impacting on Longterm Outcomes Time: marked improve- ment in quality of life over lst 3 – 6 months Competence/confidence in self-care Good relationship with ostomy specialist Satisfaction with care provided

What Ostomy Patients Need Secure pouching system Knowledge and skill to deal with day to day management Supportive counseling Awareness/access to peer support

Implications for Caregivers Preoperative Care Importance preop teaching and counseling “Informed consent” Foundation for instruction in self care postop Establishment positive relationship Importance of stoma site marking

Preoperative Teaching Critical Content Overview GI Tract Function Small bowel Large bowel/rectum Reason for surgery/ostomy Impact of ostomy Questions about life with ostomy Any potential change in sexual function

Preoperative Teaching Persons to be Involved MD Ostomy nurse Staff nurses Challenges in Delivery AM admits for elective surgery Emergent procedures

Preoperative Teaching Options for Assuring Delivery of Preop Education/Counseling Elective cases: Referral for preop teaching (individual vs group) Teaching during preadmit visit: scheduling and space issues Emergent cases: essential teaching by ED and OR staff Preop teaching kits

Stoma Site Marking Impact: flat surface critical to maintenance effective pouch seal Criteria: Flat surface In patient’s visual field In rectus muscle

Stoma Site Marking Who and When? Who: Ostomy Nurse MD Nurse Trained in Procedure (Controversy) When: Preop Visit vs. Immediately Preop Advantage of Marking in Advance/Having Patient Wear Pouch

Postoperative Period: Essential Care Establishment Effective Pouching System Instruction in Self Care (Survival Skills) Knowledge/Skills Needed for Daily Management Support for Beginning Adaptation

Establishment Effective Pouching System Pouch Selection Fecal vs urinary If fecal: drainable vs. closed end One-piece vs. two- piece Closure mechanism (consider patient dexterity)

Establishment Effective Pouch Seal “Match” pouch to peristomal surface Flat surface: flat pouch Deep creases: flexible pouch Shallow creases: flexible vs convex Skin level/retracted stoma: convex pouch

Appropriate Use of Protective Products Liquid barrier films: Protect against moisture (urine) Protect against tape damage Paste/paste strips/rings: Protect against enzymatic drainage “Caulk” to reduce undermining Fill defects

Indications for Belts/Binders Skin level or retracted stoma/ additional support needed Belts if stoma in belt plane Binders or supportive undergarments if stoma NOT in belt plane

Instruction in Self-Care: Pouch Emptying When: 1/3 – 1/2 full How to Empty: Urinary: Open spout and drain Dry and close Fecal with clamp “Cuff” end of pouch; drain Clean spout: “un-cuff”; clip Fecal with integrated closure: Create funnel; drain Clean spout and reclose

Instruction in Self-Care: Pouch Change (KIS if possible!) Size new pouch to fit around stoma Gently remove old pouch Clean skin with water (shave?) Apply sealant if needed Apply paste if needed (fecal only; “ring” vs flat); wet finger Apply pouch

Instruction in Self-Care: “Crusting” Procedure Indications Denuded peristomal skin Peristomal yeast rash Procedure Dust powder onto area of denudation or yeast rash Optional: “Blot” or “spray” over powder with liquid barrier film (or water)

Teach Patient…Key Points for Skin Protection Change pouch Q ___ days and anytime it is leaking Never tape a leaking pouch Use gentle technique to remove pouch Use protective products appropriately Apply new pouch to clean dry skin Inspect skin at each pouch change/ report any skin problems to ostomy nurse

Essential Information (Fecal Stomas): Gas and Odor Control Odor and gas MAJOR concerns Pouches odorproof Option to use pouch deodorants, room sprays, oral agents to reduce odor when pouch emptied

Essential Information: Management Gas (Fecal Stomas) Basis for high volume gas early postop Measures to reduce/ manage gas Omission/ “timing” gas producing foods (diary early postop to ID offenders) “Muffling” measures Explanations Beano and Gas-X Filters Colostomy vs ileostomy

Essential Information…Dietary Guidelines Colostomy Patient No absolute restrictions Fiber and fluid important for descending or sigmoid GAS CONTROL MEASURES

Essential Information: Dietary Guidelines Ileostomy Patient Potential for food blockage (basis) – Wait till 6 wks postop to add foods high in insoluble fiber* – Add a time in small amts – CHEW; drink plenty of fluids – Monitor response *Popcorn, nuts, peels, stringy vegetables, coconut, corn, olives, mushrooms, meat casings

Essential Information…Ileostomy Patient Dehydration Prevention Basis: High-volume output Adaptation Phase: 1 -2 liters/day Long-term: 750 – 1000 ml/day Implications Adequate replacement critical Electrolytes as well as water Guidelines for patient teaching Guidelines for periods increased loss Management diarrhea BRAT diet, fluid replacement, OTC antidiarrheals – IV fluids if any N/V or S/S dehydration)

Essential Information: Urinary Diversion Patient Mucus in urine normal “Wicking” during pouch change Nighttime Management UTI Prevention/ Recognition

Essential Information: Left Sided Colostomy Management Issues Option to Manage by Irrigation Quality of Life Data Principles Schedule and Volume of Irrigant Procedure Teaching Challenges: When? Who?

Essential Information: All Ostomy Patients Bathing/showering Clothing: modifications required? Travel Return to work and recreational activities Hernia prevention Resumption sexual activity

Support for Beginning Adaptation Acknowledgement/ discussion adaptation process (permission to grieve) “Guided tour” of stoma Involvement in decision making re: care/equipment Goal setting Referral to UOAA

Postop Education in Short Stay Environment Major Challenges Patient readiness to learn postop Impact of stress and anxiety on ability to learn Importance of repetition and support – but NO TIME! What Patients Tell Us What Home Health Nurses Tell Us

Effective Patient Education in Short Stay Environment Emerging Solutions Expanded preop teaching programs Commercially available patient education materials/kits Use of CCTV Use of videos

Optimizing Outcomes Critical Importance Post- Discharge Followup Issues/Impact/Needs to be Met Strategies Discharge Kits Followup Phone Calls Home Health Referrals Outpatient Clinic Followup (especially critical lst year postop)

Optimizing Outcomes It Takes a Team! Critical Importance Ostomy Nurse Impact of Knowledgeble Involved Staff Nurses MD Role Role of Vendors Role of Support Groups Impact Administrative Support

Summary Factors Critical to Positive Outcomes Preop education/ stoma site marking Postop teaching: self care, essential info Support for adaptation Post discharge followup Critical importance creative team approach to meeting patient needs!