04. Management of the Ostomy Patient - General Principles and Guidelines

In this class we are going to talk about management of the ostomy patient but from a very global perspective we are going to talk about general principles and guidelines kind of to give you an overview and then each component will be discussed in greater detail in subsequent classes. We are going to describe overall goals of care for the patient with an ostomy and general characteristics of an effective pouching system. We are not going into details so remember this is kind of an introductory overview discussion. So think about the patient who undergoes fecal or urinary diversion. Think how much their life has changed as a result of that surgery. So their plumbing has essentially been re-rooted. They have lost continents as they have known it. They have lost their body image as they have known it. They have lost confidence in their ability to manage. So what are our goals in managing this patient and helping this patient move through this trauma and get to the other side where they are again comfortable with their body confident in their ability to maintain continents and ready to get back into their life. So our goal is number one is to establish a secure pouching system. That is essential. A secure pouching system is foundational and we will come back to that over and over. So I need to know that this pouch is going to remain intact. This is going to contain the stool, the urine, the odor, protect my skin. I need to acquire independence in self-care if I'm physically capable of that. So between me and my caregiver, we definitely need independence in self-care. So ideally, independence for the patient, definitely independence for the patient caregiver unit. We want the patient and the caregiver to be confident, to know that they know what they need, to know that if they need to change this pouch in a public restroom, they can change the pouch in a public restroom to feel confident in their ability to move back into their life, back into their usual activities. Which is our next goal. I want this person to be able to do the things that matter to them. I want them to be able to go back to work, go back to school, resume social activities, go out with their friends, resume sexual activity. The whole goal of this surgery was to save their life or improve their physical quality of life and to get them back into that life. And eventually, I want them to feel really good about themselves to not let this ostomy interfere. So let's talk about each one of those goals briefly. We said a secure pouching system is foundational to ostomy patient rehab. So we've already said what we mean by that. What is an effective pouching system? It's a system that consistently contains urine, stool and odor that protects the peristomal skin that provides them a predictable wear time. So I should know I changed my pouch on Tuesdays and Fridays and boring some unforeseen event is going to be secure for me for that period of time. Also, I need a pouching system that maintains the health of my peristomal skin that prevents itching and burning and discomfort. I have said and will keep saying how foundational this is to rehabilitative care. You really cannot talk to me about going back to work, about going out with my friends, about going shopping, about going camping, about resuming sexual activity. We can't have any of those discussions until I trust my pouching system. Until you've come up with something that is going to stick and stay. So how do we select a pouching system that is going to meet all of those criteria? It's going to stick effectively. It's going to stay for a predictable period of time and it's going to keep the peristomal skin healthy. We have to look at peristomal skin contours. We have to look critically at the stoma and specifically the oss. Where does it empty? And then what kind of drainage does this person have, both in terms of consistency and volume? We're not going to get into those details here. I just want that to be in the back of your mind. We're going to come back to that in a later class. We won't this person and/or their caregiver to be independent in self-care. That's something we started achieving when we were toddlers, independence in self-care. That's been interrupted for this person by this surgery. We want them to re-acquire independence and confidence in self-care. Now they need to have basic self-care skills before they leave the hospital. They need to have a higher level of self-care skills before they're discharged from home health. We look at hospital care, home health care as a continuum. We start with them in the hospital. Home health picks up. By the time my patient leaves the hospital, either the patient or the caregiver or both should be able to empty the pouch effectively, clean the spout without making a mess. The patient and/or the caregiver should be able to remove the pouch and replace it. Those are basic skills. In the acute care setting, we work very hard to make sure that the patient and/or the caregiver can empty the pouch and change the pouch before they go home. Now any of you in home health are sitting out there thinking, "Well, when I go see them, they don't know any of that." Because we know there's a lot of regression that takes place when a patient's discharged home. It's absolutely critical for me to refer this patient to home health. I'm trusting my home health colleagues to pick up where I left off or maybe a little back up the road and to reinforce everything I try to teach that patient about emptying and about the pouch change procedure. The goal in home health should be to assure independence in those basic self-care skills before they're discharged. Those are the skills. There are some basic knowledge that the patient needs, the caregiver needs in addition to those skills. So if it's a fecal diversion, if it's an Iliostomy or a colostomy, you're going to hear a lot of questions about managing gas and odor. I want to be sure with answered those questions. I want to be sure that they know how to prevent diarrhea and constipation or how to manage diarrhea and constipation if they should occur. I want to make sure they're clear on any dietary modifications so that they don't get into any complications. Everyone needs to know about fluid management, whether it's a fecal diversion or a urinary diversion. And I also want to answer their basic questions about lifestyle issues. What about clothing? How do I conceal this? What about showering? Do I shower with the pouch without the pouch? How do I get the pouch dry? What if I go to the gym and I sweat a lot? What if I take a trip? How do I manage that? How do I manage my supplies? All of those lifestyle issues. I want to help my patient acquire confidence. Confidence is one of the biggest things in getting them back into usual activities. And studies have been done looking at factors that contribute to confidence and self-care. We need to be very aware of this and helping our patients get there. So we've already said secure pouching system is goal number one. There's no way I'm going to feel confident if my pouch fails on a routine basis. So I've got to have a secure pouching system. Research has also [BLANK_AUDIO] that independence and self-care is critical to confidence. So many times we, as ostomy nurses, end up kind of pushing our patients, pushing them, cajoling them, dragging them to do more than they want to do. So that they acquire independence