Rachel M. Flood Education Program
Advanced Ostomy Education Program |
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Advanced Ostomy Management is an innovative, on-line education program which provides the health care professional the flexibility to learn at their own pace on their own time. The curriculum is developed by a faculty of health care professionals experienced in caring for people with ostomies. |
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Topics include: |
A one week clinical residency conducted at Mount Sinai Hospital provides additional learning opportunity for enhanced knowledge and skills in advanced ostomy care. |
Successful graduates will receive a Certificate of Completion in Advanced Ostomy Management. |
About the Rachel Flood Education Program
The Rachel Flood Education Program is committed to providing continuing education in the care and support of people and families who live with ostomies. Health-care professionals will learn how to provide evidence supported care through the application of current knowledge, and development of clinical skills in ostomy care, which will enhance independence, dignity and an improved quality of life. The program is managed by the University of Toronto.
Supporting the Patient's Journey: Living with an Ostomy
February 1st, 2012
We are delighted to announce that the presentations - slides and
accompanying audio - for the entire program that was held on Friday,
October 21, 2011.
Topics include: Patient Advocacy, Ostomy Preoperative Patient/Family Education, Peristomal Skin Conditions; Surgical Procedures and Stoma Complications; Dietary Myths and Management; Emotional Support; Transitioning from the Hospital to Home and Special Ostomy Care Needs for the Elder.
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Rachel M. Flood Education Program in Ostomy Management
The Advanced Ostomy Education Program is designed to provide a comprehensive, evidence-based educational experience for Registered Nurses and Registered Practical Nurses practicing in all health care settings and who are interested in advancing their basic knowledge and skill competency in ostomy management. The program is managed by the University of Toronto.
Ostomy - Overview
Living with Inflammatory Bowel Disease will sometimes require surgical intervention in order to manage the disease and its symptoms. Certainly the prospects of surgery alone can be overwhelming, while the addition of an ostomy, whether it be temporary or permanent, can also be met with fear and worry. Numerous supports are available for individuals who are facing ostomy surgery, including: written information, booklets and videos, Ostomy Visitor Programs, support groups, and Enterostomal Therapy Nurses; all of which will help with the adaptation process and will provide reassurance that you can live a full and productive with an ostomy.
What is an Ostomy?
An ostomy is a surgeically created opening in a part of either the small or large bowel. The bowel is brought up through the abdominal wall (through the muscle and fat layers), everted or "cuffed", and the edges of the bowel are sutured to the surrounding skin surface. The resulting "bud" of bowel is called a "stoma". It will be moist, warm and red in colour, and may either be flush with the surrounding skin (as for colostomies) or may be protruding from the skin surface (as for ileostomies). The stoma is often referred to as resembling a puckered mouth. While it may look sore, a stoma actually has no nerve endings so will not be painful to the touch. For some individuals, a loop of bowel is brought to the surface instead of the end of bowel, so a small plastic rod will be used under the stoma to support it while healing.
The rod is generally removed about four to six days after surgery with very little if any discomfort. The stoma will always have some degree of movement (peristalsis), particularly while functioning for stool. Stomas are initially swollen after surgery, but will decrease in size about six weeks following surgery. Because there are no sphincters associated with a stoma, there is no voluntary control over when the stool (bowel movements) will be passed. Since there is no control, an external appliance must be worn to collect the stool.
Living with an Ostomy
An ostomy should not affect your ability to resume your normal lifestyle. Many people find they can continue with all of the activities that they enjoyed prior to illness and surgery. There are many individuals with ostomies who are distance runners, swimmers, skiers, skydivers, scuba divers, hockey players, and football players - the list is endless.
Bathing
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Bathing or showering is not restricted by an ostomy. You should bathe or shower with the entire appliance on, or the entire appliance off on your appliance change days. The water or soap will not hurt or damage your stoma although make sure to thoroughly rinse the soap off your skin if bathing without the appliance, so that the new appliance can attach properly. |
Do not let a shower stream fall directly on your stoma. If bathing with your appliance on, just dry the pouch with a towel, |
Hot tubs are also okay, but note that long soaks in a hot tub, or in a warm bath, may lessen the normal wear-time of the appliance and you may need to change it more frequently. |
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Clothing
There are no real "do's or don'ts" with clothing, as most choices are more a matter of comfort. Unless you chose to tell people, your ostomy appliance will likely not be obvious under your clothing. Concealment of an appliance is somewhat dependent upon the type of appliance worn (a one-piece versus a two-piece) and the location on the abdomen. In general, patterned fabrics tend to conceal the appliance more easily than solid colors. The choice of underwear is again a matter of personal preference. Some people prefer loose underwear while others want more support and may chose a lycra pant/brief; some may want the pouch covered with underwear, while others prefer to wear a low cut pant/brief. It is often a matter of experimenting to determine what works for you. Check with your ET (Enterostomal Therapy) nurse or local chapter of the United Ostomy Association to see if there are specialty shops or resources in your area for specialty clothes and underwear.
Odour
No one should ever detect an odour of stool when the appliance is secure and in place. Presence or absence of odour in the stool is somewhat determined by each individual's body chemistry. There are, however, measures, which can aid in reducing the odour of stool when the appliance is emptied. Measures would include adding commercial deodorizing tablets or liquids to aid in de-odouring the inside of the appliance or using aerosols or wicks to freshen the bathroom. It is also important to clean the lower end of the pouch after emptying with tissue or a wipe.
Gas
There are several suggestions that will help with gas production. It is important to eat regular balanced meals. Skipping meals is more likely to increase gas production. Initially after surgery, there will be more gas as well as noise as the bowel has been handled and is empty. Gas and noise lessens once diet and activity is resumed. Food should be eaten slowly and in a relaxed manner. Activities such as gum chewing, smoking, mouth breathing, drinking carbonated beverages or sucking on ice chips can all encourage swallowing large amounts of air contributing to an increase in gas production.
Ostomy Care - Selecting an Appliance
The selection of appliances for ostomy care is based on a few basic principles:
odour-proof
- leak-proof
- protects the peristomal skin from stool and trauma, irritation
- protects the stoma from damage
- promotes independence and comfort
Selection must also take into consideration how the stoma is constructed, what the surrounding skin and abdominal contours look like, the consistency of the stool, and the cost and availability of the product.
Ostomy appliances can either be a one-piece or two-piece system. In a one-piece system, the barrier, "sticky" portion, and the collection pouch are attached to each other and cannot be separated. In a two-piece system, the barrier portion (flange) and the collection pouch are two separate pieces and are connected by some sort of a locking mechanism. The flange and pouch can be separated. There are "pros and cons" to each system, and these can be discussed with an Enterostomal Therapy Nurse.
Stoma type and construction, body contours, personal capabilities (hand strength, eyesight, etc) and preferences will all contribute to the choice of appliance. Certain aspects such as stomal type and construction may dictate and limit product choices, but usually there is some degree of choice for an individual with an ostomy. After surgery, the selection process should be done with an Enterostomal Therapy (ET) Nurse. Subsequent changes should be done in consultation with an ET to ensure that unnecessary problems and expense are avoided.
Considerations
There are several considerations to make when selecting appliances.
Barrier Type
Two types of barriers exist: regular and extended wear. The barrier is fundamental to appliances since this is the substance that protects the skin from the stool.
- Regular Wear
Regular wear barriers are ideal for colostomies where the stool is semi-formed to formed in consistency, and tends to not "melt" or "wash away" the barrier during use. Typically, those with a colostomy can wear a regular barrier product for five to seven days before requiring a change. While it is not wrong for individuals with ileostomies to use a regular barrier, the stool will wash away the barrier more quickly and more frequent changes are suggested so that peristomal skin will remain protected.
- Extended Wear
Extended wear barriers are more resistant to "melt-out" and are ideal for ileostomies and urostomies (urinary stomas). Some of the extended wear barriers will actually form a thick "cuff" around the stoma (in about 24 hours after application) which enhances the seal and helps to extend the wear-time. Typically, those with an ileostomy or urostomy can wear an extended wear product for five to seven days. These products tend to be more "sticky", so slow, careful removal is suggested with each appliance change.
Full-Barrier versus Tape-Border
Appliances can either be full barrier with no tape at the edges or have the barrier in the Group with a tape border.
- Full Barrier
Full barrier products are good options for those with known tape sensitivities or allergies. As tape is not used or required to secure these appliances, reactions can be avoided. Originally, full barrier products tended to be thicker and bulkier, but there are now significant improvements and these are now lighter and thinner.
- Tape Border
Tape border products have a border of tape extending from the Group barrier which is intended to make the appliance lighter and more flexible. The tape border also has a slightly different adhesive than the barrier, so "tack" is often immediate. Sensitivities tend to happen more readily with tape borders, and sometimes with tape borders that are flesh coloured (due to dyes used).
One-Piece System
Advantages:
- Low profile: since there is no "locking" mechanism to connect separate pieces, these appliances lay flat against the body
- Increased security: there is no concern about incorrectly attaching the pouch to the flange, so unexpected leaks from the connection will not occur
- Increased flexibility: these appliances tend to be very flexible, so will curve/mold with gentle body contours
Disadvantages:
- Inability to change pouch type: one-piece appliances are generally meant to be worn for a period of time (four to five days), and so switching a short pouch to a long pouch to suit personal needs during the course of a day are not possible.
