Best practice in discharging patients with a stoma

Pre-operative preparation and postoperative education are both essential elements for the recovery and successful discharge into the community of patients with a stoma. The ultimate goal of any stoma care nurse is to provide patients with the necessary practical skills and knowledge to return to a lifestyle they enjoyed before surgery (Abrahams, 1984).

The basic pre- and postoperative planning that is required for patients who have had bowel surgery under elective conditions with a confirmed colorectal pathology, for example, rectal cancer or inflammatory bowel disease, is described below. Stomas include colostomy, ileostomy, jejunostomy and urostomy. They can either be end stomas (one segment of bowel is exteriorised), or loop stomas (two segments of bowel are exteriorised), and they may be permanent or temporary.

Pre-operative planning
This requires a step-by-step approach:

1. Meet with the patient in advance of (elective) surgery to discuss the proposed surgical procedure and the practical aspects of living with a stoma; for example, dietary needs, bathing/showering, returning to work.

Rationale: To provide written and verbal information, to give the patient an opportunity to ask questions, and to help prepare him/her both physically and mentally for life with a stoma.

2. Show the patient a typical postoperative appliance; for example, a one-piece, drainable, transparent, flexible appliance.

Rationale: To allay any pre-conceived ideas about what a bag looks like.

3. Inform the patient of what to expect immediately after surgery; for example, describe the appearance of the stoma and explain how the bowel will function. Also, describe the surgical equipment that will be required immediately following surgery, such as a urinary catheter, wound drains, a nasogastric tube and an epidural cannula.

Rationale: To reduce postoperative anxiety.

4. Choose the optimal location for the stoma. Ensure the site chosen is visible and accessible to the patient and avoids skin folds and creases, previous scars and the patient's waistline (Elcoat, 1986; Black, 1994).

Rationale: To prevent potential problems with the management of the stoma appliance, such as persistent leakage, patient demoralisation, isolation and constant anxiety. Siting a stoma requires training, experience, and skill, and the nurse must, at the very least, have taken the Principles of Stoma Care course.

5. Involve the patient's family in discussions if this is possible.

Rationale: To facilitate reintegration into the family unit.

Planning in an emergency

In emergencies, it is impossible to prepare patients fully, and in many instances they may not be seen by a stoma care nurse before surgery (see case study). Patients requiring emergency surgery are usually very unwell, often in pain and their abdomen may be distended. Undoubtedly they will have many questions, as they may be anxious at the prospect of surgery and apprehensive as to the outcome. Following surgery, they will need time to comprehend fully what has happened to them.

Information is essential, but is usually best given to patients in small fragments, allowing them time to absorb it. The stoma care nurse will work with patients at a pace comfortable to them as individuals, introducing and familiarising them with the practical aspects of stoma care within two or three days of surgery.

Postoperative planning
1. Teach the patient the necessary skills to enable him/her to manage the stoma independently.

Rationale: To prepare the patient for independent management of the stoma.

2. Identify with the patient a suitable stoma product.

Rationale: To ensure that the patient is happy with the appliance and is able to manage it.

3. Provide additional literature/reading materials where appropriate; for example, information about diet and skin care.

Rationale: To ensure the patient is armed with sufficient information to prevent possible complications such as skin irritation and redness.

4. Instruct the patient how to obtain further stoma supplies and give details of products used.

Rationale: To prevent the patient running out of supplies/equipment.

5. Liaise with the community stoma nurse, district nurse/s and GP before the patient is discharged, and provide discharge letters/ information.

Rationale: To ensure the patient has full support in the community.

6. Discuss appliance disposal.

Rationale: To ensure waste is disposed of in the correct manner.

Conclusion
Before patients are discharged home from hospital, nurses must ensure that certain criteria have been met by them: they must have recovered from the physical effects of their surgery, have developed the necessary practical skills of living with a stoma and be able to manage their appliance (Donaldson, 1989) (Box 1).

USEFUL CONTACTS
British Colostomy Association. Tel: 0118 939 1537 www.bcass.org.uk

RADAR: 0207 250 3222 http://www.radar.org.uk/

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