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Practical aspects of stoma care

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VOL: 97, ISSUE: 12, PAGE NO: 40

Elaine Armstrong, RGN, is clinical nurse specialist in stoma care at the Royal Free Hospital NHS Trust, London

The word stoma comes from the Greek word meaning 'mouth or opening', and a stoma can be created from any segment of bowel, both large (colon) and small (ileum). Stomas are created for a range of reasons, including cancer, inflammatory bowel disease, trauma and as an elective or emergency procedure.

The word stoma comes from the Greek word meaning 'mouth or opening', and a stoma can be created from any segment of bowel, both large (colon) and small (ileum). Stomas are created for a range of reasons, including cancer, inflammatory bowel disease, trauma and as an elective or emergency procedure.

Stomas can be permanent or temporary, depending on the type of surgery and the presenting clinical problem.

The creation of the first everted (spouted) ileostomy in 1952, by surgeon Brian Brook, revolutionised stoma surgery. The introduction of the black rubber bag to England between 1953 and 1954 also brought welcome changes (especially for the patient), providing a more manageable container than those previously used.

Before this innovation, many alternatives had been used to collect body waste, including coconut shell, tins, gauze and other lint dressings, which were held in place by the patient's clothing, corsets or a combination of leather belts.

Principally, two forms of stoma exist - input and output stomas (Devlin, 1984). The former include pegs and gastrostomies, which facilitate the introduction of a feeding tube into the stomach or jejunum. Output stomas, on the other hand, refer to colostomies, ileostomies and urostomies, which discharge waste (See Table 1).

For the patient undergoing abdominal surgery, and where there is likely to be stoma formation, it is essential to mark the site.

The stoma care nurse (SCN) is careful to choose the optimal position - one that avoids bony prominences, skin creases or folds and abdominal irregularities, such as hernias. She also ensures that (where possible) the mark is placed within the rectus sheath (a large abdominal muscle that helps support the stoma once it is brought out on to the abdomen). Additional factors, such as arthritis, visual impairment, loss of limb and mental impairment (Black, 1985) must be considered if the patient is to manage the stoma independently. For those with severe disabilities, such as those which necessitate the use of a wheelchair, consideration must be given to the position of support belts and splints (if worn), as well as body shape. An inappropriately placed stoma can have a profound effect on the patient's rehabilitation (Elcoat, 1986), not to mention their quality of life.

Ideally, a stoma should be visible to the patient, easy to manage and should not restrict or hinder movement or activity in any way. Morrall (1990) believes adequate preoperative preparation and counselling will influence how the stoma is accepted. This is generally upheld by SCNs and, because of this, most elective cases would be seen before surgery. The patient is given appropriate information about the procedure, stoma type, where it will be placed and how it will function.

All patients return from theatre with a drainable, transparent pouch for easy visualisation and the early detection of complications, such as bleeding, necrosis and ischaemia.

A one or two-piece system may be in situ, depending on consultant's choice. This type of appliance is used until the patient is eating and drinking normally and a more normal bowel function is achieved.

Before being discharged, the patient is shown a range of products, one of which he or she will choose. Should the product be unfavourable, then a replacement is found, as it is vital the patient feels the product is suitable, comfortable and aesthetically pleasing.

The patient should be discharged with full community back-up, thus ensuring that rehabilitation and stoma adaptation continue.

Following surgery, problems with the stoma can arise. Table 2 summarises some of these problems and how they are best managed. Other products, such as those for extra adhesion and skin healing, may also be required to achieve the desired effect from an appliance. Table 3 reviews some of the more common accessories used in stoma care.

Teaching the patient to change the appliance
Teaching the patient how to look after the stoma, as well as manage the appliance, requires formal teaching sessions. Initially, these can be carried out at the bedside and then, as the patient becomes more mobile, in a bathroom, since most stoma patients will perform stoma care in this setting once they are at home.

At the first practical session, the patient may wish only to observe and analyse the process by which the appliance is renewed. Over time, the SCN will encourage the patient to participate and take a more active role, ultimately leading to independence. The SCN will then pull back, allowing the patient to further explore his or her own body image and the barrage of emotions that can ensue as a result. The SCN is, however, always close by to offer support and reassurance.

The procedure
1. Assemble all necessary equipment

There are four basic requirements: warm tap water, a rubbish bag, gauze or lint, a new pouch (a one- or two-piece system). Scissors, a template and a pen (only if the flange needs cutting) may also be used.

2. Cutting the flange to size

Place the template over the back of the flange, centralising it over the small opening already in the flange. Draw around the template with the pen and then cut out the area marked.

The flange must be accurately cut to size. A patient with an ileostomy needs a snug-fitting flange to minimise skin breakdown due to faecal contamination. The flange must also not be placed on the stoma, as this may give rise to leakage.

A patient with a colostomy can have a flange that is cut larger than the stoma, (3-5mm), because of the nature of the output (thicker and less corrosive).

3. Emptying the pouch (if drainable)

This must be emptied before the procedure, ensuring no spillage occurs.

4. Remove the flange

By starting at the top of the flange, peel it slowly from the abdomen. The skin should be supported to avoid irritation. Once removed, discard it.

5. Clean the peristomal skin

This can be performed with moistened gauze, to remove glue and debris from the flange. Repeat the process several times until the skin and stoma are clean. While cleaning the stoma, specks of blood may appear on the gauze. This is normal and may occur every time the stoma is cleaned. It happens because the small blood capillaries on the stomal surface are very delicate and bleed easily as a result of contact with the gauze.

6. Dry peristomal skin

Use gauze to ensure the skin is dry, so the new flange will adhere.

7. Remove the backing paper from the flange

Place slowly over the stoma, allowing it to rest on the skin.

8. Press the centre of the flange and outer edges firmly on the abdomen

This will ensure it has stuck and provides security. (Attach the pouch to the flange if using a two-piece system.)

9. Attach clip (if using a drainable pouch).

10. Discard rubbish in the household waste or await collection from the council (as arranged).

Body Image
Within the constraints of this article, body image can be mentioned only briefly; suffice to say it is a large topic. For many patients, stomal surgery can be physically and emotionally draining, bringing with it feelings they have never experienced before, and do not feel equipped to deal with. These include feelings of worthlessness, repulsion and unattractiveness. The stoma is not how they imagined - it looks raw and painful, and they worry it will become infected or damaged.

People undergoing stoma formation face permanent changes to their accepted body image, lifestyle and sexuality.

The SCN can help in the rehabilitative process, by communicating sensitively. For example, they must be careful not to show any signs of distaste when changing or emptying a pouch. If the nurse is relaxed when dealing with the stoma this will help the patient come to terms with it.

Stoma surgery has done much to preserve life and to give hope to patients. Polymer sciences have also done much to promote the practical aspects of stoma care, creating the ultimate in lightweight, odour-proof and skin-friendly pouches. Surgery and product choice have enabled SCNs to provide a high-profile service. General nurses should also be encouraged to participate in stoma management, so as to acquire new skills and knowledge. It is also vital that generalist nurses know when to ask for help from an SCN.

- See also Practical Procedures, p43

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