- Inability to use a belt as some one-piece appliances do not incorporate belt tabs, so if extra security is desired or required, this may not be possible.
Two-Piece System
Advantages:
- Ability to switch pouch type: if a short pouch is desired for day-time, a longer pouch for night time, and a stoma cap for swimming, then this can be done with a two-piece system. The flange remains in place for the pre-determined time, and the 'locking' mechanism allows for the pouch type to be changed.
- Ease of application: for some, being able to apply the flange first, then the pouch during routine appliance changes, makes care easier.
- Ability to use a belt: most two-piece systems have belt tabs which allow for the use of a belt.
Disadvantages:
- Increased profile: because of the locking mechanism. The profile of the appliance is raised; the degree of profile varies between product lines.
- Decreased flexibility: most locking mechanisms tend to be quite rigid, so conforming to body contours may be problematic.
- Decreased security: incorrectly attaching the pouch to the flange may result in leakage.
Flat versus Convex
Depending upon stomal construction and surrounding body contours, a
flat appliance or one with convexity may be the optimal choice.
Flat
Flat appliances are literally flat. They work best with an abdominal
surface that has sufficient flat area to allow for the appliance to
adhere and a protruding stoma of some degree.
Convex
Convex appliances protrude at the adhesive surface (it looks like a
curve or bulge), and are designed to help flatten some body contours and
to assist with accentuating stomal protrusion. This is usually required
when a stoma is flush or retracted, or perhaps "tips" down and rests
against the skin. Sometimes, body contours (dips and creases of varying
degrees) will also interfere with an adequate seal. A convex appliance
will help to compensate for this. There are several degrees of convexity
— from shallow to deep — and the best type can be determined in
conjunction with an Enterostomal Therapy Nurse.
Pouch Length
Pouches can be of varying sizes, either mini (with virtually no capacity to hold stool), short (about 9 to 10 inches in length), or long (about 12 inches in length). Obviously the volume of stool held in the pouch is dependent upon the size. The choice can be made according to the volume of stool produced in a day, and the frequency by which the pouch must be emptied (remembering that pouches should be emptied when 1/3 full). Some people prefer shorter pouches during the day, as concealment under clothes is easier, and longer pouches at night to facilitate sleep. Mini pouches (or stoma caps) are for times when stool volume is known to be low and when discreteness is desired (i.e., swimming, sexual activity).
Drainable versus Closed-End Pouches
Drainable
Drainable pouches are those with an
open "tail" that require a clip or velcro for closure. The clip or
velcro is removed or opened when emptying of the pouch is required.
Closed-end pouches are sealed at the bottom are thrown away when half
filled with stool.
Drainable pouches are best used for ileostomies or for colostomies when the stool is thin and frequent. As emptying is frequent, the pouch is allowed to drain through the tail and into the toilet at the discretion of the individual. Because stool is thinner, it drains easily from the pouch. It is a more cost-effective means of management when emptying is frequent.
Closed-End
Closed-end pouches are primarily
intended for individuals with a colostomy. As stool tends to be thicker,
it may be harder to drain easily from a drainable pouch. A closed end
pouch allows the individual to remove it in its entirety and discard it
in the garbage, immediately replacing it with a clean new pouch. For
most individuals with a colostomy, this means one to two pouches daily.
Most closed-end pouches also have charcoal filters which releases
deodorized gas.
Pre-Cut versus Cut-to-Fit
Pre-Cut
Pre-cut flanges imply that the opening
of the barrier is pre-cut according to standard sizes determined by the
manufacturer. Cut-to-fit implies that the barrier must be cut by the
individual according to the size of his/her stoma.
Pre-cut
barriers are best used once the post-operative swelling of the stoma has
settled (at about 6 to 8 weeks). The chosen pre-cut opening should be
1/8 (3-4 mm) larger than the base of the stoma. As most manufacturers
have standard pre-cut measurements, you may find that your size is not
available. The stoma must also be essentially round in shape in order to
use pre-cut barriers, as oval openings are not generally available.
Cut-to-Fit
Cut-to-fit barriers are a good choice
in the initial weeks after surgery, as the stoma will shrink during
this time and adjustments to the opening will be required. It is also a
good option when stomas are oval or irregularly shaped allowing for a
more precise cut and opening.
Accessories
There is certainly a wealth of additional products that can be used in conjunction with pouching choices. Not all are required, and use may be based on personal preference rather than need.
Belts
Belts may be required to ensure adhesion of an appliance, but also may
be desired for personal comfort and security. Some prefer to use belts
during physical activity to allow for extra support. Belts tend to
provide support and security just at the lateral level (i.e. they pull
at 3 and 9 o'clock of the peristomal area). Belts also work best if they
are in-line with the natural waist and do not "ride-up" higher than the
level of the pouch.
Stoma Protectors
Stoma
protectors are hard plastic devises that are worn over the stoma and
appliance to protect the stoma from any trauma. These are most commonly
used during times of physical labor, or during sports activities when
the risk of damage is high.
Additional Barriers
Barriers come in different
formats, including pastes, plates or rings. These may be helpful to fill
in dips and creases, accentuate convexity or assist with adding
wear-time to an appliance. The appropriate choice and use of an
additional barrier should be done in conjunction with an ET.
Deodorants
While appliances and pouches are odour-proof, pouch deodorants (as well
as room deodorants) are available to alleviate odour while emptying.
Your ET or ostomy supply company can provide you with information regarding all of the products.
Caregiver Education
IBD Patient Care Standards
The following Inflammatory Bowel Disease Patient Care Standards have been developed for the IBD patient care unit at Mount Sinai Hospital. It is the combined effort of the multidisciplinary team that provides the holistic care for patients families coping with Inflammatory Bowel Disease.
Educational strategies and sessions need to be geared towards meeting the outcome standards.
Outcome Standards
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Patient demonstrates manageable level of anxiety as evidenced by verbal and non-verbal indicators (facial expression, body posture, and ability to rest, sleep).
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Patient demonstrates positive self-concept as evidenced by verbal and non-verbal indicators of self-esteem (ability to cope, plans to resume lifestyle and relationships, continued self-care activities, grooming).
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Patient or family demonstrate adaptive grieving as indicated by ability to share feelings, ability to share emotions in a healthy manner, ability to participate in activities of daily living and decision-making.
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Patient or family verbalize understanding of disease process, planned medical/surgical procedure/treatment, alterations in physical appearance and options for management as a result of medical, surgical intervention.
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Patient or family describe anticipated effects of medical, surgical intervention on lifestyle including occupational, school, social and sexual aspects.
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Patient or family verbalize understanding of follow-up and community resources available in order to achieve an ability to cope with the changes, losses as a result of medical, surgical intervention.
Process Standards
Members of the multidisciplinary team become involved with the patient and family either through direct referral from the primary nurse, physician, or other team member; discussion at "bullet rounds"; patient care conferences; pre-admission questionnaire that would identify "at risk" patients or at the pre-admission visit.
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In collaboration with the team, the nurse assesses the patient's and family's level of anxiety and plans interventions aimed at reducing anxiety, as appropriate.
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In collaboration with the team, the nurse assesses the patient's and family's perception of the surgery, medical intervention in relation to effect on self-concept and plans interventions aimed at attaining or maintaining a positive self-concept.
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In collaboration with the team, the nurse assesses the patient's and family's grieving response and plans interventions to facilitate the normal grieving process.
In collaboration with the team, the nurses assesses the patient's and family's understanding of the diagnosis, prognosis, planned medical/surgical intervention and initiates or reinforces patient and family education based on readiness and ability to learn.
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In collaboration with the team, the nurse assesses the potential effect of medical, surgical intervention on the patient's lifestyle - occupation, school, relationships, social and sexual aspects - and initiates/reinforces patient/family education as well as interventions aimed at providing support.
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In collaboration with the team, the nurse assesses the patient/family with respect to self-care ability, support needs, need for ongoing community resources.
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In collaboration with the team, the nurse provides verbal and written information regarding follow-up care, community resources.
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In collaboration with the team, the nurse initiates or recommends referral to appropriate community resources as indicated.
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In collaboration with the team, the nurse evaluates the effectiveness of interventions and revises the plan of care accordingly.
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The nurse documents relevant information using the appropriate document tool.
Ostomy Patient Care Standards
The following ostomy patient care standards have been developed for use in the IBD unit at Mount Sinai Hospital. It is the combined effort of the multidisciplinary team that provides the holistic care for patients families coping with Inflammatory Bowel Disease.
Educational strategies and sessions need to be geared towards meeting the outcome standards.
Outcome Standards
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Patient demonstrates manageable level of anxiety as evidenced by verbal and non-verbal Patient demonstrates positive self-concept as evidenced by verbal and nonverbal indicators of self-esteem (ability to cope, plans to resume lifestyle and relationships, continued self-care activities, grooming).
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Patient/family demonstrate adaptive grieving as indicated by ability to share feelings, ability to share emotions in a healthy manner, ability to participate in activities of daily living and decision-making.
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Patient/family verbalize understanding of disease process, planned medical/surgical procedure/treatment, alterations in physical appearance and options for management as a result of medical/surgical intervention.
