The pre- and postoperative nursing care for patients with a stoma

This article revisits the various issues that surround the nurse caring for a patient with a stoma (colostomy, ileostomy or urostomy). Understanding the basic anatomy, reasons for stoma formation and the surgical operations, including variations such as continent stomas, can assist the nurse in caring for this patient group. The article discusses briefly the various stoma appliances that can be used by the nurse or ostomate (person with a stoma). Practical tips on pre- and postoperative nursing care of the patient with a newly formed stoma are provided for the nurse. In some cases, unfortunately, complications may occur following stoma-forming surgery; these are discussed and nursing advice provided. One of the most important ways in which the nurse can support the patient is to teach the patient his/her stoma care, ensuring independence before discharge and showing empathy and compassion.     

Caring for a patient with a urostomy in a community setting

Around 7500 people in the UK have a urostomy. A urostomy is normally performed if a person has bladder cancer, congenital bladder abnormalities. Many people who have a urostomy have long term conditions and may require the help and support of community nurses. This article examines common complications of urostomy including stomal complications, urinary tract infections and dermal complications. Although stoma complications are common and can affect quality of life, many people with a stoma tend not to seek help. Community nurses can provide care and support to optimize stoma management and enable the person with a urostomy to enjoy the best possible quality of life.     

Hirschsprung's disease: diagnosis and management in children

Hirschsprung's disease is a congenital abnormality of the bowel that results in loss of peristalsis, and is one of the main reasons why an infant may require a stoma soon after birth. Various stages of surgery may be required to resect the affected part of the bowel, including formation and closure of the stoma. Following surgery, the perception of many families is that their child is now "normal" and that all previous problems of managing their child are now resolved. However, there are a variety of postoperative complications and issues relating to bowel control which can affect the child in the long term. This article looks at how potential postoperative long-term problems can be identified early, and thus minimized, by healthcare staff being aware of possible problems, taking a proactive approach to management and advising families about the issues involved.     

Providing dietary advice for the individual with a stoma

Concerns over diet and nutrition are common among ostomists and their carers. It is important for healthcare professionals involved in the care of patients with a colostomy, ileostomy or urostomy to appreciate that stoma surgery changes the body's usual processes of nutritional absorption and excretion, so that informed support and advice on diet can be provided. A considerable proportion of patients admitted to hospital in the United Kingdom are malnourished, or at risk of becoming so. Patients undergoing gastrointestinal surgery resulting in stoma formation are at particular risk as a result of the potential for preoperative malnutrition caused by the effects of their underlying disease and prolonged periods of fasting during the immediate pre- and postoperative period. Screening and monitoring of the nutritional status of individuals with a stoma should be an ongoing process, beginning preoperatively and continuing after discharge from hospital. This article will examine the effects of stoma formation on diet and consider ostomists' potential for altered absorption of nutrients. Current issues relating to patient nutrition in the hospital setting, their relevance for stoma patients and the role of the nurse in the provision of nutritional care will also be discussed.     

Multidisciplinary care of skin problems in stoma patients

Skin integrity is essential for the normal usage of a stoma appliance. There is little published on the prevalence, prevention or management of stoma skin problems. Allergic contact dermatitis is often cited as the cause, usually without evidence from formal investigations. The authors approached, by postal questionnaire, 525 patients who had had a stoma formation in the last 10 years. A total of 325 responded. All those who described a skin problem were invited to attend a multidisciplinary clinic for further investigations and appropriate treatment of their peristomal skin. This may be severe and debilitating as well as socially restricting. However, with a multidisciplinary approach a number of conditions can be recognized and easily treated, thus improving the quality of life for stoma patients.     

Managing quality of life in the older person with a stoma

Undergoing surgery and having the formation of a stoma may be required for a number of reasons and how a patient accepts their new body image and changes to their lifestyle can be greatly determined by the support and care they receive from their stoma nurse and other health professionals involved in their recovery after stoma formation. Preparing a patient pre-operatively and taking time to listen to their individual needs will enhance their perception of living with a stoma and accepting their stoma, thus not negatively impacting on what they perceive to be their quality of life. Acknowledging the quality of life of an individual and taking measures to maintain a person's quality of life at an early stage within the surgical pathway will have a positive impact on a patient's recovery from surgery and ability to cope with the daily routine involved when living with a stoma. Nurses need to understand what their patient perceives as a good quality of life and how to alter any negative factors that may inhibit a patient's ability to care for and accept their stoma.     

Parastomal hernia: an exploration of the risk factors and the implications

Risk may be defined as 'the chance that something may happen to cause loss or an adverse effect' (Concise Oxford Medical Dictionary, 2003). Patients undergoing stoma formation are at risk of developing a wide range of complications following surgery. A parastomal hernia is an adverse effect that can contribute to postoperative morbidity. The risk of developing a parastomal hernia is dependent upon a number of variables, and stoma care nurses need to be aware of these to plan the appropriate care for patients undergoing stoma formation. This article discusses the issues surrounding the development of parastomal hernias and also looks at ways in which the risk factors associated with the development of a parastomal hernia may be minimized.     

