ostomy

WHAT IS AN OSTOMY?

Ostomy; created through a surgical procedure that creates an opening from the bowel to the abdomen resulting in a stoma for the purpose of eliminating waste in the form of stool. Ostomies may be temporary or permanent depending on the reason they were created and the extent of injury or the disease process.

Stoma; a segment of bowel formed from mucosal tissue and brought to the surface of the abdomen. It should be red and moist in appearance and will ideally protrude about 1.5-2.5 cm out of the abdomen. Unlike the anus, the stoma has no sphincters or valves meaning the individual will have no control over the passage of stool from the stoma. However, there are no nerve endings in the stoma meaning it should not cause any pain or discomfort for the individual.                                                                                                                                                     (UOA, n.d & American Cancer Society, 2011)

                                                                                             (Normal Colon, 2000)

Reasons people have ostomies;

-       Inflammatory bowel disease (ulcerative colitis or crohn’s

-       Cancer

-       Intestinal blockage

-       Intestinal tear (often caused by diverticulitis)

-       Trauma or bowel injury

-       Non-healing wound

-       Infection or abscess in intestines

-       Congenital anomalies or birth defects

(Walker& Lachman, 2013 & RelayHealth, 2012) 

                                                                     

Types of Ostomies;

Colostomy; a surgical opening from the colon (large intestines) to the surface of the abdomen to form a stoma for the purpose of discharging stool.  It is usually created when a portion of the colon or the rectum is removed and the remaining colon is brought to the abdominal wall. Colosomies require an external appliance and are further defined by the portion of the colon involved.

 

(Colostomy, 2010)

 

-       Sigmoid colostomy; the most common type of ostomy where the descending (sigmoid) colon is brought to the surface of the abdomen to create a stoma. They are usually located on the lower left quadrant of the abdomen.

-       Transveres colostomy; created with the transverse colon and results in one or two stomas, that are generally located in the right upper or middle side of the abdomen.

-       Loop colostomy; created with the transverse colon and results in the construction of two stomas, one to discharge stool and one to secrete mucus.                                                      

-       Ascending colostomy; not commonly seen but created with the ascending colon and is located on the right side of the abdomen. 

                              (Ileolostomy, 2010)

Ileostomy; a surgical opening from the ileum (small bowel) to the surface of the abdomen to form a stoma for the purpose of discharging stool. They are generally located on the lower right side of the abdomen.

-       Continent ileostomy; the construction of an intra-abdominal pouch from part of the ileum. It may be referred to as an abdominal pouch. External appliances are not required, instead a few times a day a catheter must be inserted into the site to drain the waste.

-       Ileo-anal reservoir; the construction of a pouch made from the ileum and rectum, it is then placed inside the body in the pelvis and connected to the anus. It may be reffered to as a J-pouch or pelvic pouch and actually allows the individual to pass stool through the anus.

(UOA, n.d & American Cancer Society, 2011)

                                                                                                                                                                                                     

Ostomy Appliances

Ostomy appliances come in endless shapes, sizes

and brands and depend on the location and size of the stoma as well as individual preference.  The main appliances used are one or two-piece systems and flat or convex systems. Furthermore, the actual appliance ring that surrounds the ostomy can be ordered to fit the size of the stoma or can be cut to size accordingly. Ensure you are using the right size pouching system because if the opening is too small it will cause the stoma to swell and cause obstruction and if the opening is too big then it may cause leakage or the skin around the stoma to become irritated. Ostomy bags should be emptied as per individual preference and when about 1/3 full, the entire appliance should be changed every 3-7 days.                                                                   (American Cancer Society, 2011 & personal communication, March 6, 2013)

A good pouching system should be:

-       Secure, with a good leak-proof seal that lasts for 3 to 7 days

-       Odor resistant

-       Protect the skin surrounding the stoma

-       Nearly invisible when covered with clothing

-       Easy to put on and take off

-       Easy to empty                                         (American Cancer Society, 2011)

                 

Skin barriers are used to protect the skin surrounding the stoma and most common ones used are barrier wipes, ostomy rings and stomahesive paste. However, please note that barrier wipes are NOT covered by insurance and will have to be paid out of pocket, make sure you patients are aware of all options before pursuing the wipes.   (Potter, Perry, Ross-Kerr and Woods, 2009 & personal communication, March 6, 2013)