and self-care. And we do that because we know that if we can push them to the point where they can empty independently, if we can push them to the point where they can change the pouch independently, is going to translate directly into increased confidence, increased willingness to resume usual activities. Support system makes a big difference in confidence as well. So health care professionals, we're part of the support system. We're going to teach you what you need to know. We're going to push you to do more than you want to do so that you can take those steps toward confidence. Other individuals with ostomies make a huge difference. So throughout this course, we're going to be talking about the importance of connecting patients to other people who have already walked this path. Other people who have an ostomy. We're going to be talking about the United Ostomy Association. We're going to be talking about online resources. We're going to be talking about the benefit of identifying a person with an ostomy who's willing to come in and talk to my patient. Because talking to someone, either online or face-to-face, who has an ostomy, who's going to work, who's going out with their friends, who's doing the things they want to do, who's resume sexual activity, nothing can replace that. It gives them an unspoken message, a nonverbal message, just the fact that this person walks in or this person answers their questions online. And they're like, oh, I just got back from a camping trip or I just got back from a trip to Europe or whatever. Because it says to this person, gosh, there's all these other people out there. They've had the same operation and look what they're doing. And then family and caregiver support makes a big difference. And we'll talk about the importance of providing support to the family, to the caregivers. But you can imagine if you have someone right there with you saying, you can do this and I'll help you. I'll be your coach. I'll learn the steps of the procedure. If you need help sintering that pouch, I'll help you center that pouch. It gives you the support to move forward to achieve independence, which in turn helps you achieve confidence. And what we know is that it takes some time. Studies have shown that there was an extensive study done in Europe with thousands of ostomy patients. And what they found is that the first three to six months are the most difficult. And that by six months post-operatively, the vast majority of patients were feeling much better, were resuming usual activities and verbalizing a much higher level of confidence. So long as they receive the critical foundational care, help identifying an effective management system and that push and support toward independence. Eventually, we want people back in their lives sooner rather than later. I don't want to get this person just to the point where they go home and sit in their house and never go anywhere and never do anything. Then what did they gain? I don't want to have a patient who says, I miss going to church so much, but I just don't feel comfortable. Or I wish I could go shopping, but I guess it's a really good thing they have online shopping now 'cause I just don't feel comfortable going out around other people. I just don't think I can be around other people. So our ultimate goal is that the patient's able to resume their usual activities to include social activities, to include sexual activity, unless there's some health issue that precludes those activities. I know you've already heard this, but I'm gonna say it one more time. To get there, we have to establish the secure pouching system and we have to push that person toward independence and confidence. Now there are some very important factors that impact on somebody's ability to take those steps to get back into their life. One is their basic personality. Some people are just problem solvers and they push forward and they're basic optimists and they're like, I can do this and it's gonna be okay. And I'll figure it out as I go. Whereas other people are much more inclined to be conservative and cautious and to worry. And also the amount of support I get. So if I have people all around me say, and look, we're so glad you're through the surgery. We're so glad you're out of the hospital. You know, if you need help, we'll help you, but come on, come on. We're gonna go out to eat, you come to. We're gonna go to the movie, you come to. That makes a huge difference. So we know what we want for our patient. We want them back in their lives. We want them feeling confident and comfortable. We want them feeling good about themselves. How do we get there from here? So we're gonna divide it into what needs to be done preoperatively, what needs to be done during the initial post-op period, and what needs to be provided long term. So preoperatively, we need to talk to the patient. We need to be sure they understand what's being done, why it's being done. We need to answer any questions they have. And absolutely critical. We need to mark the stomicide. We need to provide input to the surgeon about the best places to put this stoma, the sites where it will be most manageable. Absolutely critical to do that preop. You can't make up for failure to mark this stoma site. You can't make up for that post-op. Post-operatively, I've gotta get in there. I've got to assess, make sure that the stoma's viable, everything's working okay. I've got to do a thorough evaluation of abdominal contours where the stoma empties come up with an effective pouching system. I have to assess the patient's emotional status and how much support they have and provide them with support. And I have to provide baseline instruction in self-care, critical self-care skills, critical knowledge. I have to start that process. And I have to hand off to home health and home health before their discharge needs to be sure that this person can empty, they can change, they can manage minor skin irritation, they know where to get their supplies, they know how to prevent complications and they know what their resources are. And then long-term management is gonna be provided in the outpatient arena. And this is gonna be really important because everything changes over time. The height of the stoma can change over time. Abdominal contours can change over time. Characteristics of output can change over time. So something that looks very appropriate and works very well at eight weeks post-op, might need revision at six months post-op. So I've gotta make sure that patient is referred to an outpatient clinic that they have that long-term follow-up. So here's our goals. We want them to have a secure pouching system. We want them to be independent in self-care and to feel confident in their ability to manage with the ultimate goal that they're back into their usual activities. They're back in their life. This ostomy might be a nuisance, but it's not keeping them from doing anything they really wanna do. And the strategies are gonna be pre-op teaching and stomicide marking. Postop, my initial assessment is focused on is this stoma healthy, is it functioning normally? And what kind of pouching system is gonna provide this patient with a secure seal? Once I get there, I'm gonna focus on teaching this patient self-care, the patient caregiver unit, teaching them the things they need to know to prevent complications, providing supportive counseling and referrals is needed to help them get over that hump and back into their life. Thank you.