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Patient/family describe anticipated effects of medical/surgical intervention on lifestyle including occupational, school, social and sexual aspects.
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Patient has optimal stoma site placement to promote self-care and rehabilitation.
Post-operatively and Ongoing
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Patient attains/maintains adequate nutritional status as indicated by laboratory values reflecting protein stores and other clinical indicators of nutritional status (weight, general appearance, presence/absence of edema, decreased muscle mass, appetite, nutrient intake). More applicable to an ileostomy
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Patient maintains adequate fluid and electrolyte balance as evidenced by fluid intake, urinary output, vital signs, electrolytes, hemoglobin, haematocrit, and absence of signs and symptoms of fluid/electrolyte imbalances. More applicable to an ileostomy.
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Patient and/or family describe daily Ileostomy/Colostomy care and options for management.
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Patient and/or family demonstrate how to properly empty and change the ostomy pouching system.
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Patient attains/maintains intact peristomal skin and incisional tissue integrity.
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Patient and/or family demonstrate understanding of appropriate peristomal skin care for prevention/management of breakdown.
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Patient and/or family demonstrate an understanding of potential complications following Ileostomy/Colostomy surgery and measures to take if complications should occur. Potential complications include mechanical/food-related blockages, high Ileostomy outputs.
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Patient verbalizes ability to resume, maintain or initiate a satisfactory sexual relationship.
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Patient/family will resume role-related responsibilities and relationships to extent patient and family have set goals for.
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Patient and/or family will resume role-related responsibilities and relationships to extent patient and family set goals for.
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Patient and/or family identify/assess the resources needed for effective management of Ileostomy/Colostomy in home setting.
Process Standards
Members of the multidisciplinary team become involved with the patient/family either through direct referral from the primary nurse, physician, or other team member; discussion at "bullet rounds"; patient care conferences; pre-admission questionnaire that would identify "at risk" patients or at the pre-admission visit.
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In collaboration with the team, the nurse assesses the patient/family's level of anxiety and plans interventions aimed at reducing anxiety, as appropriate.
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In collaboration with the team, the nurse assesses the patient/family's perception of the surgery/medical intervention in relation to effect on self-concept and plans interventions aimed at attaining/maintaining a positive self-concept.
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In collaboration with the team, the nurse assesses the patient/family's grieving response and plans interventions to facilitate the normal grieving process.
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In collaboration with the team, the nurses assesses the patient/family's understanding of the diagnosis, prognosis, planned medical/surgical intervention and initiates /reinforces patient/family education based on readiness and ability to learn.
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In collaboration with the team, the nurse assesses the potential effect of surgery (Ileostomy/Colostomy) on the patient’s lifestyle and initiates/reinforces patient/family education as well as interventions aimed at providing support.
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In collaboration with the team, the nurse ensures that stoma siting according to pre-established criteria is completed pre-operatively.
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In collaboration with the team, the nurse assesses the patient’s nutritional status and plans interventions aimed at maintaining/restoring nutritional status.
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In collaboration with the team, the nurse assesses the patient’s fluid and electrolyte balance and plans interventions aimed at maintaining/restoring balance.
Patient Teaching
Teaching patients and families about Inflammatory Bowel Disease and
living with this devastating illness is a crucial aspect of providing
care. In the hospital in particular, health professionals need to
provide endless information about medications, procedures, tests,
treatments and special instructions.
The reality is, we also
need to go beyond the hospital stay and prepare patients and families as
best as possible to cope with the changes and challenges they may face
in day to day living once they go home. While community resources are
available, it is very important to be effective teachers and help
facilitate learning before discharge.
In order to be effective teachers and ensure learning is occurring, it is important to have some knowledge about adult learning and consider adult learning principles in your approach to caring for these individuals. The following is an outline of the principles of adult learning and strategies that will help you in the teaching process.
Adult Learning Principles
Learning is:
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a process
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an integral part of living
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a consequence of living
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initiated by the learner
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restructuring of previous knowledge
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co-operative and collaborative
Learning is best:
- when it occurs in the whole person:
- cognitive
- affective
- psychomotor
- when it is relevant to the situation
- when it focuses on tasks or problems
Other considerations to keep in mind:
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people bring a lifetime of experience
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developmental stages influence adult learning
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people learn in a variety of ways
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teacher and learners share responsibility for learning
Strategies for Teaching
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It is important that our patients have respect for us as health care providers and that we have respect for our patients. We must be positive, have an empathetic concern for the individuality of the learner.
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We need to empower our patients. Empowering our patients will allow them to recognize and develop their own abilities in order that they can meet their own needs, solve their own problems and mobilize their own resources to feel in control of their own lives.
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We need to create an environment that is conducive to learning. Ensure that your patient is free from pain and nausea, is rested and alert. Learning can be emotionally exhausting.
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Establish privacy, limit noise and disruption and most importantly give yourself the time to teach.
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Avoid prolonged teaching situations. Introduce the information slowly, allow accomplishment and reinforce all teaching steps.
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Set mutual goals. Both you and your patient need to agree on the learning goals.
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Draw on your patient’s past experiences. Ask how your patient best learns. Is it through verbal repetition, or does he respond best to written material or picture format? Make use of all forms of teaching material and methods.
Involve family members or friends for support. They can be instrumental in encouraging and helping to reinforce learning material.
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Allow your patient to make mistakes. Learning takes time. Humans do not readily gain comfort or confidence with new material.
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Encourage and praise your patient with accomplishments whether it be learning a new task or acquiring a new skill.
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Take into consideration your patient’s developmental and emotional stage, their physical limitations, culture and family dynamics. That entails truly knowing your patient which can only come with continuity of care and caregiver.
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Evaluate your teaching. Ask the questions and be aware of your patient’s verbal and nonverbal responses.
Patient Engagement
Whether you are a social worker or a health care professional working with patients, the process of engagement is an essential part of connecting with people in a meaningful, therapeutic way.
Engaging with your patient allows you to understand their personal stories and struggles, and to develop a common definition of their situation and problem. Developing a common definition of the patient's problem during the engagement phase can facilitate movement toward mutual problem resolution.
While the process of engagement is ongoing, the importance of developing a therapeutic connection is most significant in the first meeting. It is during the initial connection that the basis for your ongoing work together occurs. Although the development of a strong engagement and therapeutic alliance is important for work with all patients, when working with the chronically ill, the relationship built at the beginning will set the stage for possible long-term work together during the progression of different phases of illness.
During the engagement phase, a patient will be assessing whether you are someone that they can feel safe and comfortable with to share their very personal stories and struggles, and whether they can see themselves developing a therapeutic alliance with you for ongoing work. Engagement is a multi-faceted skill involving many layers of practice. Developing successful engagement with patients is key to our success as health care professionals. The "Engagement Experiential Module" written by University of Toronto, Faculty of Social Work outlines helpful strategies to facilitate engagement.
Before meeting with a new patient, we as professionals can bring personal qualities or "attributes" to the relationship with a prospective patient which will set the stage for the engagement process. The "Engagement Experiential Module" outlines these as follows:
Attributes
respectful attitude toward patient and family genuine/authentic presentation of self acceptance/non-blaming/non-judgmental approach/attitude self-awareness, especially about own emotions/discomfort and how these may impact patient engagement work together. trustworthiness (displays willingness to help) controlled emotional involvement: aware of own emotional reactions, so it does not impede the work together positive attitude warmth interest awareness of cultural/diversity issues and address them when required
The above-mentioned personal qualities or "attributes" form the foundation on which health care professionals can build engagement skills and behaviors during all phases of the therapeutic relationship with the patient
How do we engage a patient?
Clarify your role and purpose of your visit. Introduce yourself with warmth and friendliness. Present yourself in a professional manner without using technical jargon or knowledge that is difficult to understand. Obtain verbal consent from the patient to proceed with visit. Create a safe, private environment for the meeting (if possible). Start where the patient is by inquiring about the problem in a respectful manner. Maintain eye contact when talking with the patient. Employ good listening skills. Use active listening, body language which reflects openness, and calming facial expressions. Pay attention to your voice - modulate tone, rate of speech, volume. Develop a mutual understanding of the problem or issues affecting the patient by encouraging feedback.
Moving forward in the engagement process
Provide support to "help the patient verbally tell their story". Encourage the patient to “tell their story”. This involves a complex combination of skills. Use open-ended questions to engage the patient in discussing their “story”. Pay attention to verbal and non-verbal cues during communication. Support the patient in expressing his or her feelings, and validate his or her feelings and concerns by providing realistic reassurance and hope. Respect the patient’s boundaries and do not push them into disclosure. Create an environment and opportunity for patients to discuss sensitive issues. Address and be attentive to issues of culture/diversity where necessary.
Although these strategies are from engagement literature in the field of social work practice, these skills can be adapted to the practices of most health care professionals. The engagement process is the fundamental foundation on which to build a therapeutic relationship with patients and their families.
Reference:
Power, R. "The Engagement Experiential Module", University of Toronto, Faculty of Social Work, 3-7, October, 2004. The material for the "Engagement Experiential Module" was a summary of a literature analysis, some of the key references for it follow:
Coady, N. (2002). The helping relationship. In F. Turner (Ed.), Social work practice: A Canadian perspective (pp. 116-130). Toronto: Prentice Hall
Marziali, E. (1988) The first session: An interpersonal encounter. Social Casework (1), 23-27.
