Ageing can affect the ability to cope with stomas even in people who have had them for years. Nurses need to be able to identify problems and offer solutions
Trudi Pearson, RGN, is Charter Healthcare Community stoma care nurse, West Midlands.
Pearson T (2010) Older people should be given practical support to effectively manage their stomas. Nursing Times; 106: 11, early online publication.
People who have had a stoma for many years and managed it effectively may encounter problems as they grow older as a result of physical and/or cognitive impairment. This article outlines some of the problems the ageing process can cause and offers potential management strategies.
Keywords Stoma, Stoma care nurse, Ageing process
- This article has been double-blind peer reviewed
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- People with a stoma should be reviewed annually by a stoma nurse.
- They should have a contact number for a stoma nurse in the local hospital and community.
- Nurses should be aware that illness and disability can affect people’s ability to manage their stoma.
- People with a stoma should be assessed when they have contact with health services to identify whether they are coping with it.
- Nurses should ensure that those in this group are aware of stoma care clinics held in their area and how to attend.
- Organisations such as the Colostomy, Ileostomy and Urostomy Associations can provide general support and advice.
Advancing age can lead to problems for people who have had a stoma for many years (Black, 2000). Even those who have managed their stoma without support from their local stoma care service may experience problems as a result of illness or disability. It is important that all nurses recognise and acknowledge the problems that can occur as a result of the ageing process and know how to refer patients to specialist services for review.
Stoma nurses are usually involved in caring for patients immediately after surgery. In fact patients are rarely discharged from these nurses’ care as they are offered periodic reviews or encouraged to directly self refer if they have problems or concerns. However, over time some patients do lose touch with their stoma nurse as they become confident and able to manage their stoma independently.
If problems do arise, patients may not know how to access their stoma nurse and may allow problems to escalate before seeking help. In these situations they are likely to contact their GP, practice or community nurse.
The ageing process
A number of physiological and degenerative changes may occur over time which can cause problems for older people with a stoma and are listed in Box 1.
Box 1. Problems that may affect stoma management
- Wrinkles and sagging skin can result in problems with skin integrity.
- Weight loss and weight gain lead to changes in the shape and size of the stoma and surrounding area.
- Stomal complications such as hernia or prolapse.
- Arthritis which may reduce dexterity.
- Visual impairment.
- Memory loss.
- Changes in health status, for example, illness or disabilities that may impact on practical management of their stoma, such as Parkinsons disease or stroke.
Patients are usually able to recognise normal appearance and function of their stoma and the skin. However, subtle changes may occur over a long period of time, for example, wrinkling and drying of the skin, and these may result in problems such as leakage from the stoma appliance. (Breckman, 2005) notes that leakage and skin soreness can occur if the stoma appliance does not fit well around the stoma or adhere securely to the skin. Leakage is embarrassing for patients and can profoundly affect their psychosocial behaviour, body image and quality of life.
An annual visit to a stoma clinic can help to address these problems, as it provides an opportunity for patients to review new products and ensure that all current products are effective, still required and are used appropriately (Taylor, 2003).
Wrinkles and skin sagging
The loss of skin tone associated with ageing means that abdominal skin can wrinkle and sag. Several factors contribute to wrinkles, including persistent gravitational forces and loss of subcutaneous fat (Nigam and Knight, 2008).
Skin folds and creases in the peristomal skin (skin around the stoma) increase the likelihood of leakage between the stoma appliance and the abdomen (Turnbull, 2000). Creases can be identified by looking at the peristomal skin without a stoma appliance and asking the person to sit and bend to identify where the skin creases.
It is important to teach patients how to put their appliance onto wrinkled skin. Standing or sitting upright will mean the skin on the abdomen is stretched and as crease free as possible; they can then use a mirror and stretch the skin to obtain an even surface.
Creases can be filled in using an accessory such as a filler paste, with the aim of making the peristomal area as flat as possible so stoma appliances can adhere. Mouldable rings or strip paste can also be used.
Stoma nurses may recommend using a convex pouch if leakage is a problem. The convex shape produces an outward curve on the flange - the adhesive layer in contact with the skin - that pushes the stoma out. This helps direct the output from the stoma into the appliance rather than leaking onto the peristomal skin (Black, 2000). However, a stoma nurse should be involved in assessing individuals’ suitability for this appliance as inappropriate use can cause pressure damage, such as bruising or ulceration, to the peristomal skin area.
Thin and dry skin
The skin becomes thinner and drier with age and is prone to damage. It can tear or bruise easily and healing takes longer. This may be a problem for older people with a stoma as removing the appliance can result in skin damage. Appliance adhesive removers are available in spray or wipe form and can help to remove the flange without trauma to the peristomal skin.
Using a skin barrier wipe or thin layer of barrier cream may help to protect and moisturise the skin without making it greasy. Barrier creams containing glycerol and silicone gel do not interfere with the adhesion of the pouch if used sparingly. Stoma nurses can give advice on products suitable for individual needs.