Stoma care: empowering patients through teaching practical skills

Teaching patients practical skills in stoma care is a complex process and although, arguably, at the very heart of stoma care nursing practice, has been largely ignored in the literature. Teaching principles are based upon social learning theory and educationalists provide guidelines on the most effective way to teach a practical skill. These guidelines have been utilized by nurses when teaching patients with newly formed stomas how to change a pouch. The process of adapting to a stoma and its daily management takes time. Psychologically, however, some patients will adapt more easily than others and researchers have attempted to identify factors which may account for this. Studies have demonstrated that patients who are satisfied with the amount of preoperative information they receive are less likely to develop psychological problems. Psychological adjustment may be affected if patients feel that they have developed insufficient pouch changing skills or have problems with leakage from their pouch or sore skin around their stoma. Studies have also demonstrated that cognitive factors, such as patients feeling in control of their illness and stoma, have been found to play a role in psychological adaptation. Clinical nurse specialists in stoma care are in an ideal position to target these cognitive factors using a variety of strategies including effective practical teaching to empower patients, thus facilitating psychological adaptation following stoma surgery.     

Stoma siting: what the community nurse needs to know

Stoma siting is often regarded as the most important part of preoperative preparation. Marking the abdominal skin at the proposed stoma site takes place after a period of assessment, discussion, observation, consideration and evaluation that will have begun on the first meeting between the patient and the nurse. The siting procedure is a joint decision made between the patient and the nurse about the most suitable place for their stoma. The position of the stoma should allow the patient to manage it independently and to resume their normal activities after recovery. The success of the stoma can depend on the site and its condition. The purpose of this article is to describe and discuss the siting process and how it benefits the patient. Community nurses should gain a greater understanding of the issues involved, as well as the considerations for both the nurse and the patient. This article is intended to help the community nurse feel more aware of the issues involved in siting, and feel more prepared to assist the patient to prepare for and begin their life with the stoma. The outcome and effects of a 'poorly' or 'less than ideally' sited stoma (e.g. formed during emergency surgery), and its care and management will also be discussed. Illustrations have been included to assist the reader through the process of siting.     

Innovative surgical procedures and stoma care in the future

Innovative surgical procedures require particular attention to the technical, educational, and emotional issues. Patients need thorough education to understand surgical options, complications, and expected outcomes. Because of the new aspect of these procedures, patients and significant others may feel quite isolated from others. Recognizing behaviors which may indicate this problem and seeking opportunities to provide emotional support and role modeling from other patients are most therapeutic. The quest for continence provides the patient with alternatives to be cured of disease and avoid the need for an external appliance and an abdominal stoma.     

Considerations for managing stoma complications in the community

Complications related to stoma surgery can occur immediately post surgery or following discharge from hospital, and will either resolve spontaneously or become a difficult management problem for both the stoma patient and healthcare practitioner. In the early stages of rehabilitation, the patient with a stoma relies heavily on the expertise of the healthcare practitioner to assist them in returning to the lifestyle they once enjoyed. Literature acknowledges that adjustment to life with a stoma depends largely on whether complications following the creation of a stoma are persistent (Bekkers et al, 1996; Taylor, 1999; Cottam and Richards, 2006). Evidence demonstrates that prolonged unresolved stoma problems hinder adaptation and adjustment to the stoma (Bekkers et al, 1996; Williams et al, 2010), therefore, it is important for the healthcare practitioner to be well informed and skilled regarding common stoma problems. This article aims to highlight common stoma complications and offer guidance on evidence-based management of such problems to inform healthcare practitioners working in the community setting.     

Teaching the stoma care routine to a patient with low vision

Teaching the patient with a newly formed stoma but who also has low vision to manage his/her stoma independently can be a difficult task. This case study shows how a nurse taught a patient with low vision to become independent in relation to his newly formed stoma, with a view to being discharged home successfully. At the time the stoma care nurse used her past experience and common sense in achieving this aim. After the event the stoma care nurse researched the literature and discovered that there are accessories/devices available to assist patients with low vision to manage their stoma and help improve their vision. On reflection, the stoma care nurse felt she did not have sufficient time preoperatively with the patient, which prevented her from being able to change the course of action. She has now improved her knowledge, which will assist her in the future if she has to care for another patient with low vision who has had a newly formed stoma.     

Stoma management: enhancing patient knowledge

Community nurses are likely to encounter people with a stoma, most commonly a colostomy. An appliance is used to collect and contain the stomal output. There are various appliances available, each designed to specifically care for a particular type of stoma. Ostomates (people with a stoma) are trained to care for their stoma while they are in hospital by the stoma specialist nurse. However, it is possible that complications can occur, such as sore peristomal skin, and in this instance a stoma accessory can be used to good effect. There are many accessories available, which can make choice difficult. However, an understanding of why accessories are used can assist in the assessment and treatment choice. It may be necessary to request the assistance of the stoma specialist nurse.     