Emptying an Ostomy

Emptying an ostomy is very easy but often done wrong by nurses in the hospital due to a lack of understanding and education when it comes to ostomies. The bag should be emptied when it reaches about 1/3 full, as needed or when there is significant gas build up. Emptying the ostomy bag frequently ensures there is a smaller chance of the ostomy leaking, bursting or bulging underneath clothes. When emptying an ostomy ensure to turn the end of the bag inside out and empty as much stool as possible. After the bag is empty, clean the end of the bag with toilet paper or a throw away cloth. By having the end of the bag turned inside out it helps to keep the tail of the ostomy bag clean and stool free. If the patient is emptying the ostomy independently, have them do it in the washroom over the toilet with the above steps. Lastly, ensure to wash your hands and have the patient do the same after emptying their ostomy.                                       (personal communication, March 6, 2013)

Changing an Ostomy Appliance

The ostomy should be changed approximately every five days or as needed.

1.     gather all your supplies including garbage bag and new ostomy appliance

2.     carefully take off the old appliance (be prepared to move quickly if the stoma is very active)

3.     cleanse the stoma and skin surrounding the stoma with warm soapy water (use a mild soap)

4.     dry the skin around the stoma thoroughly

5.     prepare the skin with a barrier OR apply the barrier paste/ring to the new appliance

6.     if needed, cut the flange to the proper size of the stoma (not too big or small)

7.     take the tape off the back of the ostomy appliance and secure it to the skin

8.     if using a two- piece system, secure the bag to the appliance

9.     ensure there is a good seal of the ostomy appliance to the skin and the bag to the appliance

10. wash your hands                                                                                (personal communication, March 6, 2013)

                                                                                                  (Ostomy Supplies, 2013)

It is important for HCP to note;

-       what the stoma looks like (ie. red, moist and active)

-       what the appearance of the stool looks like (ie. liquid, pasty or formed)

-       what type of appliance and skin barrier the patient uses

-       what size the stoma is

-       any issues with the stoma or surrounding skin (ie. skin rash or swollen stoma)

-       how did the patient respond/ are they independent in stoma and ostomy care/ do they need further teaching                                                                       (personal communication, March 6, 2013)

Lifestyle / Ostomy & Stoma Care

-       Nutrition; well balanced diet and adequate fluid intake are very important with the management of an ostomy. While there are foods difficult to digest with an ostomy, there are actually no “off limit” foods. It is recommended that and individual doesn’t eat these difficult to digest or stringy foods all in the same sitting (ie. celery, lettuce and other raw vegetables). It is also very important that people with an ostomy chew their food very well, this will help prevent blockage by food at the stoma site.

-       Bathing; a normal bathing routine is encouraged for individuals who have an ostomy. It is personal preference whether the individual likes to shower or bathe with their appliance on but it is important to ensure the stoma is cleansed on a regular basis with mild soapy water and that the ostomy appliance is changed if it becomes very wet or the seal is broken. It is recommended that patients use waterproof tape around the outsides of the appliance in order to protect the barrier and appliance. Lastly, it is always important for the individual and HCP to perform hand hygiene after changing or emptying an ostomy.

-       Exercise; it is recommended that people with ostomies still get the regular recommended daily exercise and activity. However, keep in mind that heavy/weight lifting and contact sports risk the chance that there could be damage to the stoma or a chance of herniation.

-       Sexual activity; sexual relationships and intimacy are encouraged to continue with individuals who have a stoma and ostomy. While sexual function in women generally doesn’t change, men can occasionally be affected by changes and have difficulty getting or keeping an erection, however this should not last for long. The most important part of resuming sexual activity after surgery to create an ostomy is communication between partners and making sure that any concerns are discussed openly.                                 

     (American Cancer Society, 2011 & personal communication, March 6, 2013)

                                                                    (Colostomy Stoma, 2013)

Complications and Concerns

-- It is normal for your ostomy to have short periods of time where there is little to no output. However, if the stoma is not active for over 4-5 hours or there is a new onset of cramps or nausea then there may be a block or obstruction to the ostomy. Obstruction can be caused by a food blockage or internal changes such as adhesions. If this happens; drink ginger-ale or warm liquids, take a warm bath to relax the abdominal muscles, try changing positions, do NOT take laxatives and if none of these tips are working, contact the doctor or ET nurse or go to the   emergency department.                                                                                                           

-- A rash or denuded skin can occur due to an improper appliance fit or seal. Itching and burning are signs that the skin needs to be cleaned and the pouching system should be changed. Denuded skin or “burnt” skin generally means that stomach acid and stool is leaking onto the surrounding skin and this means the appliance should be changed and a better seal around the stoma needs to be created.