Weight loss or weight gain
Stomas change in size and shape throughout life and also with weight gain or loss (Rayson, 2003). They can become stretched if people gain weight and the hole in the appliance may need to be enlarged, or it may need to be reduced if they lose weight (Myers, 1996).
Patients should be reminded to periodically re-measure their stoma, particularly if their weight changes.
Excessive weight gain can also cause extra bulges and creases that may obstruct the stoma and the appliance should be reviewed if this occurs.
Stomas may become retracted as a result of weight loss or gain and accessories such as stoma paste and rings can be used to protect the skin and build up creases or dips. Convex pouches can also be used following assessment by a specialist nurse.
Parastomal hernias occur when the peritoneum bulges through the weakened muscle wall around a stoma. These can vary from a slight bulge to a large, unsightly swelling (Lawson, 2003) and are associated with ageing, weight loss and gain (Turnball, 2009). Fig 2 shows an example of an incisional hernia associated with a stoma.
Lyon and Smith (2001) estimated that 2-3% of all people with a stoma will develop a hernia, whereas others suggest that up to 20% will be affected (Black, 2000).
Although the problem is usually managed with a support garment, sometimes surgery may be considered.
Arthritis and dexterity
People who develop arthritis or have impaired manual dexterity should have regular reviews of their appliance.
Stoma appliances are continually being developed and people should be given an opportunity to try new devices. For example, two piece stoma systems originally had a mechanical coupling, similar to a Tupperware lid, which some patients found difficult to use because it requires precision and pressure to attach. A newer adhesive coupling requires no pressure and is easier to secure. Fig 1 shows the two types of devices. Nurses should be aware that people need to feel confident that their appliance will not leak and they need reassurance and support when trying a new product.
Product delivery services can pre cut flanges for patients, which is helpful for those who find scissors difficult to use.
People who are blind or have visual impairment can learn to care independently for their stoma (Burch, 2008). Allowing them to familiarise themselves with new pouches through touch may help them to find a system they can use.
Some may find mechanically coupled two piece products useful as they can feel the ring and hear an audible click when fixing the pouch together. Others may prefer a pouch with an adhesive coupling (see Fig 1). All patients should have an opportunity to try different products until they find one that suits them.
Using a flange cutting service from the delivery company can help retain independence by ensuring the flange is consistently cut to size to fit neatly around the stoma.
Some people with visual impairment may have to rely on help from family or carers, which can be distressing and embarrassing and may result in a change in relationships if a partner takes on a caring role. Nurses need to be aware of how people with a stoma and family members feel about this and ensure that all other options have been explored.
Ageing may affect memory and some older people can forget they have a stoma appliance or forget to empty it.
People with poor memory may benefit from written instructions being placed in the bathroom and toilet or where they usually sit during the day to prompt them to think about caring for their stoma.
A written step by step guide can act as a refresher and checklist to ensure they have remembered all their equipment and the pouch changing procedure.
A standing order can be arranged where products can be delivered automatically each month and patients do not have to worry about running out of stock.
If memory loss reaches a point where the individual cannot remain independent, a care package at home or a residential care home may be considered. It is important that the stoma care nurse is informaed of any changes so that teaching and information tailored to the individual can be incorporated into their plan of care and long term support.
Changes in diet
People often find they eat less as they get older due to physical inactivity and loss of muscle mass. Some older people may not feel like cooking and eat snacks throughout the day. This can have an effect on the stoma’s output, resulting in constipation or diarrhoea.
Nurses can compile a list of the foods that will help thicken output or prevent constipation.
Patients should be encouraged to take small, well balanced meals with plenty of fluids to help maintain their weight and manage stoma output.
Admission to a general ward
Ward nurses should deliver stoma care as part of general nursing care. It is often informed and empathetic ward nurses who support, educate and advise patients with a stoma and have a positive impact on the quality of care they receive (Porrett and McGrath, 2005).
Ward nurses need to be aware of the stoma equipment patients need, where to get stock from and how to assess whether they are well enough to continue to care for their stoma while in hospital.
While patients may be embarrassed to talk about their stoma, it is important to assess how they have been managing and how their illness will affect their ability to cope. Assessment should address the following points:
- Does the patient usually look after their stoma?
- Does a family member or carer look after it?
- Are they currently having any problems with the stoma?
- Does the appliance require attention now?
- Do they have their equipment with them?
- Has the stoma care nurse been informed of their admission?
Patients may be in contact with their stoma nurse and ask to see them. If they do not have contact with a stoma care nurse being admitted may be a good opportunity to make a referral.
Stoma care nurses have a role in supporting and educating general nurses to ensure they have the skills to care for patients (Elcoat, 1986). Ward staff should ask for help and advice if they are unsure about any aspect of stoma care.
People with a stoma can experience problems as a result of advancing age, disability and ill health. General nurses have an important role in identifying when patients are having problems managing their stoma and should know how to refer them to a stoma nurse for specialist advice. Some people may require long term support from family, carers or healthcare professionals in managing their stoma and general nurses need to be aware of their role in this important aspect of care.
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