Stoma care in the school setting.

An ostomy is an artificial opening in the body for the purpose of eliminating excretions from a working organ or for providing nourishment. Artificial openings may be from the stomach, intestine, urinary bladder, kidney, or trachea. The stoma is the terminal end of the ostomy, or the opening that is visible on the surface of the skin. This article will discuss stoma creation and the care of a stoma, as well as the complications and effects of living with one. Although the focus of this article is urinary stomas, the care is similar for all types. It is imperative that all care providers understand stoma care and potential problems that may arise. There are ongoing issues of quality of life for children with stomas, including body image and peer reaction. School nurses are in a unique position to educate children and families on the proper care of a stoma, to recognize potential complication, and to educate staff and student peers.     

Common peristomal skin problems and potential treatment options

Stomas are encountered by nurses in many different fields and may be newly formed or many years old. Caring for ostomists can be problematic, particularly if complications occur. One of the more common problems for ostomists is excoriated peristomal skin. Sore skin can occur for a number of reasons and the cause can be an indicator for the therapy required. At times the treatment can be simple but often the skills of a stoma specialist nurse are required. This article focuses on some of the more commonly encountered ostomy problems that nurses may be faced with. The potential problems are described and potential treatment options are offered.     

Peristomal skin irritation and the use of a silicone-based barrier film

Maintaining skin integrity is vital to ensure good adhesion of the stoma pouch, and to avoid discomfort for the person with a stoma, ensuring a good quality of life. However, there are many risk factors associated with potential peristomal skin soreness, and a large number of research studies have highlighted the vast number of patients who actually experience these problems (Mahjoubi, 2005; Ratliff et al, 2005; Herlufsen et al, 2006; Lynch et al, 2008; Meisner and Balleby, 2008). Clinical nurse specialists in stoma care are responsible for ensuring that all patients are fully assessed, and also that patients are given appropriate evidence-based care to avoid peristomal skin irritation, where possible. This article will discuss the common causes of peristomal skin breakdown, the tools available to assist with assessment, and how to best treat peristomal skin irritation.     

Preoperative care of patients with kidney disease

Patients with chronic kidney disease often require surgical interventions for vascular access and for medical problems related to comorbid conditions. Perioperative morbidity and mortality rates are increased in these patients. Preoperative attention to common medical problems that occur in patients with impaired renal function can lower some surgical risks. Hyperkalemia can be temporarily improved by the intravenous administration of an insulin-dextrose combination or bicarbonate, and polystyrene binding resins or dialysis can remove excess stores of potassium. Increased bleeding related to uremic platelet dysfunction can be managed by the administration of desmopressin, cryoprecipitate, or estrogens, and by avoiding the use of medications with antiplatelet effects close to the time of surgery. Transfusions of red blood cells should be reserved for use in patients with clinically significant anemia, because antibody formation may decrease the likelihood of successful renal transplantation in the future. Cardiovascular disease is the most common cause of death in patients with renal disease. Patients with chronic kidney disease may have hypertension and hypoglycemia in the perioperative period. Preoperative testing may be necessary in patients with cardiac risk factors. If future vascular access grafting is contemplated, intravenous line placement and blood draws should be avoided in a patient's nondominant arm.     

Fecal diversion in complex anal fistulas: Is there a way to avoid it?

Temporary fecal diversion by a diverting colostomy or ileostomy is occasionally performed for serious complex fistulas. The main indications are highly complex and extensive cryptoglandular anal fistula, anal fistula associated with severe anorectal Crohn’s disease, recurrent rectovaginal fistula, radiation-induced fistula and anal fistula with associated necrotizing fasciitis. The purpose of stoma formation is to divert the fecal stream away from the anorectum and the perianal region so as to control the infective process and prevent trauma to the operated repaired tissues. Once the fistula has healed, the diverting stoma is closed. However, two questions are relevant. First, is it certain that the same disease would not relapse (or the fistula would not recur) once the colostomy is closed? Second, is there a non-surgical method which can obviate the need for a diverting colostomy? An attempt is made to answer both these questions in this review.     

Management of stoma complications

More than 100,000 people in the UK have a stoma and most experience problems at some point. This article gives an overview of some of the more common complications and possible solutions. Treatment often involves using stoma accessories, which are products used in conjunction with stoma appliances. Nurses or patients can also contact the stoma specialist nurse in their local hospital for further help and advice.     

Stoma care nursing: what the community nurse needs to know

The transition from hospital to home can be a worrying period of time for a patient with a newly formed stoma. It is well documented that community care is important, however this transition has been seen as a weak link in the care for a patient with a stoma (Allison 1996). In most cases following discharge from hospital, the nurse specialist in stoma care will visit the patient at home as a means of maintaining continuity of care. It is also important that the patient's GP, district nurse and other relevant community services are introduced to ensure a cohesive approach to the patients care at home (Taylor, 2003). This article therefore aims to offer the community nurse an overview of stoma care nursing in order to provide the continuity of care much needed by this group of patients.