Download Many causes - poor fitting appliance, flush stoma, poorly

GP Update on Stoma Care
Heather Wilson
Stoma Care Nurse Specialist
Gateshead Health NHS Foundation
Trust
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
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
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
End Colostomy
End Ileostomy
Loop Ileostomy
Reasons for needing a stoma
• Varied
• Cancer – bowel/rectum or bladder
• Inflammatory Bowel Disease – Crohn’s Ulcerative
Colitis
• Diverticular Disease
• Congenital abnormalities
• Bowel ischaemia
• Irradiation damage, fistula formation
Stoma Care Nurse Specialist
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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
• 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
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 an‘expert’ in stoma
management and adapts to life with a stoma
Stoma Problems
Divided into 3 main areas
1. Problems in the management of a stoma
e.g. hernia, prolapse, stenosis
2. Skin conditions which may arise due to
the stoma or wearing of an appliance
3. Psychological issues
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.
Colostomy
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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.crohn’s, cancer, sub acute obstruction
• Imodium
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
• 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 patient’s fingers
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.
Necrosis / Sloughy Stoma
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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
Necrosis and Dehiscence
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
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
Parastomal Hernia
• Affects 40% plus an
increasing problem
• More common in
older patients
• Loss of muscle tone
• Appliance review
• Support garment
• Observe patient
• Surgery
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
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
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
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
Skin Problems
• 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
(1)
Skin Problems
• Allergic reaction
• Allergic contact
dermatitis
• Patch test. Change
pouch type.
• ? Refer to
dermatologist
• May need topical
steroid . Lotion,
inhalers, nasal spray
(2)
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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
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
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
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.
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.
• Thank you for listening
• Any questions ?