Murphy, B. and Dillon, C. (2003) Interviewing in action: Relationship, process and change. Pacific Grove, California, Brooks/Cole ch. 10 The Clinical relationship: Issues and dynamics, p 221-246
Marziali, E. & Alexander, L. (1991) The power of the therapeutic relationship. American journal of orthopsychiatry. 61 (3), 283-391
Shulman, L. (1999) The skills of helping individuals, families, groups, and communities. Illinois: Peacock Pub Inc
Ostomy Patient Teach Guide
1. Appliance Change
The patient is able to independently change the appliance:
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patient observes stoma
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patient participates with appliance removal
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patient participates with peristomal cleansing
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patient participates with appliance change and application
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sizing of stoma
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tracing pattern onto flange (two-piece) or pouch (one-piece)
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cutting opening
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removal of backing
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application of paste or strip paste (optional)
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application of pouch
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patient empties/rinses pouch independently
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patient applies closure to pouching system independently
Two-Piece System
The following steps are generic and applicable for a two-piece system.
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Assemble the Necessary Supplies
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Flange and pouch, measuring guide, scissors, pen, strip paste or tube paste (optional), wet/dry cloth, and plastic bag.
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Remove Flange and Pouch
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Gently remove the pouching system. Keep one finger against the skin and always remove in the direction of hair growth. Dispose of flange and pouch.
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Care for the Skin and Stoma
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Remove any excess stool or mucous with dry gauze. Gently cleanse the stoma and surrounding skin with wet, warm gauze. A mild soap may be used as long as all residue is removed. Pat skin dry. Washing the stoma and skin can be done in the shower.
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Use a mirror and observe both the stoma and surrounding skin. The skin should always be healthy with no signs of redness or irritation. The stoma should always be pinkish red, moist and smooth.
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Measure the Stoma
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For the first six weeks following surgery, the stoma should be measured and the flange opening adjusted accordingly. It is important that there be a small amount of space (1 1/8”) between the cut opening and stoma. This allows room for the stoma to expand and pass stool through the opening. After six weeks, measurement is generally not required and flanges may be pre-cut in advance.
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Prepare the Flange
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The flange should be warmed prior to application. This can be done by placing the flange between your hands for a few minutes or sitting on it during preparation.
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Trace the pattern of the stoma shape onto the back of the flange.
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Cut the flange to match the pattern.
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Remove the clear plastic backing from the flange and set the flange aside.
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Apply the strip paste or tube paste around the cut opening of the flange or directly against the skin around the stoma.
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Apply the Flange
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Centre the opening over the stoma and apply the flange against the skin. A mirror may be used to help centre the flange.
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Apply the Pouch
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Place the pouch onto the base ring of the flange.
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Start from the bottom and gently work the pouch onto the flange.
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Slide the lock into the position that is most comfortable and snap it in place (if using system with a lock device).
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Gently pull the pouch to ensure the pouch is secure and in place.
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Close the End of the Pouch
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If using velcro closure, fold the pouch three times towards you and fold the tabs over the velcro.
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If using a closure clip, fold pouch once over the clip and secure in place.
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Remove the Pouch
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Press the centre of the lock to release (if using system with lock device).
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Grasp the pouch at the top and gently pull downward.
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General Guidelines
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Empty the pouch when its 1/3 to 1/2 full of stool or gas. Always ensure the "tail" portion of the pouch is kept clean and dry following emptying of the pouch.
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Change the pouch at your discretion
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Change the complete system every 5-7 days.
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Change the complete system if visible signs of leakage or if you experience a burning or itchy sensation.
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Notify your Enterostomal Therapy nurse of any concerns or questions.
2. The Stoma
Patient is able to state:
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expected stoma function
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expected stoma output
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expected stoma appearance
The stoma can be either a loop (often temporary) or end (often permanent). A loop stoma will have two openings - a proximal opening, which passes stool and gas and a distal opening, which is generally seen at the base of the stoma and which will pass mucus. The loop is held in place with a rod, with or without sutures depending upon institution. If sutured, the rod is generally removed within five to seven days.
The stoma is red and moist, not unlike the lining of the mouth. Initially there will be swelling and it generally takes six weeks for all swelling to subside. It is important that measurement of the stoma take place for at least six weeks. At six weeks there should be no further need to measure the stoma and the appliances can be pre-cut at that point.
The stoma may appear delicate or inflamed to many patients largely due to the colour. Patients need to be reassured that red is health, that there are no nerve endings to the bowel and thus very little sensation. The blood supply to the bowel is rich and it would not be unusual to see some bleeding when caring for the stoma. There is nothing sterile about the bowel and a clean technique is used when caring for the stoma. Many patients will routinely wash their stoma and skin in the shower with their routine appliance change.
It generally takes 24-48 hours before an ileostomy will start to function. Prior to that there may be bloody effluent present in the pouch. With a return of bowel function, there will initially be bile, and flatus. Once food is introduced, the stool will change colour– yellowish-brown with the consistency of porridge. Most people with an ileostomy will empty their pouch 4-6 times during a 24-hour period.
It may take five to seven days for a sigmoid colostomy to function. Initially flatus will be passed followed by brown liquid drainage with gradual thickening to a soft or semi-formed consistency. The degree of thickness depends on the location of the stoma along the colon. Many people with a sigmoid colostomy tend to follow bowel patterns they had prior to surgery making the use of a closed-end disposable pouch quite convenient.
An ileal conduit or urostomy will start to function immediately for urine. The urine will have mucous shreads due to the fact that ileum is used to construct the conduit. Many people with a urostomy empty their pouches of urine 4-6 times during a 24-hour period. The kidneys will continue to function overnight which may necessitate the need for the pouch to be attached to bedside drainage for convenience.
3. Protection of Peristomal Skin and the Stoma
Patient is able to discuss protection measures for peristomal skin and stoma
Peristomal skin is the two inches of skin around the stoma. It should always be healthy without signs of redness or irritation. Ideally a flange can stay on for five to seven days. A patient experiencing burning or itchiness around the stoma, discomfort or pain around the stoma or discolouration of the flange or adhesive should remove their appliance regardless of the day. These signs usually indicate leakage, and stool on the skin can be very irritating. Any red, irritated or weepy skin can be treated with a light application of protective powder followed by a skin sealant. If the skin remains irritated, the Enterostomal Therapy Nurse’s expertise will be required.
Hair growth around the stoma can be quite painful when removing the appliance and can lead to a condition called folliculitis or irritation of the hair follicles. Excess hair should be removed with an electric razor or scissors. Solvents (designed for ostomy care) may be used to help remove the appliance. Always remove the appliance in the direction of hair growth.
The stoma itself is a pretty hardy organ but direct trauma or a blow to the area should be avoided. People engaging in contact sports should protect the stoma with either a specially designed stoma cap or cone, or extra padding such as the padding used in hockey.
4. Resumption of Activities
Patient is able to discuss resumption of activities, return to work/school.
An ostomy should not affect a person’s ability to resume an active lifestyle. Most people find they can continue all of the activities that they enjoyed prior to illness and surgery. There are many individuals with ostomies who are distance runners, swimmers, skiers, skydivers, scuba divers, hockey players, and football players.
Edging the flange with waterproof tape while swimming may provide extra security. Printed bathing suits as opposed to solid colours often help to camouflage the outline of the appliance. Some women prefer bathing suits with skirts or sashes and some men may wear a Speedo type bathing suit under a boxer-style trunk, but snug-fitting suits can be worn. A closed-end pouch may be used in place of the drainable pouch with closure clip to further add comfort and provide a smoother line under the suit.
Many people are concerned with return to work or school activities. “Will I smell, will there be noises, will they see it, what if someone asks?” are commonly expressed concerns. Patients need to be reassured that there should be no odour. The pouches are designed for stool, but deodorant drops or room aerosols for the bathroom can be used to add confidence and comfort. Noises are often muffled by clothing and can be further muffled by placing an arm across the stoma site. The appliance itself should not be visible - the key point to remember is that as a person he/she has not changed, only a surface change exists, one that g ives them back their health. The decision to share with others that they have an ostomy is very personal and individuals vary greatly as to when and with whom they choose to confide in.
5. Clothing
Patient is able to discuss clothing.
The style of clothing that was worn prior to ostomy surgery can generally be worn following surgery. Some men may prefer suspenders as opposed to a belt; some people find it more comfortable to wear pants with pleats. A full, fairly snug undergarment is generally recommended to give support to the pouching system and create a smooth line under clothing.
6. Personal Hygiene
Patient is able to discuss personal hygiene.
A person with an ostomy can shower or bathe with or without the pouching system in place. Many people find it quite convenient to plan the “weekly” change around the shower. Water, soap or shampoo cannot harm the stoma as long as the skin is well rinsed and dried before the system is re-applied.
Hot tubs or sitting in bathtubs are not harmful but it is unlikely that the flange would maintain its seal for 5 days. Waterproofing the edges with waterproof tape may help to increase wear time. A wet flange can be dried with a towel or blown dry with a hair blower set on a cool setting.
7. Odour Control
Patient is able to identify potential complications, preventive measures for, and management of, odour control.
