GP Update on Stoma Care

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GP Update on Stoma Care

• Heather Wilson
• Stoma Care Nurse Specialist
• Gateshead Health NHS Foundation Trust

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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

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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

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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

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End Colostomy
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End Ileostomy
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Loop Ileostomy
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Reasons for needing a stoma

• Varied
• Cancer bowel/rectum or bladder
• Inflammatory Bowel Disease Crohns Ulcerative
  Colitis
• Diverticular Disease
• Congenital abnormalities
• Bowel ischaemia
• Irradiation damage, fistula formation

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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

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• 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

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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 anexpert in
  stoma management and adapts to life with a stoma

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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

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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.

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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

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

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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

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• 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
  patients fingers

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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.

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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

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Necrosis and Dehiscence
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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

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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

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Parastomal Hernia

• Affects 40 plus an increasing problem
• More common in older patients
• Loss of muscle tone
• Appliance review
• Support garment
• Observe patient
• Surgery

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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

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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

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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

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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

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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

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Skin Problems (2)

• Allergic reaction
• Allergic contact dermatitis
• Patch test. Change pouch type.
• ? Refer to dermatologist
• May need topical steroid . Lotion, inhalers,
  nasal spray

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• 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

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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

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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

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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.

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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.

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• Thank you for listening
• Any questions ?