-- Bleeding can occur because blood vessels in the tissue of the stoma are very sensitive and can bleed easily. Small amounts of blood after cleaning the stoma is not concerning however it becomes a concern if the bleeding continues or worsens, if this occurs contact the doctor, ET nurse or go to emergency department.

  

-- Odor is inevitable with ostomies just as it is with a normal bowel movement. Certain foods may cause an individual more gas or odor but it is very personal so the individual must learn from experience. In order to limit odor; empty the ouch often, use an odor resistant pouch, ensure the pouch is sealed properly to the skin and odor resolving tablets or spray can be added to the pouch if necessary.

-- Hernia’s occur commonly after the creation of an ostomy or during heavy lifting and is the bulging of an area or loop of the organ or tissue surrounding the stoma. Hernia’s generally occur over a longer period of time so alert your doctor or ET nurse if you are noticing any changes or new bulges in the skin post-op.

-- Diarrhea is frequent, loose or water bowel movements and usually signifies that something is not quite right. It can be caused by certain food or beverages but becomes dangerous when it continues for greater than 5-6 hours as it can lead to severe electrolyte imbalance. It is recommended that you contact a health professional if diarrhea or a significant change in stool occurs. Note: depending on the placement of your colostomy (ie. transverse and ascending) and ileostomy the ‘normal’ bowel movement might be very liquidy, this is normal and not considered a concern or emergency.                                                     (American Cancer Society, 2011 & personal communication, March 6, 2013)

Ostomies and Nursing

Ostomies are becoming more common on hospital units due to cancer, surgery and trauma it is important that floor nurses and health care professionals know how to care for patients with ostomies. It is very important that nurses have the tools and resources in order to help patients to learn ostomy self care as well as to help them through any emotional, physiological or physical issues or challenges they may come across with having an ostomy. When in doubt, consult an ET nurse who specializes in ostomy and wound care. Enterostomal Therapy nurses (ET nurse) are trained in ostomies and do stoma and ostomy education with patients preoperatively and postoperatively. ET nurses help the patients adjust to their new stomas and work with the patient to find a good fit for an ostomy appliance. These nurses are an excellent resource for floor nursing staff when they have questions or concerns regarding a patient with an ostomy (ie. rash around stoma develops, stoma changes colour or continuously leaking appliance) and their knowledge and skills should be utilized as they are ‘experts’ in the field of ostomies.

 (personal communication, March 6, 2013)

References

American Cancer Society. (2011). Colostomy: a guide. Retrieved from http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/ostomies/colostomyguide/colostomy-guide-toc

American Cancer Society. (2011). Iliostomy a guide. Retrieved from http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/ostomies/ileostomyguide/ileostomy-living-with-ileostomy

Colostomy. (2010). Relay health [online image]. Retrieved March 10, 2013 from http://www.summitmedicalgroup.com/library/adult_health/aha_colostomy

Colostomy Stoma. (2010). Healthwise incorporated [online image]. Retrieved March 14, 2013 from http://www.webmd.com/digestive-disorders/colostomy-stoma

Ileostomy. (2010). Relay health [online image]. Retrieved March 10, 2013 from http://www.summitmedicalgroup.com/library/adult_health/aha_colostomy

Normal Colon. (2000). Radiographics [online image]. Retrieved March 12, 2013 from http://radiographics.rsna.org/content/20/2/399/F1.expansion.html

Ostomy Information. (n.d). United Ostomy association of Canada (UOA). Retrieved from http://www.ostomycanada.ca/ostomy_information

Ostomy Supplies. (2013). Steveneddy [online image]. Retrieved March 14, 1013 from http://steveneddy.wordpress.com/pics/ 

Potter, P. A, Perry, A. G., Ross-Kerr, J. C., & Wood, M. J. (Eds.). (2009). Canadian fundamentals of nursing (4^th ed.). Toronto, ON: Elsevier Mosby.

Relay Health. (2012). Colostomy and ileostomy. Retrieved from http://www.summitmedicalgroup.com/library/adult_health/aha_colostomy

Walker, C. A., & Lachman, V. D. (2013). Gaps in the Discharge Process For Patients with an Ostomy: An Ethical Perspective. MEDSURG Nursing, 22(1), 61-64.