Presence or absence of odour in the stool is somewhat determined by each individual’s body chemistry. There are, however, measures which can aid in reducing the odour of stool when the appliance is emptied. These include:
- using commercial deodorizing tablets or liquids for inside of the pouch
- using aerosols or wicks to freshen the bathroom
Being aware of foods which tend to produce odour:
- fish
- chicken
- fried eggs
- onions
- beans
- vegetables of the cabbage family
Being aware of foods which may reduce odour:
- cranberry juice
- yogurt
- buttermilk
- fresh parsley
If odour is not controlled by the above measures, it may be controlled through the use of tablets taken orally. These tablets contain charcoal or chlorophyll.
8. Managing Flatus
Patient is able to identify potential complications, preventive measures for, and management of, flatus.
Suggestions for managing flatus include:
- Eat regular balanced meals. Skipping meals is more likely to increase gas production. Initially after surgery there will be more gas as well as noise due to the fact that the bowel has been handled and is empty. Gas and noise will lessen once diet and activity is resumed.
- Eat slowly, chew food well.
- Avoid gum chewing or situations such as smoking, mouth breathing, drinking carbonated drinks or sucking on ice chips – all of these encourage swallowing large amounts of air.
- Be aware of potential gas producing foods and experiment by excluding them from your diet.
Troublesome foods may include:
- vegetables of the cabbage family
- asparagus
- sweet potatoes
- onions
- milk and milk products
- dried beans and peas
- spicy foods
- beer
- cheeses such as Roquefort, Brie and other strong cheeses
9. Constipation
Patient is able to identify potential complications, preventive measures for, and management of,
constipation (as related to a colostomy).
Suggestions would be to include foods such as:
- fresh fruit and vegetables
- bran cereal/muffins
- fruit juices especially prune
- extra fluids
If diet modification is not helpful, the family physician or surgeon needs to be consulted for further suggestions.
10. High Ileostomy Output
Patient is able to identify potential complications, preventive measures for, and management of, high ileostomy output.
High ileostomy output (over 1000cc in a 24-hour period) may occur following the construction of the pelvic pouch with a loop ileostomy. The stoma can be constructed quite proximal following pelvic pouch surgery to avoid tension on the bowel. This surgical scenario may result in higher than normal stool outputs.
With high ileostomy output, the patient would experience the following signs and symptoms:
- liquid watery stool
- emptying the appliance more than 8-10 times per day
- signs of dehydration: increased thirst, dry mouth and skin, decreased urine output, fatigue, shortness of breath, stomach cramps
- signs of sodium loss: loss of appetite, stomach cramps, cold arms and/or legs, fatigue, feeling faint
- signs of potassium loss: fatigue, muscle weakness, shortness of breath, decreased sensation in arms/legs, gaseous bloated feeling
The patient needs to be encouraged to:
- increase fluids
- decrease foods that may contribute to high outputs - fruit juices, sweetened drinks, coffee, spicy foods, beer
- increase foods and fluids high in sodium - salt, milk, cheese, egg nog, tomato juice, bread, butter, pickles, cola beverages, chicken soup, bouillon, pretzels
- increase foods and fluids high in potassium – orange juice, tomato juice, tea, bananas, potatoes, melon
- separate fluids and foods - wait 30-45 minutes after eating to have fluids
- reduce intake of sugars and sweets
- include foods higher in soluble fibre - applesauce, bananas, tapioca, barley, oats
If outputs remain high, medications such as Imodium™ or Lomotil™ may be introduced to help slow the tract. Medications should only be administered under the supervision of a physician. Intravenous replacement fluid may also be required.
11. Food Blockage (Ileostomy)
Patient is able to identify potential complications, preventive measures for, and management of, food blockage (as related to an ileostomy).
A food blockage is an accumulation of undigested food particles in the intestine, which are not able to pass through the ileostomy.
There are specific signs and symptoms of a food blockage which patients need to be taught:
- stool may change from semi-liquid to liquid
- amount of stool may increase
- ileostomy may function almost continuously
- stool may have a noticeable odour
- abdominal cramping or pain
- abdomen may feel bloated
- nausea/vomiting may be present
- if blockage complete – no stool will be passed
If signs of a food blockage are present, the patient should be taught to:
- walk, or assume a knee-chest position
- massage the abdominal area
- take a warm bath or shower
- drink warm fluids
- avoid food
If symptoms do not subside within a few hours, the patient should be encouraged to go to their local Emergency Department.
Food blockages are often resolved with IV hydration, nothing by mouth,
and time. A bland, low fibre diet with increased fluids is encouraged
for a few days following a blockage.
12. Dehydration and Electrolyte Imbalance (Ileostomy)
Patient is able to identify potential complications, preventive measures for, and management of dehydration and electrolyte imbalance (as related to an ileostomy)
The patient should be aware of the signs and symptoms of dehydration and electrolyte imbalance. Dehydration and electrolyte imbalance can occur more commonly in a patient with an ileostomy as opposed to a colostomy.
Dehydration
Increased thirst, dry mouth, dry skin, decreased urine output, fatigue, shortness of breath, stomach cramps.
Sodium Loss
Loss of appetite, stomach cramps, cold arms, and/or legs, fatigue, feeling faint.
Potassium Loss
Fatigue, muscle weakness, shortness of breath, decreased sensation in arms and legs, and a gassy bloated feeling.
Be aware of treatment measures for dehydration and electrolyte imbalance.
Dehydration
Increase fluids of any kind.
Sodium Loss
The highest sources of salt include:
- boullion, instant powder soups, canned soups
- salted crackers, pretzels
- pickles
- tomato juices
- smoked meats, ham, wieners
Cottage cheese, cheeses, milk and drinks such as Gastrolyte, club soda, or Gatorade are lower sources of salt.
Potassium Loss
High sources of potassium in the fruits and vegetable family include:
- tomatoes
- V-8 juice
- potatoes
- squash, carrots
- vegetable and cream soups
- salad greens
- oranges, grapefruits, bananas, melon and avocado
High sources of potassium in other foods:
- smooth peanut butter
- nuts
- butter
- tea and coffee
13. Dietary Modifications
The patient is able to identify dietary modifications.
Having an ileostomy is not usually associated with a highly restricted diet. After surgery, the diet will require some modification, but eventually the person will be able to enjoy most if not all of their favourite foods.
During the first six weeks following surgery, it is often recommended that “potential problem foods” such as skins, seeds, nuts, fibre be excluded from the diet. These foods tend to be more difficult to digest for a person with an ileostomy and could lead to a food blockage. Following the six week period, all foods should be gradually reintroduced. A person with an ileostomy should always be aware of the importance of fluid intake – at least eight glasses of fluid per day, as well as extra salt and potassium. The colon has either been removed or bypassed and thus some of the ability to absorb water, salt and potassium has been reduced.
There are generally no dietary modifications related to colostomy surgery. Unless otherwise indicated, the importance of healthy eating, including foods high in fibre need to be stressed.
14. Medication Considerations
The patient is able to discuss special medication considerations.
Individuals with an ileostomy should be aware of enteric coated or sustained released preparations. Enteric coated or sustained release drugs may not be effective because such drugs can pass unabsorbed through the intestinal tract. Products which can be either crushed, chewed, swallowed or injected are best.
Specific Drugs and their Effect
Antibiotics
Some broad-spectrum antibiotics that are effective against a wide range of bacteria can alter the normal bacteria in the bowel and may cause diarrhea or yeast infections on the skin around the stoma. Antibiotics may also cause the stool to be more odorous.
Vitamins
Generally, supplemental vitamins are unnecessary unless the patient is debilitated with significant weight loss. Vitamins can cause a strong odour in the stool and must be injected (Vitamin B12) to be effective.
Diuretics
Diuretics should be used with great care because salt imbalance and dehydration can result from additional fluid loss.
Laxatives
A person cannot become constipated with an ileostomy. Laxatives, enemas, rectal tubes or rectal thermometers should not be used. If a person were not passing stool or flatus, the concern would be a blockage.
Miscellaneous
There have been no reported problems with the absorption of the birth control pill in individuals with ileostomies. Magnesium-containing antacids may produce diarrhea and aluminium hydroxide may slow the bowel and produce constipation in individuals with colostomies. Analgesics that contain codeine will slow the action of the bowel.
15. Travelling Tips
The patient is able to discuss travel tips.
The following "tips" can be shared with your patient:
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Always carry identification which would include your type of stoma, appliance used and names of physician/Enterostomal Therapy Nurse. Your ostomy chapter, ostomy retailer or company will often supply ostomy identification cards.
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Before departing on a trip, check for the name and address of the local ostomy vendor as well as the Enterostomal Therapy Nurse (ET). Your ET nurse can provide you with that information.
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Always take at least twice as many ostomy supplies than your normal requirement and always carry supplies in your hand luggage. Do not check them with luggage as they could get lost.
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With the new airline regulations, you will want to avoid carrying scissors in your luggage. Pre-cut your flanges or pouches in advance.
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To avoid unnecessary questioning by immigration in the event of luggage checks, a letter outlining the medical reasons for the ostomy supplies may be helpful. Your Enterostomal Therapy Nurse can provide you with the letter.
