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.
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 (4th 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.