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Always carry a supply of prescription drugs that you are using. Also, have a written prescription, with the name address and telephone number of your doctor. Obtain the generic names or chemical compositions of drugs from your doctor or pharmacist. Brand names vary in different countries. Keep prescriptions in their original bottles instead of other plastic containers. This way, you will not have to explain your medication to a customs officer.
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Make sure you have travel insurance.
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Place your closure clamp underneath your watchband when emptying your pouch to keep it from falling or being misplaced.
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Take advantage of available bathroom facilities to empty your pouch more frequently than you normally would to avoid unexpected bathroom delays.
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Carry extra toilet tissues or pre-moistened wipes in the event a restroom is lacking.
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Always be prepared for potential problems by carrying an “emergency kit”. A make-up bag, tobacco pouch, glass case or man’s handbag (fanny pack) can be used. The kit should contain a zip lock baggie, extra closure clip, pre-cut flange, pouch, paste (optional), individually packaged pre-moistened towelettes or J-cloths to serve as a washcloth/towel and mirror. It is important to periodically check your kit. Heat can interfere with the adhesives of the appliance.
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In an emergency, your pouching can be emptied into a zip lock bag or baggie with twist tie until it can be disposed of later.
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Apple sauce, oatmeal, bananas, cheese, creamy peanut butter, boiled rice, tapioca, boiled milk will help to thicken loose stool.
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Drink at least 6-8 glasses of non-caffeine liquids each day.
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Caffeine may cause diarrhea. Beverages such as coffee, tea, chocolate and cola drinks contain caffeine.
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Eat lightly and sensible, especially on airplanes. Gases expand as the plane ascends.
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Yogurt helps to control gas formation and buttermilk helps to soothe an irritated bowel.
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If carbonated drinks result in gas problems, a shake of salt or sugar will cause fizzing which helps to dissipate the carbonation.
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Plan your visits to the washroom on airplanes to avoid peak times, such as after meals, after the movie, and before landing.
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Travel with understanding, patient people
16. Sexuality / Intimacy
The patient is able to express sexuality/intimacy concerns.
It is not unusual for persons with an ostomy to have concerns about resuming relations or whether their sex life will change or if they will be less attractive to their partner. Fears of rejection, odour, leakage, and performance are natural. Patients need to be encouraged to share their feelings and concerns. Understanding each other’s feelings is a very important part of coping with an ostomy. An ostomy should not limit or curtail sexual activity. In fact, many people report that the experience of the surgery and the knowledge that the disease is treated has brought their families and loved ones closer together.
During sexual activity, one may want to experiment with different positions to find the one most comfortable. Prior to sexual intimacy they will want to empty their appliance to minimize concerns about leakage or spillage. A closed end pouch, mini pouch, a frilly half-slip, crotchless panties, or a tube top stretched over the abdomen can often help to keep one from thinking about their ostomy. It is advisable to have patients/families seek additional professional help if difficulties are not resolved.
With some surgeries such as an abdominal perineal resection or cystectomy, physical alteration in sexual function may occur. Nerve damage can occur resulting in an inability to obtain an erection. Patients need to be advised pre-operatively of this risk and reassured post-operatively that interventions exist which can improve sexual function.
PLISST Model
The PLISST model is a model used in sexual counselling and can be helpful when addressing sexual issues and concerns with your patient.
P – Permission
Let your patient know it is okay to have concerns about body image and
sexuality. Use open-ended statements such as: “Many people have concerns
about their partner’s reactions following surgery. Is this an area of
concern for you?” With this statement you are normalizing concerns and
giving permission for the patient to share concerns/fears.
LI – Limited Information
- Talk openly and honestly about sexuality and body image.
- Create a therapeutic relationship that is trusting, and open.
- Explore their thoughts and feelings about surgery and the ostomy.
- Questions you may ask include: How do you feel about your body now, and how do you think your feelings will change with surgery? How do you normally cope with changes and losses? Who is your partner? Do you feel your partner is supportive? Do you feel you have a strong relationship? Do you have open communication or are topics around intimacy taboo? What are your specific concerns about living with an ostomy?
- Clarify misconceptions
SS – Specific Suggestion
- Discuss “helpful hints” with your patient/partner
- Share information.
T – Therapy
There will be times when a
patient and his/her partner require intensive therapy which can only be
offered by a trained professional. The important thing to remember is to
recognize when problems and issues extend beyond your knowledge base
and to consult others with added expertise in the area.
17. Resources and Supplies
The patient is able to identify supplies and community resources available after discharge.
Each province, state and country will vary in their financial support of patients with ostomies. Prior to discharge, it is important to discuss financial reimbursement/ insurance concerns, and how and where to purchase supplies. Ostomy supplies should be readily available worldwide.
There are numerous resources available for patients with ostomies. These include Enterostomal Therapists, support groups and associations, literature, Web sites, videos, and ostomy supplier support.
Pelvic Pouch - Patient Teaching Guide
1. Skin Care
The patient is able to state measures to maintain perianal skin integrity.
Looseness and frequency of stool is not uncommon during the early months following pelvic pouch surgery. It generally takes at least six months for the pouch to "adapt" - begin functioning and acting like a pouch or reservoir. It is extremely important to keep the skin around the anus clean, dry and intact.
Suggestions to maintain perianal skin integrity:
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Cleanse and dry the skin thoroughly following each bowel movement or mucous discharge.
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Moistened soft tissues or cotton balls are ideal for cleansing the skin and are less abrasive than ordinary tissue.
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No-rinse cleansers are also very effective.
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Warm water is generally all that is needed. Soap tends to dry the skin and may leave a residue resulting in itching.
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Pads or panty-liners should be changed frequently to keep the skin clean and dry
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Cotton underwear rather than nylon or polyesters are advisable. Cotton absorbs perspiration and allows air to circulate.
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Skin barrier creams (ProShield™, Desitin™, Penaten™, PeriCare™, Cavilon™) are soothing and add a layer of protection for irritated skin. Barrier creams should be applied following each movement and used until stool numbers decrease and stool consistency becomes thicker.
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Sitz baths are a gentle, thorough way to cleanse and soothe irritated skin and may follow each movement.
If the skin should be become reddened, broken or itchy, assessment by the family doctor, or outpatient ET nurse is advisable. A fungal infection can occur because of moisture if left untreated. If suspected, this should be assessed by a professional.
2. Frequency
The patient is able to discuss measures to allow for Pouch adaptation.
The "average" person at six months following the pelvic pouch procedure has between 4-6 movements a day. However, everyone's experience is different. There is a period of adaptation with the pelvic pouch. The pouch has to learn to expand and hold stool and this takes time.
Suggestions to help for pouch adaptation:
- Not responding to every urge to have a movement. Deep breathing, tightening the sphincter muscle and allowing the sensation to disappear may help.
- Dietary changes may help to decrease the number of stools. Foods such as applesauce, bananas, rice, creamy peanut butter, potatoes, cheese, marshmallows, pretzels, toast, yogurt and tapioca pudding are examples foods which have been found to help decrease the water content of the stool.
- Limiting the intake of fried and fatty foods, milk/milk products, spices, rich sauces with tomato base, sugars, caffeine beverages, raw fruits and vegetables may also help.
- Bulking agents such as Metamucil™, Prodium™, Citricel™, Fibercon™, or Konsyl™ also help bulk or thicken the stool. These products are taken with little fluid to allow the extra fluid in the gastrointestinal tract to be absorbed. They can be taken up to three times daily. They should only be used with the approval of the surgeon or gastroenterologist.
- Medications such as Lomotil™ or Imodium™ are also sometimes prescribed to slow down the frequency of movements. They should only be used with the approval of the surgeon or gastroenterologist.
3. Nighttime Movements
The patient is able to discuss concerns regarding night-time movements.
Suggestions to maintain perianal skin integrity:
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Limiting what is eaten 4 - 6 hours before bedtime. This also includes avoiding large quantities of liquids (especially carbonated beverages) and evening snacks.
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Eating the largest meal of the day for lunch is encouraged.
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Taking medications such as Lomotil™ or Imodium™ before the evening meal and/or at bedtime may also be helpful. Medications should only be taken with the consent of the surgeon or gastroenterologist.
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Protecting the perianal skin at night is important because during deep sleep, there can be small amounts of stool or mucous which may escape when the sphincter muscles are relaxed. If this does occur, it is usually temporary and often due to the very loose stool that is initially produced.
4. Pouchitis
The patient is able to state the definition of pouchitis, signs and symptoms of pouchitis, diagnosis, occurrence, causes, treatment and prevention for pouchitis.
Pouchitis is an inflammation of the mucosa, or lining of the pouch.
Symptoms
The main symptom for most patients is an abnormally large number of stools: an increase from 4 to 6 (on average), or more. Patients may also experience rectal bleeding, abdominal cramping, a sense of "urgency" before having a bowel movement, and fever.
Diagnosis
Patients who have any of the symptoms listed above could have pouchitis. However, several other conditions also could cause similar symptoms. These include irritable bowel syndrome, small bowel obstruction from scar tissue, narrowing of the join (anastomosis) between the anus and the pouch, an intestinal infection with bacteria or parasites, and Crohn’s disease. For this reason, patients whose symptoms suggest pouchitis should be seen by either their colorectal surgeon or gastroenterologist or have a flexible sigmoidoscopy (examination of the pouch with a flexible lighted instrument). At this time, biopsies (tissue samples) of the pouch should also be obtained. In patients with pouchitis, flexible sigmoidoscopy will reveal inflammation, similar to that found in ulcerative colitis, in the mucosa of the pouch. When examined under the microscope, the biopsies will also show inflammation. If inflammation is not present, then other causes for the symptoms should be considered.
Occurrence
The cause of pouchitis is not known. Researchers have suggested several theories; an excess of bacteria in the pouch related to stool stasis; a recurrence of inflammatory bowel disease in the pouch and misdiagnosis of ulcerative colitis. In a minority of patients, it may be difficult to differentiate between Crohn’s disease and colitis. Problems that may occur postoperatively could be related to the fact that the patient has Crohn’s disease.
People who suffer from pouchitis often improve with antibiotics, which suggest that bacteria are an important factor in the development of this condition. Pouchitis occurs more commonly in people with extraintestinal problems associated with ulcerative colitis (e.g., arthritis or abnormalities of the liver, skin, or eyes). These findings suggest that pouchitis may be a new type of IBD, which recurs in the pouch. Most patients with pouchitis do not have Crohn’s disease.
Research is being done to identify the cause of pouchitis. Some investigators are looking for “triggering” bacteria or disease markers, such as antibodies. One early finding is that pouchitis is more common in ulcerative colitis patients who have antineutrophil cytoplasmic antibodies (ANCA) in their blood. Not everyone who has ANCA will get pouchitis. The most likely cause is two fold: a genetic susceptibility to both ulcerative colitis and pouchitis, combined with a “trigger,” such as bacteria, within the stool in the pouch.
Treatment
Antibiotics are the most common treatment for pouchitis. The most commonly used antibiotic is metronidazole (Flagyl). Most, if not all, patients initially improve after taking metronidazole, usually within one or two days. The length of treatment is usually one-two weeks. A small minority of patients may require continual treatment for chronic pouchitis.
Italian researchers are reporting that high doses of probiotics appear to be an effective therapy for maintaining remission in patients with chronic pouchitis who are in remission. Other studies have shown that 5-aminosalicylates, steroids, immunomodulators, anti-TNF-alpha therapies, may also be effective in treating recurrent or chronic pouchitis.
Prevention
Helpful suggestions include a liberal intake of fluids to keep the system flushed, and yogurt that includes the healthy bacteria acidophilus (yogurts that contain the living strains of L. bulgaricus and S. thermophilus are more appropriate). Another suggestion is not to allow stool to stay inside the pouch for long periods of time. Going to the bathroom prior to sleep is recommended.
Pouchitis does not affect everyone with the pelvic pouch. Even people who do develop pouchitis report that their quality of life is better than when they had ulcerative colitis. In almost all cases, having an ileostomy can eliminate the problem of chronic pouchitis.
5. Emptying Problems
The patient is able to state measures to alleviate emptying problems.
Looseness and frequency of stool is not uncommon during the early months following pelvic pouch surgery. It generally takes at least six months for the pouch to "adapt" - begin functioning and acting like a pouch or reservoir. It is extremely important to keep the skin around the anus clean, dry and intact.
Suggestions
Allowing time for movements is an important factor in successfully emptying of the pouch. The rectum normally contracts to squeeze stool out like you would squeeze toothpaste from a tube. This is why going to the bathroom is normally fairly quick and easy. A pelvic pouch, however, has to empty using gravity and this can take time. If individuals with pouches spend only a few seconds on the toilet they may only empty stool from the bottom quarter of their pouch. Then, 10 minutes later stool in the upper part of the pouch falls into the lower part and there is another trip to the toilet. It is suggested that a patient sit and rest. Allowing the pouch to empty more completely will decrease the number of toilet visits.
It has been suggested that Imodium™ or Lomotil™ is helpful in slowing the bowel but Imodium may also create additional problems. By thickening the stool too much and by reducing peristalsis even further, it may make emptying the pouch more difficult and make matters worse. Sometimes a semi-liquid stool is an advantage.
Individuals have also reported that shifting on the toilet, standing and sitting allows for a better, more complete evacuation.
6. Sexuality Concerns
The patient is able to discuss concerns regarding intimacy and sexuality.
Following pelvic pouch surgery, some women will initially complain of pain with intercourse and vaginal dryness. The pouch sits very closely to the vagina and if the pouch is full, pressure can be placed in the region of the vagina. Ensuring the pouch is emptied before intercourse and experimenting with different positions may help alleviate the discomfort.
Vaginal dryness can be due to hormonal changes following surgery. If it occurs, it is usually temporary and can be remedied through use of vaginal hydrating gels. There is no time restriction in terms of resuming sexual relations - the key is to be ready and comfortable. It is important to keep open dialogue and have the patient share concerns/fears with his/her partner.
7. Fertility
The patient is able to discuss concerns regarding pregnancy and fertility following the pelvic pouch procedure.
For Women
Some women may experience increased fertility due to removal of the inflamed colon. Unfortunately, others may have decreased fertility from adhesions or scar tissue that develops after the removal of the rectum. Additionally, with pregnancy, the method of delivery remains controversial (C-section versus a vaginal delivery) because any injury to the anal sphincter (control) muscles may lead to the inability to control stool. It is important to inform the obstetrician of the changes in anatomy as a result of the pouch so he/she can perform a C-section should any problems arise during the vaginal delivery.
For Men
Impotency and retrograde ejaculation (the sperm going into the bladder instead of out the end of the penis with ejaculation) are serious but relatively rare occurrences. It is essential that your surgeon be aware of any difficulties with intercourse following pelvic pouch surgery.
8. Health Eating
The patient will be able to state measures to take to maintain healthy eating habits.
Following pelvic pouch surgery there will be a period of adaptation that may take up to one year. The pouch storage capacity will increase and the number of bowel movements per day will decrease. Stool consistency will thicken over time. Diet and medication can help to improve pouch function. It will be important for patients to resume normal, healthy dietary patterns over time.
General dietary tips:
- Develop regular eating patterns that allow the pouch to adapt and function in an appropriate manner.
- Smaller meals may be better tolerated, but in this case it is important to eat more often to ensure an adequate intake.
- Eat meals in a relaxed environment. Foods should be chewed slowly and thoroughly.
- Drink plenty of fluids each day (i.e. more than eight cups of liquid per day).
- Gradually add "potential" problem foods to the diet to see how food is tolerated.
- Foods that cause a problem should be temporarily eliminated, and then reintroduced at a later date.
- Strive for a balanced diet. Choose food from all food groups.
- Include foods and fluids high in potassium and salt during periods of stool looseness and frequency.
Foods or beverages that may cause stool to become loose or to increase pouch output:
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Foods that thicken stool or decrease pouch output:
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Foods that may contribute to anal irritation:
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Keep in mind that everyone's response following the pelvic pouch surgery is unique. What may upset or create problems for one individual may be well tolerated by another. Tolerances may change with time, so periodically patients should be encouraged to try small quantities of any foods currently being avoided.
Care Plans
Anger
Anger experienced post-operatively can be related to a new diagnosis, prolonged and complicated hospital stays, treatments, the unknown, poor relationships with health care providers, or stress.
To help alleviate anger seen in patients, the nurse can:
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Acknowledge the patient. Do not ignore the patient.
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Encourage patient to identify and verbalize real sources of anger.
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Confront patient with empathetic stance and set limits on unreasonable demands.
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Establish limits and rules for behaviour.
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Discuss with patient what is reasonable to expect.
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Ensure that patient receives consistent messages from all health care team members.
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Be consistent — schedule enough time to work with patient so neither of you feel pressured. If assistance is required, consult with the Enterostomal Therapy Nurse, Clinical Nurse Specialist, Social Work, Psychiatry.
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Teach difference between good nursing care and catering to excessive demands.
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Consult psychiatric team if agitation continues and is not responsive to verbal interventions.
Anxiety
Anxiety experienced post-operatively can be due to an actual or perceived threat to self-concept, an actual or perceived loss of a significant other, a threat to one’s role function, the unknown.
To help alleviate anxiety seen in patients, the nurse can:
- Assess the level of anxiety – on a scale of 1-10 with 1 being the least and 10 being the most. 1_______2_______3_______4_______5_______6_______7_______8_______9_______10
- Refrain from making demands or asking the patient to make decisions.
- Support the present coping mechanisms.
- Decrease sensory stimulation.
- Focus on the here and now. Set short-term goals.
- Limit contacts with others that are anxious.
- Teach anxiety interrupters — control breathing, lower shoulders, slow thoughts or teach patient to “stop” any repetitive thoughts, guided imagery, change perspective — imagine watching situation from a distance.
- Communicate clearly and simply. Ensure consistent information is provided to nursing/team.
- Allow patient ample opportunities to express feelings – listening to patient is more important than offering advice. Consult with Enterostomal Therapy Nurse, Clinical Nurse Specialist, Social Worker, Psychiatry as needed.
- Consult physician for possible pharmacological therapy if verbal interventions are ineffective.
Self-Concept, Body Image, Alteration
Altered self-concept and change in body image experienced post-operatively can be related to ostomy surgery and the resultant loss of bowel control, and changed body appearance.
The nurse can help the patient post-operatively by:
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Initiating primary nursing to establish a therapeutic relationship.
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Encouraging patient to express feelings and concerns.
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Acknowledging and accepting feelings of anger, grief, dependency, relief, etc.
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Discussing with patient and family the affect of the surgery.
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Observing patient's and family’s non-verbal and verbal behaviours.
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Providing support by listening to concerns and answering questions.
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Assisting patient to identify positive behaviours that will aid recovery.
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Identifying what the patient expects with regards to the stoma appearance, incision, drains.
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Dispelling misconceptions.
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Identifying patient's and family’s understanding of the effect of stoma on clothing, bathing, activities, work, diet, relationships, sexuality.
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Arranging for an ostomy visitor (if appropriate).
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Providing literature to reinforce information.
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Determining patient’s main source(s) of support and usual coping mechanisms. Arranging for involvement of family in care — as desired by the patient and family.
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Discussing with family ways to provide support.
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Assessing and addressing the needs and concerns of the family.
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Encouraging patient and family to communicate feelings to one another in a direct manner.
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Assisting patient to make decisions about self-care.
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Gradually involve the patient in self-care activities.
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Praising achievements; offering continued support.
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Discussing resumption of usual activities at home.
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Consulting with others re additional counselling — Enterostomal Therapy nurses, Social Workers, Clinical Nurse Specialists.
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Arranging for ongoing support at home.
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Discussing how to increase personal comfort and acceptance of ostomy — hygiene and odour control, pouch selection, lingerie.
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Discussing how to prepare for intimacy. Include partner in ostomy teaching.
Ineffective Individual Coping
Ineffective coping experienced post-operatively can be due to negative self-concept, disapproval by others, inadequate problem-solving, loss-related grief, sudden change in life pattern, recent change in health, inadequate support systems, unanticipated stressful events, occurrence of several major events in a short period of time, unrealistic goals.
The nurse can help the patient post-operatively by:
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Assessing the patient’s present coping status. Identify coping strategies.
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Demonstrate to the patient that you believe her/his desire to help — avoid challenging, minimizing patient’s feelings, arguing or trying to reason with her/him.
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Offering support as the patient talks — reassure that their feelings must be difficult. Provide a more helpful, realistic perspective if the patient is pessimistic. Document your strategies.
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Assisting the patient to problem solve in a constructive manner (What is the problem? Who or what is reasonable for the problem? What are the options? (make a list) What are the advantages and disadvantages of each option?
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Discussing possible alternatives (talking over problem with those involved, trying to change the situation, or doing nothing and accepting the consequence).
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Helping the patient to identify problems that she/he cannot control directly and help her/him to produce stress-reducing activities for control.
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Teaching patient relaxation techniques.
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Having patient describe previous encounters with conflict and how she/he managed to resolve them.
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Giving options — but leaving decision-making to the patient. Give many choices.
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Coordinating possible multidisciplinary activities to serve patient’s best interests. Consult with Enterostomal Therapy, Clinical Nurse Specialist, Social Work, Psychiatry as needed.
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Encouraging patient to deal directly with individuals with whom there are conflicts (do not put self in middle).
Depression
Depression experienced post-operatively can be due to stress, hopelessness, helplessness, lack of support systems, chronic illness, chronic pain, palliative care diagnosis, extensive surgery,inadequate coping skills, separation from family, role changes or identity crisis.
To help alleviate depression seen in patients, the nurse can:
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Assess for feelings of hopelessness, isolation, anger, hostility, helplessness, and guilt/shame.
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Determine how the patient has previously coped with depression.
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Work with positive goals to affect change in attitude.
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Be non-judgmental and empathetic.
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Encourage interactions with others.
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Encourage appropriate expression of anger and hostility.
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Facilitate examination of stresses, present/past coping mechanisms — assist in planning alternatives.
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Involve patient in planning treatment goals and evaluating progress.
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Provide teaching that will prepare patient to deal with life stresses (relaxation, problem-solving skills, how to express feelings constructively).
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Recognize increase in risk (i.e. change in behaviour, verbal, nonverbal communication, withdrawal, signs of depression, decrease in sleep or appetite, hopelessness, helplessness, increase self-destructive thoughts of behaviours.
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Consult with Psychiatry, Social Work, CNS, Enterostomal Therapy nurses for additional support.
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If anti-depressant medication is prescribed, reassure patient it may take three to six weeks before differences in mood are noted.
Altered Family Processes
Altered family processes can be related to the impact that an ill family member can have on the family system. An illness, hospitalization, surgery, previous diagnoses, coping styles, culture can all place tremendous stress on a family and greatly interfere with keeping a family strong and united.
To help family members deal with illness, the nurse can:
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Assess causative and contributing factors — assist patient to define them.
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Acknowledge your feelings about the family and their situation.
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Approach family with warmth, respect and support.
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Avoid vague and confusing advice and cliches. Be clear and concise.
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Reflect family emotions to clarify these feelings (i.e. "this is very painful for you” or “you must find this very frightening”).
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Identify family strengths to them.
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Identify and involve family members in care of ill person if possible.
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Involve family members in patient care conferences where appropriate.
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Promote self-esteem of individual family members.
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Facilitate communication; encourage verbalization of guilt, anger, blame and hostility and subsequent recognition of own feelings in family members.
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Enlist help of other professionals when problems exceed realm of nursing – Enterostomal Nurse, Psychiatry, Social Work, Clinical Nurse Specialist.
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Discuss stresses of hospitalization and assist patient to identify them.
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Describe implications of the “sick role” and how it will return to the “well role”.
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Facilitate family involvement with social supports. Identify social supports.
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Assist family to re-organize roles at home and set priorities to maintain family integrity and reduce stress.
Hopelessness
Ineffective coping experienced post-operatively can be due to negative self-concept, disapproval by others, inadequate problem-solving, loss-related grief, sudden change in life pattern, recent change in health, inadequate support systems, unanticipated stressful events, occurrence of several major events in a short period of time, unrealistic goals.
The nurse can help the patient post-operatively by:
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Assessing the patient’s present coping status. Identify coping strategies.
-
Demonstrate to the patient that you believe her/his desire to help — avoid challenging, minimizing patient’s feelings, arguing or trying to reason with her/him.
-
Offering support as the patient talks — reassure that their feelings must be difficult. Provide a more helpful, realistic perspective if the patient is pessimistic. Document your strategies.
-
Assisting the patient to problem solve in a constructive manner (What is the problem? Who or what is reasonable for the problem? What are the options? (make a list) What are the advantages and disadvantages of each option?
-
Discussing possible alternatives (talking over problem with those involved, trying to change the situation, or doing nothing and accepting the consequence).
-
Helping the patient to identify problems that she/he cannot control directly and help her/him to produce stress-reducing activities for control.
-
Teaching patient relaxation techniques.
-
Having patient describe previous encounters with conflict and how she/he managed to resolve them.
-
Giving options — but leaving decision-making to the patient. Give many choices.
-
Coordinating possible multidisciplinary activities to serve patient’s best interests. Consult with Enterostomal Therapy, Clinical Nurse Specialist, Social Work, Psychiatry as needed.
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Encouraging patient to deal directly with individuals with whom there are conflicts (do not put self in middle).
Manipulative Behavior
Manipulative behaviour is a coping mechanism sometimes used by patients when facing stress. It can be very destructive and can greatly interfere in the nurse/patient relationship.
To help a patient with manipulative behaviour, the nurse can:
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Assess a patient’s needs or anxieties, which he/she is addressing through manipulative behaviour.
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Assist patient in recognizing his/her pattern of behaviour.
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Teach patient direct ways to communicate needs.
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Ensure patient does not“split” (i.e. tell you something about someone else). Encourage patient to communicate directly with involved party.
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Give consistent, clear messages.
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Establish a written contract with the patient as necessary.
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Involve the Enterostomal Therapy Nurse, Clinical Nurse Specialist, Social Worker, Psychiatry as necessary.
Powerlessness
Powerlessness experienced post-operatively can be related to lack of knowledge, previous inadequate coping patterns, and insufficient decision-making opportunities.
The nurse can help the patient post-operatively by:
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Increasing regular, frequent communication between patient and health care provider.
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Explaining all procedures, rules, plans and options to patient.
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Allowing time to answer questions.
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Keeping patient informed about schedule, condition, treatments, and results.
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Anticipating questions, interest, and offering information.
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Pointing out positive changes in patient’s condition.
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Allowing patient to verbalize concerns and feelings.
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Providing consistent staffing within framework of primary nursing.
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Discussing daily plan of activities and allowing patient to make as many decisions as possible.
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Keeping promises.
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Providing daily recognition of progress, praise gains and achievements .
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Assessing patient’s usual responses to problems and stressors.
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Identify short-term realistic goals and give positive reinforcement when achieved
Care Plans
Health care professional working with individuals with IBD will benefit from case studies. They are designed not only to test existing knowledge but also to identify learning needs.
Questions and Answers
Most of the case studies include questions and answers.
Answers can be inputted online. Upon completion, a set of correct answers can be viewed alongside the answers inputted with the option of printing.
Care Plans
The “Test your Knowledge” area is an assessment tool for health care professionals working with Inflammatory Bowel Disease patients.
Tests are designed to examine factual knowledge as well as identifying learning opportunities.